Category: Free Essays

The following essay will give a critical evaluation of the role of an Occupational Therapist (O.T) within vocational rehabilitation in the private mental health setting. Firstly the essay will describe a critical analysis of vocational rehabilitation and the added value of an O.T within this setting. Secondly it will analyse the trends within vocational rehabilitation and how these relate to O.T philosophy and core tenets, thirdly an examination of concepts of management that relate to vocational rehabilitation and finally a justification of the identification of a model relevant to vocational rehabilitation.

Work can be seen as being an important part of health and wellbeing and also social inclusion. Waddell & Burton (2006) suggest that work is therapeutic, helps promote recovery and rehabilitation. Leads to better health outcomes, minimises physical mental and social effects of long term sickness absence and worklessness, decrease the chances of chronic disability, long term incapacity from work and social exclusion. Also promotes full participation in society, independence and human rights, reduces poverty and improves quality of life and wellbeing. Work can be divided into four different areas: paid (contract, material reward), unpaid (housework, caring, volunteering), hidden (illegal, morally questionable) and substitute (sheltered workshop, work projects, day centres) (Ross 2007).

The demand for work is extremely high due to the amount of people that are living. Compared to other countries, the United Kingdom employment figures are high with people being employed with a health related condition increasing (Department of Health 2008).

It has been estimated that 175 million days were lost in 2008 due to illness with 600,00 people turning to incapacity benefit. (Department of Health 2008)

It has been shown that 40% of medical certificates issued have been related to mental ill health with the average time off working being 15 weeks. (Department of Health 2008)

Work has been shown to be good for your health and employers who adopt a good approach to health, by protecting and promoting it, are important in stopping illness from occurring. This is an area in which O.T’s can provide a key role in supporting and maintaining people back into work or who are already in work to stay there.

Vocational rehabilitation is important. This has been shown in the government’s new mental health strategy ‘No Health Without Mental Health’ (Department of Health 2011). One of the aims is working to help people with mental health problems to enter, return to employment and stay in it.

The application of O.T within this area is important as our core philosophy is to enable individuals to engage in meaningful occupations, therefore there is a key role for O.T’s to play within vocational rehabilitation. The following quote demonstrates that meaningful engagement in occupation can be important, which reflects O.T’s core ethics and philosophies. ‘Not everyone wants to be employed but almost all want to work, that is to be engaged in some kind of valued activity that uses their skills and facilitates social inclusion’ (College of Occupational Therapist 2007 p9).

Currently within vocational rehabilitation, employment specialists are trained in advice and guidance and REC level 3 advanced certificate in recruitment practice. Employment specialities tend not to be mental health professional but have skills in vocational rehabilitation or industry experience (Waghorn 2009). O.T’s already have these skills and also can add a holistic client centred approach from an occupational perspective. O.T’s can also add an educative approach, combine medical and occupational models and use activity analysis. They can assess occupational function/performance, build therapeutic relationships, carry out psychosocial assessments and interventions, cognitive evaluation and training, help with work life balance for the client and work with client’s strengths. (Waghorn et al 2009, Devline et al 2006 & Joss 2001, cited in College of Occupational Therapist 2007 p15)

An O.T can bring seven core skills to vocational rehabilitation: collaboration with the client e.g. building therapeutic relationships, assessment e.g. Model of Human Occupation Screening Tool, enablement, problem solving, using activity as a therapeutic tool, group work and environmental adaptations e.g. graded return to work (Duncan 2006 p45)

Current themes and drivers within mental health are social inclusion, return to work agenda, recovery. Social exclusion happens when people are ‘unemployed have poor skills, low incomes, poor housing, high crime, bad health and family breakdown’ (social inclusion and co-production 2011)

A report called ‘Mental Health and Social Exclusion’ was published in June 2004 by the Office of the deputy Prime Minister. It aimed to improve the live’s of people with mental health problems by getting rid of obstacles to employment and social participation. There are five main reasons why social exclusion occurs for people with mental health problems. Firstly stigma and discrimination, in which an O.T can help by activity speaking to employers about mental health and how reasonable adjustments, could be made. An O.T can help by increasing low expectations, help promote vocational and social outcomes, help provide ongoing support whilst in employment by regular outreach appointments and help access basic services e.g. dry runs on transport, membership to sports centres (Office of the deputy Prime Minister 2004). Overall an O.T can help people remain in their jobs longer and return to employment faster and manage the work environment better by grading work, breaking down activities and rebuilding them step by step and making adaptations to the work environment for example.

Another trend is recovery. Recovery is ‘building a meaningful and satisfying life, as defined by the person themselves, whether or not there are ongoing or recurring symptoms or problems’ (Slade et al 2008). Recovery encourages people to develop relationships which give their life meaning. There are five stages of recovery: moratorium (withdrawal, loss, hopelessness), awareness (realisation), preparation (strengths and weakness regarding recovery), rebuilding (positive identity, goal and taking control), growth (living a meaningful life, self management of illness, resilience, positive sense of self) (Andresen, Caputi & Oades, cited in Slade et al 2008). Satisfying work supports recovery and as such O.T’s can have a great impact here by ensuring clients are in jobs they really enjoy and able to cope with the work demands. By working in a client centred way, listening, help identify and prioritise personal goals for recovery; identify examples of own lived experience. Also pay attention to goals which will enable the service user to get back into work, suggest non-mental health resources (friends, contacts, organisations), encourage self management of problems, discuss what the service user needs in terms of psychological treatment, convey an attitude of respect and continue to support, an O.T can help a service user to achieve their ideal job.

The return to work agenda is about helping people in and/or return to work. O.T’s can aid this by grading work activities e.g. working hours to start with 16 hours per week and gradually increase by 5 hours per week until full time hours are achieved for example. Also by providing support whilst in job by light touch support, setting up group work activities and training the service user. A practice called ‘place then train’ helps increase motivation and confidence by placing someone in work and then training them instead of the other way around. It improves employment outcomes and peoples mental and physical health over a long period of time (Centre for Mental Health 2011). Its philosophy emphases rapid job searching, individualised job placement in work followed by on-the-job training and ongoing support (Twamley et al 2008).

Currently the concepts of management in vocational rehabilitation within the private mental health sector follows the following structure:

Area manager

Service lead

Employment specialists Volunteers

With the introduction of an O.T manager the following structure will be placed:

O.T Manager

Band 5/6 O.T

Employment specialist/ Volunteers

O.T.A

Referrals will either come from people themselves or via the community e.g. mental health teams, doctor surgery’s, job centres. With new referrals the degree of risk, impact of O.T on service user, consequences of service user not receiving treatment, length of waiting time and the appropriateness of skills and abilities will be considered.

To get people on board for the change in management, people will be listened to for their points of views, concern will be shown, the manager must be approachable e.g. leaving door open and using positive body language, change will be promoting in a positive manner e.g. it will benefit the patients and questions will be encouraged, integrity and charisma will be shown, also have a good ability to communicate, set direction and unify and manage change.

The Lewins stages of change (Mullins 2007) will be adopted where first unfreezing will take place followed by moving and then refreezing. Unfreezing is about getting ready to change by understanding that change is necessary and moving out of comfort zones. It’s about weighing up benefits and negatives of the change.

Moving or change is when people are unfrozen and decide to move toward a new way of working. This is often the hardest for people and support is needed.

Refreezing is stability once the changes have been completed. These changes have been accepted and become the norm. People create new relationships and become comfortable with the new routines.

The O.T manager will provide supervision to the band 5/6 O.T and have supervision from a paid outside O.T at that equivalent level. The Band 5/6 O.T will have supervision from the O.T manager and the Occupational therapy assistant (OTA) / employment specialist and volunteers will be supervised by the band 5/6 O.T. Volunteers will be looked after by the OTA.

Management will be in a democratic style by listen to people opinions and having staff work with the manager, not against. Make sure that management set examples by dressing correctly, not being late for work; develop an image, project self confidence, influence others and establish personal authority (Martin et al 2010). Also address self management by managing time, self and case load e.g. size up task, knowing themselves (need for breaks, strengths and weakness), prioritising and planning control(keeping a dairy, decreasing interruptions). Bad management will be discouraged such as not resolving problems, criticising staff, poor decision making, disorganisation, failing to deal with staff issues, done give recognition, inflexibility, and have an uncaring attitude and poor communication skills (Moore et al 2006)

Management will consider professional duties and responsibilities such as the code of ethics, continues professional development (competence), health and safety (risk assessments) and deal with the present.

A number of factors may influence management style: confidence in staff e.g. their abilities, need for certainty (risks of handing over control), personal contribution and stress (overload, worry, pressure) (Martin et al 2010).

The justification of a model relevant to vocational rehabilitation is the Model of Human Occupation (M.O.H.O). M.O.H.O looks at people’s motivation (volition), routine planning (Habituation) and the influence of environment on occupation (performance capacity). Some of these areas will be affected by the service user.

Volition is the thought and feelings we adopt whilst doing things. This involved three areas: personal causation, value and interest. To change motivation these areas will need to be addressed. By looking at the service users present and potential abilities relating to work and how able they are to bring about work (what is good, right and important) e.g. security, accomplishment and interests, having positive feelings associated with working. Habituation looks at reoccurring patterns of behaviour that make up our daily routines. A service user can change their habits by learning new ways of doing occupations and by changing their perceived role to one of a worker/bread winner. Performance capacity is how the musculoskeletal, neurological, cardiopulmonary and other body systems are used during performance. If there is a problem in performance capacity, the environment must be addressed.

Work is an increasing important aspect in our lifes. Some of us live and breath work spending the majority of our waking hours working. Work gives us a sense of identity, an occupation, money to spend. It also provides us with a role in the community helping others with our knowledge in a particular area.

Work provides us with a purpose, includes us within society preventing social exclusion, increases self esteem and gives us a role/meaning within society.

Definition

Work can be seen as the idea of doing, either mental or physical, giving an economic reward, social interaction, the structuring and organisation of time, opportunity for social interaction, contribution to society and self identity (Baker & Jacobs 2003)

What can Occupational Therapy offer that is different?

Occupational Therapy can offer an approach which looks at the whole of a person by putting the client at the centre of their treatment from an occupational perspective. Occupational therapists can also educate people, focusing on independence and ensuring participation in meaningful activities.

Occupational Therapists are able to combine medical and occupations models. This means they can look at the impact that physical, social and cultural environments have on everyday activities.

Patch Three

The following patch will give a critical evaluation and analysis of social policy, legislation and ethical issues impacting on vocational rehabilitation in a report style.

Legislation

No Health without Mental Health (Department of Health 2011)

The government is helping people with mental health problems to enter, stay in, and return to employment. This can by achieved by using light touch support, increase confidence in returning to and remaining in work, help manage conditions and help the interaction between appropriate work and well being. It consists of six main objectives:

‘more people will have good mental health, more people with mental health problems will recover, more people with mental health problems will have good physical health, more people will have a positive experience of care and support, fewer people will suffer avoidable harm and fewer people will experience stigma and discrimination’ (Department of Health 2011 p6).

Its outcome strategies is to focus on how people can be best empowered to lead the life they want to lead, to keep themselves and their families healthy, to learn and be able to work in safe and resilient communities and how practitioners can be supported to deliver what matters to service user.

Occupational Therapists can provide high quality employment support which will include building confidence in returning to and retaining work, changing employers and service user’s beliefs, that they can perform the job and their condition is manageable. Support Interaction between appropriate work and wellbeing and help employees to make appropriate recruitment decisions and manage workplace health.

New Horizons (Department of Health 2009)

This mentions that work can be good for mental health and wellbeing and support recovery. Those who are unemployed are at an increased risk of developing mental illness and benefit from early support.

Employment should be seen as an important outcome to the treatment of mental illness in health care settings.

O.T’s can help change attitudes to mental health, can improve health and wellbeing in work, provide swift intervention when things go wrong, coordinate help tailored to individuals needs and build resilience from the early years and thought working lives.

Health, Work and Wellbeing – Caring for Our Future (Department of Health 2005)

Suggests that work is recognised by all as important and barriers to starting, returning to or remaining in work are removed. For people to remain in and return to work, that healthcare services meet the needs of people of working age. That health is not affected by work and good quality advice and support is available. Ensure work offers opportunities to promote health and wellbeing and access to the retention of work promotes and improves population, people with health conditions and disabilities are able to optimise work opportunities and people make the right lifestyle choices from an early age.

O.T’s already recognise the importance of work for their patients wellbeing and can provide the assistance necessary to fulfil their key roles in helping patients to remain in and return to work.

O.T’s can help people return to work following and absence by employment advice and helping to find a suitable job by adapting the work place environment e.g. time flexibilities.

National Skills Framework – 5 years on (Department of Health 2004)

Help to prevent social exclusion in people with mental health problems, improving their employment prospects and opposing stigma and discrimination. O.T’s can help prevent social exclusion by building confidence, motivation and skills, speak to employers about mental health and how reasonable adjustments could be made, help provide ongoing support whilst in employment and help reduce stigma and discrimination by educating people.

Working for a healthier tomorrow (Department of Health 2008)

Is concerned with the health of people of working age (females 16 to 59 and males 16 to 64). Identifies factors that prevent good health and changes in attitudes, behaviours and practices.

Three main principal objectives:

prevention of illness and promotion of health and wellbeing

early intervention

improvement in health of those out of work

O.T’s can prevent illness and promote health and wellbeing by using activity as a therapeutic tool, ensuring early intervention and help those out of work by doing group work to build confidence, motivation and reduce anxieties.

Ethics

There are at least five potential ethical issues which may be encountered within vocational rehabilitation in a private mental health charity organisation. These are confidentiality, consent, autonomy and welfare, human rights, issues of power and control (College of Occupational Therapists 2005):

Confidentiality

Safeguarding of confidential information relating to clients, only disclose information when client has given consent, there is a legal justification or it is in public interest to prevent harm. Only disclose to third parties if there is a valid consent or legal justification to do so. Keep all records locked away securely and only make available to those who have a legitimate right or need to see them. Clients can see their records and prior to producing material, issues of confidentiality will be addressed.

Use the confidentiality model: Protect (look after information), inform (ensure service user is aware), provide choice (allow service user to decide if information will be disclosed and improve (look for better ways to protect, inform and provide choice) (Department of health 2003)

Consent

Making sure the client has the capacity to consent. The 2005 Mental Capacity Act makes provision for people who are thought to lack capacity to make their own decisions. It has five key areas: ‘a presumption of capacity’ – every adult has the right to make choices and must be assumed to have capacity to do so unless it is proved otherwise; ‘the right for individuals to be supported to make their own decisions’ – appropriate help must be provided before anyone suggests that they cannot make their own decisions; ‘that individuals must retain the right to make what might be seen as eccentric or unwise decisions’; ‘Best interests’ – anything done must be in the best interest for the service user and ‘Least restrictive intervention’ – anything done should be the least restrictive of service users basic rights and freedoms. (Department of health 2007)

Autonomy and welfare

Respect client’s autonomy and promote dignity, privacy and safety of client. Give patients the right to make choices and decisions about their own healthcare and independence. Provide sufficient information to enable them to give informed consent and in a language that can be understood. Make sure client understands the nature, purpose and likely effect of intervention and acknowledge refusal.

Human rights

A right not to be discriminated against regardless of person’s religion, sex, race, colour or mental health

A right to respect for private and family life e.g. medical record keeping, parental involvement, collection of data

A right not to impact on the individual’s freedom of thought, expression or conscience e.g. spoken language and access to interpreters

Issues of power and control

Respect individuals, enable client to take power and promote partnership

Management of Quality Issues
Quality assurance

The service provided will ensure that it meets the needs and expectations of clients and communities, that there is an understanding of service delivery systems and its key services, that data is analysed, problems are identified, performance is measured and that a team approach to problem solving and quality improvement is used.

Clinical Governance

Involvement

Make sure service users, carers and public are involved within the service by holding focus groups, open days, suggestion boxes, questionnaires, panels e.g. to find out opinions on waiting times, attitudes of staff and the physical environment

Risk management

Establish what could go wrong and rank this. Think how probable it is likely to occur, what can be done about it and what action should be taken if incident happens again (Health & Safety executive 2006). E.g. service users deliberately harming herself in occupational therapy session or a spillage on the floor. The Healthy and Safety at Work Act (1974) states that it is the duty of the employer ‘to ensure so far as is reasonable practical, the health, safety and welfare at work of all his employees (section 2 (1) Health and safety at work act 1974). Although it is the duty of the employee to take reasonable care for the health and safety of him/her and others who may be affected by his/her acts of omission and to co-operate with their employer in regard to any duty or requirements imposed (section7 Health and Safety at Work Act 1974)

Clinical audit

Identify topics relevant to vocational rehabilitation e.g. referral response times, set standard (3 days), collect data (computer package), analyse data (if standard not met then why) and implement change. Other examples may be how the service compares with standards set by other clinical governance activity.

Clinical effectiveness

Ensure that all treatment is up to date and based on evidence based practice, National Institute of Clinical Excellence and National Service Framework guidelines.

Staffing and staff management

All staff recruited have the skills and qualifications needed to do the job e.g. that they are Health Professional Council (HPC) registered, induct them, give supervision and appraisal and deal with poor performance. Also supervision on a regular basis and appraisal once a year. Use an indirect approach which is more centred around the person, talk less and listen more, provide a supportive relationship, ask questions, accept and use ideas, reflect and summaries ideas (Enthwistle 2000)

Education, training and Continues Professional Development (CPD)

Ensure mandatory training is given e.g. fire training, child protection, health and safety. Complete CPD portfolios and HPC audits; provide training and opportunities to enhance CPD such as visits to another vocational rehabilitation service. The HPC (2011) states five standards for the CPD. A registrant must maintain:

‘an up-to-date and accurate record of their CPD activities’

‘demonstrate that their CPD activities are a mixture of learning activities relevant to current or future practice’

‘ make sure that their CPD has contributed to the quality of their practice and service delivery’

‘ensure that their CPD benefits the service user’

‘present a written profile containing evidence of their CPD on request’

Use of information systems

Use information systems to record treatment sessions that service users attend, time spent preparing treatment sessions, time spent on phone calls to service user and time spent in case discussions. Also handling patient identifiable information by applying the data protection act and locking information away. The data protection act implies that anyone collecting personal information must ‘fairly and lawfully process it, process it for limited, specifically stated purposes, use the information in an adequate relevant and not excessive way, use information accurately, keep information on file no logger than necessary, process information in accordance with legal rights, keep information secure and never transfer information outside U.K without adequate protection’ (Direct Gov 2009)

Patch Four

The following patch will provide a reflective narrative of the learning experienced throughout the module utilising the Gibbs reflective cycle. This has been developed from Kolb’s ideas and develops the features of the

experience-reflection-action cycle (Jasper 2003):

Description

Action plan Feelings

Reflective cycle

Conclusion Evaluation

Description

The Gibbs cycle consists of six stages and asks a series of questions about the experience. Description stage is what happened, feelings stage is what where you thinking and feeling, evaluation stage summarises what is good and bad about the experience, description stage involves making sense of the situation, conclusion stage is what else could have been done and the action plan stage asks if the situation arose again, what would you do.

To begin with the whole assignment seemed extremely daunting as I had never participated within a role emerging placement/role before. I had also never completed a patch work text and knew very little of both. As part of the assignment we were asked to discuss ideas with peers. I felt it was a good idea to share information with others and thought that this would be an ideal opportunity to reflect on things I was not sure about and where to go for more information. Whilst discussing ideas with my peers I was thinking how what we had discussed would fit into my assignment and in what patch. It made me feel a little more comfortable sharing with other as we could bounce ideas and thoughts off each other. I feel other peers also felt that group discussions were useful and helpful. From start to finish I felt good about discussing information and still feel that this was of great benefit to all of us.

Exchanging views helped put things in some kind of order and others could help in areas where I had difficulties. I do not feel there was anything negative about this experience in general. Sharing ideas with others went well as we all had views to share. To contribute, I helped others to see what went in each patch and gave ideas about the assignment.

Overall there is not much I would have done differently with this peer review work. The aim was to share and discuss information and this was done successfully. If I were to do peer review work again I would do the same by sharing ideas and information with others.

During my visit to a vocational rehabilitation setting I got to see how the service was run, where referrals come from, meet staff and service users and view leaflets. Upon arrival I felt overwhelmed by information and was intrigued about the service. I was thinking how I could relate this to my assignment and what role an occupational therapist would play within such a service. The service manager, who showed me around, knew about occupational therapy as previously they had worked as an assistant in such a role. This made me feel happier as I could share some ideas with them. I felt the visit went extremely well and it was a positive learning experience. From the start I felt comfortable about visiting the service and knew I would collect lots of relevant information from it. Access to information and ideas was the most significant factor for me.

Actually seeing a vocational rehabilitation service running was a great inspiration and thought provoking for me, as I could see where parts of my assignment would fit in. I feel the whole visit went well and managed to collect a lot of relevant information.

To complete patch work two we were asked to produce a leaflet aimed at our intended service users. I found this patch difficult because selecting relevant information was not easy e.g. font, colours, headings, content, pictures. When I first started the leaflet I had previous knowledge from another module, so had an idea how to construct the framework. I was thinking what type of content would go into the framework of the leaflet and how. Others mentioned that the leaflet should be easy to read and with bullet points, pictures and a calming background. I felt this would be a good idea, by aiming the leaflet at my service user group in particular. I thought that the leaflet was starting to take shape and it was aimed at who it was intended for. To start with I felt a little lost as to what to so but with help from my peer review group I eventual found a way. The most significant thing to me was being able to reflect ideas with other people about the leaflet.

I feel that putting the leaflet together was a good experience as it has taught me how to present information to a targeted audience by using easy to understand phrases rather than jargon. Also working in peer review groups was a good experience as we were able to share ideas with each other and share information. The only thing that didn’t go so well was working out how to transfer the leaflet from publisher to a word document, also slimming down the content without vital information being lost.

I feel the leaflet went well and managed to collect and produce the correct information. Others did help by offering encouragement and ideas which aided me in producing the leaflet.

I realise now that I should have consulted my peer group earlier to starting the leaflet as their ideas helped and guided me.

To complete patch three we were asked to critically evaluate and analyse social policy, legislation and ethical issues impacting vocational rehabilitation. I found writing this patch extremely difficult as I had no idea of legislation, ethical issues and quality issues relating to this subject.

When I started this patch I felt very nervous and worried as to how I would find such information. I was wondering how I would go about doing this patch and what was involved. When I was looking for information I found a vast array. I had to sieve through relevant legislation and apply it to

Recent decades have witnessed a dramatic rise in cohabitation in much of Western Europe including the United Kingdom (Ermisch 2005; Ermisch and Francesconi 2000a; Haskey 2001; Kiernan 2001; Murphy 2000). This rise has taken place against a dramatic decline in marriage rates. A so-called “golden age” of marriage that prevailed in the United Kingdom from the 1950s up to the 1970s (Festy, 1980), has been eroded. Marriage is no longer the exclusive marker of first union nor the pre-eminent context within which children are born; (Kiernan, 2001). The decline in the popularity of marriage indicates that ‘no longer is marriage seen as the only organizing principle for relationships’ (Hall, 1993: 8) and therefore legal marriage has ‘given way to a variety of optional non-traditional forms of ”living together” (Boh, 1989: This essay will seek to examine whether the rise in cohabitation will witness a decline in marriage to a point where marriage is a rare phenomenon. This will entail an analysis of statistical evidence on both cohabitation and marriage and the explanations that have been provided. These include notions of selfish individualism (Morgan, 2000), notions of the democratic, consensual and “pure” relationship (Giddens, 1992; Beck-Gernsheim, 2000), Becker’s (1973, 1981) model of marriage, the common-law marriage myth, commitment in cohabiting partnerships, and the use of ‘lived law’ to create a DIY variety of marriage (Duncan et. al. 2005).

The 1960s and the early 1970s was a golden age of marriage in the United Kingdom during which marriage was highly popular among the young ages (Kiernan & Eldridge 1987) and a record peak of 480,285 marriages was recorded in 1972 (ONS, 2008). However, since the 1970s there have been considerable changes amounting to a structural shift in individuals’ demographic behaviour and societal norms (Haskey, 2001) and among these are increases in divorce and in cohabitation, that is, in couples who live together in intimate relationships without being legally married. Similarly, Ferri et al. (2003) have documented several demographic changes which led social commentators to lament the ‘end of marriage’. These include significant rises in cohabitation, divorce, lone parent families, single parent households, children born out of marriage and age of marriage.A These changes, it was assumed, led to the disintegration of traditional structures and codes and ultimately to the end of marriage.

Statistical evidence indeed shows that there has been a long-term decline in marriage rates and a significant rise in cohabitation. From 1971 to 1995 first marriage rates fell by 90% for teenage women and 80% for women aged 20-24. Median age at first marriage rose from 23.4 to 27.9 yrs for men and 21.4 to 26.0 years for women (Murphy and Wang 1999). The decline in remarriage rates has been even more pronounced. For divorced men, the remarriage rate has fallen by 75% since 1971 (Murphy and Wang 1999). There were 311,000 marriages in the UK in 2004 and this figure fell to 270,000 in 2007. This represents almost half the number of marriages that took place in 1972 when marriage peaked (ONS 2009).

On the other hand, cohabiting is the fastest growing family type in the UK (with the proportion of cohabiting couple families increasing from 9% to 14% between 1996 and 2006), (ONS, 2009). Among single women marrying during the latter part of the 1990s, 77% had cohabited with their future husband, compared with 33% of those marrying during the late 1970s, and only 6% of those marrying in the late 1960s (Haskey 2001). During the 1960s, 40% of remarriages were preceded by a period of cohabitation; and this figured had soared to around 85% in 2000. (Murphy 2000). The 2001 Census recorded just over 2 million cohabiting couples in England and Wales (a 67% increase from 1991). When the new form of cohabitation arrived in the 1970s it was mainly a child-free prelude to marriage. Increasingly, children are being born to cohabiting couples. In 2006, 56% of births in England and Wales were outside of marriage compared with 8% in 19z71. (ONS, 2009). Between 1996 and 2006, the number of cohabiting couples in the UK increased by over 60%, from 1.4 million to 2.3 million, ONS, 2009). The number of cohabiting couples in England and Wales is projected to almost double to 3.8 million by 2031 (which will be over one in four couples on this projection). (ONS, 2009).

Social theorists have conceptualized these trends in terms of individualization theory. The theory which includes notions of the democratic, consensual and “pure” relationship (Giddens, 1992; Beck-Gernsheim, 2000) and notions of selfish individualism (Morgan, 2000), has emerged as the dominant contested theoretical approach in explaining whether the rise in cohabitation means ‘the end of marriage.’ According to the former, modern society is viewed as having entered a ‘late modern’ epoch of ‘de-traditionalisation’ and ‘individualisation’ in which traditional rules and institutional frameworks have lost ground, only to be replaced by more modern and rational rules (Beck, 1992 and Giddens, 1992, 1994). Institutional forces such as education, the modern economy and the welfare state have freed individuals from externally imposed constraints, moral codes and traditional customs, a development which Beck (1994) says is a disembedding of individual lives from the structural fabric of social institutions and age-specific norms.

According to Brannen and Nilsen (2005), social class no longer has the same structuring role that it once had.A Individuals who used to have a standard biography no longer have pre-given life trajectories but are instead compelled to reflexively make their own choices and hence create their own biographies. At the same time, the ‘project of self’, with an emphasis on individual self-fulfillment and personal development, comes to replace relational, social aims. This results in ‘families of choice’ which are diverse, fluid and unresolved, constantly chosen and re-chosen (Weeks 2001) and which Hardill, (2002) refer to as the ‘postmodern household’. In ‘families of choice’ all issues are subject to negotiation and decision making (Beck and Beck- Gernsheim1995, Beck-Gernsheim 2002). Individuals are seen as preferring cohabitation to marriage because they wish to keep their options and their negotiations open ( Wu, 2000).

The individualisation theory sees modern relationships as being based on individual fulfillment and consensual love, with sexual and emotional equality, replacing formal unions based on socially prescribed gender roles. Sexuality is largely freed from institutional, normative and patriarchal control as well as from reproduction, producing a ‘plastic sexuality’, which serves more as means of self-expression and selfactualisation rather than as a means to reproduction and cementing institutionalized partnership (Giddens, 1992). Giddens argues that that such plastic sexuality as part of the ‘project of self’ is realized in ‘pure relationships’ an ‘ideal type’ that isolates what is most characteristic for intimacy in reflexive modernity, ‘Giddens (1991, 1992).A This is ‘pure’ because it is entered into for its own sake and for the satisfaction it provides to the individuals involved. The pure relationship must therefore be characterized by openness, involvement, reciprocity and closeness, and it presupposes emotional and sexual democracy and equality, ‘Giddens (1991, 1992). According to Cherlin (2004:853), the pure relationship is not tied to an institution such as marriage or the desire to raise children. Rather, it is ‘free-floating’, independent of social institutions or economic life’.

The individualisation theory asserts that these changes in relationships contribute towards the ‘decentring’ of the married, co-resident, heterosexual couple. It no longer occupies the centre-ground statistically, normatively, or as a way of life (Beck-Gernsheim, 2002; Roseneil and Budgeon, 2004). Instead other forms of living such as cohabitation, living alone, lone parenting, same-sex partnerships, or ‘living apart ‘ have become more common and are both experienced and perceived as equally valid.

However, most English-speaking commentators (e.g. Morgan, 1995, 2000, 2003; Bellah et al., 1985; Popenoe, 1993; Dnes and Rowthorne, 2002) have developed a pessimistic view of family change. In cohabitation they have seen a moral decline and its harmful effects on society, a loss of family values, individual alienation, social breakdown, rise in crime and other social ills and social, emotional and educational damage to children. For them, the trend in statistics is clear evidence of selfish individualism and have thus advocated for ‘turning the clock back’ by promoting marriage among other things. Morgan (1995) for instance, argues that without the traditional family to socialize children and in particular to provide role models and discipline for young men, delinquency and crime will escalate and society as a whole will be at risk. To avoid this social policy should seek positively to support marriage and promote traditional gender roles for men and women. According to Morgan (2003), cohabiting relationships are fragile. They are always more likely to break up than marriages entered into at the same time, regardless of age or income. On average, cohabitations last less than two years before breaking up or converting to marriage. Less than four per cent of cohabitations last for ten years or more. She also believes that cohabitation should be seen primarily as a prelude to marriage but increasingly it is part of a pattern which simply reflects an ‘increase in sexual partners and partner change’ (Morgan, 2003:127). Morgan (1999) also argues that cohabitation is concentrated among the less educated, less skilled and the unemployed.

The individualization theory in its various versions, has been seen as having its merit in terms of indicating trends in post-modern societies, but has been criticized for lacking reliable methodologies and for lacking empirical and historical evidence. According to Thernborn (2004), individualisation theory should be seen as a geographically and historically limited exaggeration among the variety and long durees of socio-sexual systems. Individualisation theory is seen as largely resting on the evidence of qualitative work using purposive samples of particular social groups in particular contexts and localities. They do not often use representative samples or total population figures which can accurately portray overall social patterns. According to Sayer (1992) individualization theorists have used ‘intensive’ research design which are indeed in-depth and able to access social process more directly, and understand its context but points out that such work needs to be complemented by ‘extensive’ research on patterns and distributions, using representative survey for example. Duncan and Edwards (1999) share the same view that the use of both intensive and extensive research designs will enable generalizations to be made. In addition intensive work will enable better interpretation of the representative patterns revealed by extensive work and to link process to pattern directly rather than depending upon post-hoc deduction, (Duncan and Edwards 1999).

Critics of the individualisation theory have argued that the theory underplays the significance of the social and geographical patterning of values and behaviour and neglects the importance of local cultural and social contexts. According to Duncan and Irwin structures of economic necessity, social groups and moral codes have not gone away, although they may have changed. Family forms are still deeply influenced by local structural conditions or contexts and although people might be less constrained by older traditions, this does not necessarily mean individualisation. The ‘traditional’ structures of class, gender, religion and so on have a continuing importance, (Duncan and Irwin, 2004, 2005).

Individualisation theory assumes that individuals can exercise choice and shape their lives. However, the theory has been criticized for taking insufficient account of the context in which individuals make their choices. Critics of individualisation have pointed out, people’s capacity to make choices, for example in respect of separation and divorce, must depend in large measure on their environment, whether for example, on the constraints of poverty, social class and gender, or, more positively, on the safety net provided by the welfare state (Lasch, 1994; Lewis, 2001a). In addition, the context in which people are making their choices is constantly shifting. Thus the meaning of what it is to be married, or to be a parent has changed and continues to change. Actors will in all likelihood be affected by these changes over their own life course and must expect to have to re-visit the decisions they have made, for example in respect of the division of paid and unpaid work, especially at critical points of transition such as parenthood. Charles and Harris (2004) have argued that choices regarding work/life balance are different at different states of the lifecycle.

The individualization theory in its various versions, has been seen as having its merit in terms of indicating trends in post-modern societies, but has been criticized for lacking reliable methodologies and for lacking empirical and historical evidence. According to Thernborn (2004), individualisation theory should be seen as a geographically and historically limited exaggeration among the variety and long durees of socio-sexual systems. Individualisation theory is seen as largely resting on the evidence of qualitative work using purposive samples of particular social groups in particular contexts and localities. They do not often use representative samples or total population figures which can accurately portray overall social patterns. According to Sayer (1992) individualization theorists have used ‘intensive’ research design which are indeed in-depth and able to access social process more directly, and understand its context but points out that such work needs to be complemented by ‘extensive’ research on patterns and distributions, using representative survey for example. Duncan and Edwards (1999) share the same view that the use of both intensive and extensive research designs will enable generalizations to be made. In addition intensive work will enable better interpretation of the representative patterns revealed by extensive work and to link process to pattern directly rather than depending upon post-hoc deduction, (Duncan and Edwards 1999).

Critics of the individualisation theory have argued that the theory underplays the significance of the social and geographical patterning of values and behaviour and neglects the importance of local cultural and social contexts. According to Duncan and Irwin structures of economic necessity, social groups and moral codes have not gone away, although they may have changed. Family forms are still deeply influenced by local structural conditions or contexts and although people might be less constrained by older traditions, this does not necessarily mean individualisation. The ‘traditional’ structures of class, gender, religion and so on have a continuing importance, (Duncan and Irwin, 2004, 2005).

Individualisation theory assumes that individuals can exercise choice and shape their lives. However, the theory has been criticized for taking insufficient account of the context in which individuals make their choices. Critics of individualisation have pointed out, people’s capacity to make choices must depend in large measure on their environment, whether for example, on the constraints of poverty, social class and gender, or, more positively, on the safety net provided by the welfare state (Lasch, 1994; Lewis, 2001a). According to Lupton and Tulloch, (2002), people’s choices may depend in part on the consideration they give to the welfare of others, and on how far others influence the way in which they frame their choices. In addition, the context in which people are making their choices is constantly shifting. Thus the meaning of what it is to be married, or to be a parent has changed and continues to change. Charles and Harris (2004) have argued that choices regarding work/life balance are different at different states of the lifecycle.

Scholars have examined public attitudes towards marriage and cohabitation in order to assess whether the trends in statistics confirm the deinstitutionalisation of marriage (Cherlin, 1994), in which an increase in the acceptability of cohabitation can be interpreted as evidence for weakening of the social norms.

Using data from a number of British Social Attitude Surveys, Barlow et. al. found clear evidence of changing public attitudes. More and more people in the United Kingdom were accepting cohabitation both as a partnering and parenting structure, regardless of whether it is undertaken as a prelude or alternative to marriage. In 1994, 70 per cent agreed that ‘People who want children ought to get married’, but by 2000 almost half (54 per cent) thought that there was no need to get married in order to have children; cohabitation was good enough. They found increasingly liberal attitudes to pre-marital sex, with the proportion thinking that it was ‘not wrong at all’ increasing from 42 per cent in 1984 to 62 per cent in 2000. By 2000 more than two-thirds of respondents (67 per cent) agreed it was ‘all right for a couple to live together without intending to get married’, and 56 per cent thought it was ‘a good idea for a couple who intend to get married to live together first’.

Studies by Dyer (1999) and Barlow et al. (2005) found there was a clear difference in attitudes towards cohabitation from young and old generations, indicating a shift in social viewpoint to an acceptance of cohabitation. The younger age groups were more likely to find cohabitation acceptable than older age groups, but all age groups had moved some way towards greater acceptance of pre-marital sex and cohabitation. Barlow et al. argue that over time there is a strong likelihood that society will become more liberal still on these matters, although particular groups, such as the religious, are likely to remain more traditional than the rest. This change in public attitude is echoed by former Home Secretary, Jack Straw who was quoted in the Daily Mail as saying ‘the important thing is the quality of the relationship, not the institution itself’ (Daily Mail, 16th June, 1999). This acceptance in politics as well as in society is probably one reason why people drift into cohabitation. Barlow et a!. suggest Britain will ‘probably move towards a Scandinavian pattern, therefore, where long- term cohabitation is widely seen as quite normal, and where marriage is more of a lifestyle choice than an expected part of life’.

Barlow et al, however, do not interpret the public attitudes to indicate the breakdown or ‘end of marriage’ as a respected institution. In the 2000 survey, 59 per cent agreed that ‘marriage is still the best kind of relationship’. A mere 9 per cent agreed that ‘there is no point getting married – it is only a piece of paper’, while 73 per cent disagreed. Despite the increasing acceptance of cohabitation, Barlow et al. therefore argue that, ‘overall, marriage is still widely valued as an ideal, but that it is regarded with much more ambivalence when it comes to everyday partnering andA parenting’. While only 28 per cent agree that married couples make better parents, just 40 per cent disagree – figures virtually unchanged since 2000, (Barlow et al, 2005)

According to Barlow et al. (2005), there is a body ofA qualitative research that shows that for many cohabitants, living together is seen as a form of marriage rather than an alternative. Moreover, just as the majority think that sex outside marriage is wrong, the same applies to sex outside cohabitation: the large majority of cohabitants, over 80 per cent, think that sex outside a cohabiting relationship is wrong, (Erens et al., 2003). These findings give little support to the notion that many people cohabit outside marriage because cohabitation is more congruent with a project of the self, as individualisation theory would have it (Hall, 1996). Instead research seems to indicate that many traditional norms about relationships still hold true and cohabitation is seen as the equivalent of marriage. According to Barlow et al, (2008), cohabitation is socially accepted as equivalent to marriage and whilst marriage is seen as ideal, social attitudes show great tolerance to different styles of partnering and parenting relationships.

To consider the process and practice of admitting young people into residential care today it is important to have an awareness of the history of residential child care. The second half of the 19th century saw the introduction of Children’s homes by philanthropists such as Victorian Gentleman William Quarrier and the Reverend Jupp. Residential child care was provided in groups of small cottages usually in rural locations. Residential child care today still contains charitable/voluntary interventions. (RGU 2007)

Prior to 1983 there was no specific legislation that controlled the admission of young people into secure accommodation, an exception to this was if a young person was convicted of a serious offence through the criminal courts. In these circumstances the Secretary of State had the power to place the young person in a place of security. A hearing could name a specific school for a young person or child but it was left to the head of the establishment as to whether or not the placement was in a secure or open setting. This meant that the child could be moved between the units within the residential establishment without informing the hearing system. This raised concerns that the European Convention of Human Rights was being breached by Scotland. The three heads of the existing establishments and the Scottish office set out criteria for admission into secure accommodation. This resulted in new legislation being added to the health and social services and social adjudications Act (1993) which took effect from 1st February 1984. (Secure in the Knowledge, 2005, p7, p8)

Scandals that led to public enquiries involving the standards of residential care for children and young people have also contributed to the higher level of care now provided.

Grounds for referral: The reasons a child or young person is referred to the reporter and children’s hearing system vary, the child may have been abused physically or sexually or both. They may have been absent from school without reasonable cause, offended, been a victim of an offence or bullying, misused drugs or alcohol, be out with parental control, or any combination of these could be grounds for referral. (Children’s hearings 2011)

Referral: The foundation of the children’s hearing system has laid out the following guidelines for the children’s reporter and panel. When a Reporter receives a referral, they will undertake an initial investigation to decide what course of action, if any, is in the child or young person’s best interests. The Reporter has to consider whether there is enough evidence to support the grounds of the referral and then decide whether compulsory measures of supervision are required. The Reporter has statutory discretion when deciding the next step, they may

aˆ? decide that no further action is required. The child or young person and usually the parent or appropriate person will be informed of any decision in writing.

aˆ? refer the child or young person to the local authority so that advice, guidance and/or assistance can be given on an informal and voluntary basis. This usually involves support from a social worker.

aˆ? arrange a children’s hearing because they consider that compulsory measures of supervision are required for the child. A children’s hearing panel is made up of three members of the public who have had training in this area. It must be made up of both male and female members and aims to have a balance of age and experience. One of the panel members will chair the hearing. The hearing thinks about and makes decisions on the welfare of the child or young person, taking into account all of the relevant circumstances, including any risk taking and offending behaviours. (ibid)

According to Getting it Right for Every Child (GIRFEC) Consultation Pack on the Review of the Children’s Hearings System, the most common decision for disposal of a hearing is a supervision requirement. This means that the child will have contact with a social worker or other identified professional on a regular basis. The child or young person will have to meet certain criteria. This is as well as other people and professionals having to do specific tasks to work with the child or young person. A supervision requirement can have any condition attached if the hearing thinks it will help the child or young person. The local authority has to put the supervision requirement into action. Some examples of conditions attached to disposals are: seeing your appointed social worker regularly; attending a special programme to address their behaviours; being placed in foster care or in a residential school or in a secure unit because of particular concerns; victim-awareness and/or mediation. (GIRFEC)

Pre-admission: Requests for placements must normally be made by Practice Team Workers. Exceptions to this are out-of-hours Referrals from the Emergency Social Work Services or emergency Referrals through the Criminal Justice system from Court Social Workers. Once initial requests for placement are received and considered appropriate, and then the referring worker will be required to complete our Secure Referrals Application Form. This will then be considered by the next meeting of the Secure Referral Group. The main principles that guide this decision are: Secure Accommodation must only be used as the last resort and all secure placements must be for the shortest time possible. (Edinburgh Secure Services 2009)

It is always better if there is a transition plan put into place for a child or young person coming into care but this is not always available as the child or young person may have a secure warrant attached to them or they may have to be accommodated imideatly for their safety or the safety of others.

Admission:

The admission process is the same for all children and young people who are entering the care system. This is however a more relaxed process if the child or young person has a planned transition into care. A transition plan follows a basic four week plan. This is not set in stone but the principals are.

Week 1 induction, this is a chance for the keyworker to become familiar with the young person’s background and file, do risk assessments based on the available information and start to develop a transition plan.

Week 2 transition plan, this will include meeting the young person discussing the care plan and putting a transition plan with visits to the unit into place.

Week 3 introducing the young person to the open unit through meeting staff and other young people,

Week 4 building on Week 3, within the secure environment there would be preparation for endings.

The keyworker from the secure unit would also visit the young person in the open unit during the move and once they have moved to provide support for their transition. (ibid)

By following these guidelines the trauma of being admitted into care can be minimised although the child or young person will still suffer the feelings of loss and separation from their family, community and peers. Elizabeth, Kubler Ross describes the stages of separation and loss as D.A.B.D.A, Denial, Anger, Bargaining, Depression, and Acceptance. These stages of grief can also be applied to a young person going into care and will not necessarily follow any set order. (Kubler Ross, 1969)

Anthropologist Kalervo Oberg discussed four stages of culture shock which an individual can go through when entering a strange culture. These stages can also be related to a young person entering into care. The four stages of culture shock are described as, the honeymoon period, the crisis phase, the adjustment phase and adaptation. Young people coming into care often display behaviours that they would not normally use, this will include being really quiet, angry, violent, hostil and submissive before they accept the new milieu they find themselves in.

Staff in the unit can also assist in a less traumatic transition by assisting the young person to decorate their bedroom with posters and personal effects to make them feel more at home. Facilitating contact with parents or careers and ensuring the child is made to feel welcome in the unit by introducing them to the other residents and staff.

“Institutionalism is the syndrome which is now used to describe a set of poorly adapted behaviours that are induced by the pressures of living in any institutional setting”. (McNown, Miriam. Johnson Rhodes, Rita. 2007)

There is always a danger of becoming institutionalized when staying in care for extended periods, by trying to promote a sense of self and personal identity within the young people this is less likely to happen.

If a young person is to be secured under section 70 of the Children (Scotland) Act 1995 they have no involvement in the identification of a placement. The resources available may mean that the child is placed out with their geographical area. This is an institutional response which is in direct conflict with the rights of the child; thought also needs to be given to statutory requirements and the law. The national care standards for care describe what each individual child should expect from their time in care. The relevant section is “beginning your stay” standards 1-7. The standards are grouped under headings that follow the child or young person’s journey through the service. The significant ones in this case are “Beginning your stay” (standards 1 to 7)

1 Arriving for the first time

2 First meetings

3 Keeping in touch with people who are important to you

4 Support arrangements

5 Your environment

6 Feeling safe and secure

7 Management and staffing arrangement

By following these standards admission trauma can be minimized and the young person will be able to continue to have a sense of self and personal identity.

Forming new attachments is another area that a young person coming into care can find problematic, a securely attached child, according to, Mary Ainsworth, in the “Strange Situation” study, exhibit distress when separated from caregivers. Edinburgh children and Families department are now working towards an attachment promoting model of care. This will work in conjunction with anti-oppressive and anti-discriminatory practice.

“It is vitally important to us that young people are able to develop their identity within a positive environment. Therefore, we will not tolerate any unfair treatment or discrimination of young people which is based on their age, gender, culture, race, religious practices or beliefs, sexual orientation or indeed any other characteristic of the young person that they have a right to hold or express”. (Edinburgh Secure Services 2009)

In 1989, governments worldwide promised all children the same rights by adopting the UN Convention on the Rights of the Child. These rights are based on what a child needs to survive, grow, participate and fulfil their potential. They apply equally to every child, regardless of who they are, or where they are from. (GIRFEC)

Within the care setting it is vital that all children have access to a children’s rights officer to act as an advocate for the young people who are looked after by Children families Services.

The Care Commission was set up in April 2002 under the Regulation of Care (Scotland) Act 2001 Regulation of Care (Scotland) Act 2001 to regulate all adult, child and independent healthcare services in Scotland. From 1 April 2011 a new regulatory body, Social Care and Social Work Improvement Scotland (SCSWIS), is responsible for regulating social services. (National Care Standards)

Health visiting is governed by four principles which are the search for health needs, the stimulation of awareness for health needs, raise awareness of health needs and the influence on policy affecting health (). Performing a holistic Health needs assessment is a fundamental part of health visiting. The assessment process is one of the principles set out in the standards of proficiency for Specialist Community Public Health Nurses (Nursing and Midwifery Council, 2004). Wright (1998) explains assessment of health needs is not a process of relying on personal experience or listening to client’s, but is a systematic method of recognising health needs that are unmet and making changes by encouraging client’s to meet these unmet needs.

Using a model or a framework is a systematic method of collecting information allowing a clear identification of problems or needs that need to be addressed. Such framework would also go on to guide the planning and implementation of interventions required to meet the priorities for individuals and families.

The framework taken from system one, Child Individuals needs assessment was used to perform an assessment. System one is a computer system used in the authors practice area to record patient information. The Child individual needs assessment has been developed from the Framework for the Assessment of Children in Need and their Families (DoH, 2000). This assessment framework supported the shift in policy from one that focused on abuse and significant harm to an assessment that adopted a broader view of children’s needs and wellbeing and identified impairment in terms of developmental need (Cowley, 2008).

Consent has been gained to use the information. In accordance with the Nursing and Midwifery Council (NMC) The Code (2008), and to protect confidentiality the names mentioned will remain anonymous.

This case study focuses on a mother, Jody who is a single parent of three children. Due to the current demands on the Health Visiting team an antenatal contact visit had not been done. The Health Visiting team had been notified about the birth of baby Harrington and therefore this was a planned home birth visit at 14 days.

Health visitors have core contacts they make with families as part of the Health Child Programme () and one them is an antenatal contact. This contact allows health visitors to establish a relationship with families and identify their need. Cowley (2008) states visiting clients in their homes allow health professionals to identify a families area of need and then target services appropriately for their need. However research has demonstrated an antenatal contact is useful to in helping health professionals to identify the risk and resilience factors and create a therapeutic relationship with the client which is necessary for the delivery of future services (Puura et al, 2002, Robert et al, 2002). Recommendations made recently suggest any preventative strategies need to be initiated in the antenatal period (Cowley, 2008).

Coles et al () explains a starting point for assessing individual’s needs is to analyse whether the need is normative which is defined by professionals, felt need which is defined by the client, expressed need when a felt need become a demand and comparative needs when comparing to others around them and fall short of the established standard. Wills (2007) explains it is important to consider that needs will be thought of differently depending on who is being consulted.

The assessment covered Economic Wellbeing Observations which included residence and accommodation status as this can impact on a child. Jody living in a third floor council flat with three children, explained that she would like more space as the flat had two bedrooms with a living room she thought was not big enough. She explained the first bedroom was where she slept and would now have baby Harrington with her in the room. The second bedroom which was small, had a bunk bed and had no room to play in was shared by her eldest daughter Rosie, eleven years old and her younger daughter Ella four years old.

The early life environment of a child shapes their life course and in turn can have an effect on their health status over a course of time (Wills, 2007). Housing is an environment where children spend most of their time in the first few years of life therefore require adequate space to live and sleep in. Good quality homes are important for the health and well-being of adults as well as children (). A child’s development and wellbeing is shaped by factors such as family characteristics and the social, economic and physical environments in which they are raised. Poor housing environments and overcrowding can have significant impact on children’s physical and mental health as well as emotional and cognitive development (Marsh et al, 1999).

The House of Commons () explains overcrowding as having too many people in one room or a room that is not an adequate size. Living in an overcrowded house has found to be linked with ill health costing the NHS approximately 600 million a year (House of Parliament, 2011). Research suggests that poor housing and overcrowding can have a physical impact on a child’s healthy development leading to increased risk of asthma, respiratory distress, anxiety as well as lead to accident and injury. Adequate sleep, nutrition and exercise also contribute to a child’s healthy physical functioning. Jody revealed she had visited the GP several times in the course of three months complaining that Ella had recurrent chest infections, and taken baby Harrington to the GP the day before as she felt he was having difficulty breathing. Jody went on to say that the bedrooms were showing signs of damp and she had reported this to the housing company and was yet to come out review this. Jody saw the need for more housing space as an expressed need as she wanted more living space for herself and children to play in.

The housing report (2012) states the latest data found that the number of people living in overcrowded conditions continues to rise, as in 2009 – 2010 there were 630,000 in overcrowded housing which has risen to 655,000 in 2010 – 2011.

The assessment revealed Jody had no extended family support as her family live in the south of England therefore are far to offer consistent support. Jody had moved to the area over eight months ago following the breakdown of her relationship. The father had left the family due to drinking habits and since the family had struggled to make ends meet. Jody is in receipt of benefits and has not made many friends in the area.

Parents are an essential part of a child’s development and require support to enable them to provide the right environment. Jody appears to be socially isolated, Armstrong (2002) articulates social isolation can occur when there is a lack of family and peer support. With the lack of this support Jody had it indicated that she had a risk of developing postnatal depression which can have detrimental effects on baby Harrington and her elder two daughters (Bee and Boyd, 2009). Honey, Bennett and Morga (2002) suggest research indicates postnatal depression can hinder a mother’s ability to look after the child as well as affect the relationship between mother and child. This can cause problems in the child’s emotional and cognitive development. Jody revealed since she had come home from the hospital she had a few teary moments but now felt fine, and also said she had postnatal depression following the birth of Ella. The author planned another visit which would be in a fortnight. This visit would include an assessment of postnatal depression which is carried out at four to six weeks in the practice area. A tool called the ‘Edinburgh postnatal depression scale’ would be used, which is a ten question self report questionnaire designed by Cox, Holden and sagovsky (1987). (ADD STRENGTHS/ WEAKNESSES OF TOOL?) Meredith and Noller (2003) proposed maternal depression increases the risk of difficult attachment with the infant, developmental, social problems and may lead to suicide.

Baby Harrington being 14 days old was in the infancy stage of lifespan development. During infancy a baby will change physically more than any other stage of their life (Bee et al, 2009). Early childhood is consequently the most crucial and vulnerable period of brain development during lifespan. The start of Baby Harrington’s life will lay the foundations of good health and well being for later years. Therefore what happens during pregnancy and the early years of life lays the foundations for future development of cognitive, language, physical, emotional, behavioural and social. Language and cognitive development is important during the first six months to three years of life. Sheridan (2008) proposes stimulation, warmth and positive parenting from parents during the early years is vital for the infant to gain maximum growth in the brain. The brain is increasingly sensitive to the influences of the external environment during early childhood. A child in an environment with increased stimulation will mean a child will learn and develop more. A child in an environment with less stimulating, emotionally and physically supportive, development of the brain is affected leading to cognitive, social and behavioural delays. High levels of stress during early childhood increases the risk of learning problems and stress related disease in to the adult years of life.

The author found support to be a normative need for Jody, as a supported family environment is a fundamental component in raising a child. Jody’s perception was that she was coping with the current situation and did not need support from family or friends as she felt she would be judged by them for not being a good parent to her children.

Income was another factor identified through the assessment. The low income was a felt need for Jody as she said her parents were helping her financially. The author saw that having adequate income as a normative need in order to provide the children as well as Jody herself adequate healthy nutrition and a healthy future of well being. A newborn baby can increase expenditure on a family. This may cause Jody stress as it is an increase on feeding another child,

Health in the UK is strongly associated with income and is a key determinant of health (Naidoo,). Naidoo () explains having a low income can affect children and adults health directly; this can be due to not having enough to eat or enough to buy a healthy diet. Research suggests obesity in low income families to be linked (). Jody does not drive therefore finds it difficult at times to access the larger supermarkets and is reliant on her local grocery store which can have limited choice and be more expensive. Mostyn et al (2011) suggest if money is an issue parents will feed children food they know they will be likely to eat to avoid wastage. Obesity in children can lead to health problems later in life such as heart disease and diabetes ().

Living with a low income can also cause multiple stresses such as lead to parents worrying about their future well being of their children (). Children who live in families in poverty with a low income are also at an increased risk of lower academic achievement (). Jody revealed that she would start looking for employment in the area. Naidoo et al () states individuals who are unemployed are at a greater risk of ill health and mortality.

Neumans systems model is a theory based on the importance of an individual’s wellness in relation to stress and their reaction to these stressors. Neuman defines stressors as any condition or situation that cause an alteration in the individual’s normal state of wellness. The stressors are determined by variables affecting the client system; physiological condition, developmental status, sociocultural influences, cognitive skills and spirituality. The model proposes a continuum of wellness to illness, with the focus on the individual’s continuum being influenced by the interaction they may have with a variable and the stressors they encounter. Neuman identified environment that surrounds an individual at any given time can affect their well being.

Environment and the individual

Clients are influenced by environmental factors

The role of the health professional is to focus on the stressors and keep the stressors and the stress response from having a detrimental effect on the individual. This is done through three levels of prevention. Firstly primary prevention is protecting client wellness through prevention and reducing the possibility of an encounter with a stressor as a reaction to the stressor has not yet occurred. This is done by strengthening the individual’s line of defence. Secondary prevention is treating symptoms to stabilize the individual’s system by strengthening the internal line of resistance reducing the reaction to the stressor. Tertiary prevention focuses on educating an individual to prevent a reoccurrence of an stress response to the stressor through strengthening resistance to these stressors.

Jody’s environment was a stressor for her as it was affecting her and her children as they did not have enough space to live in and the children did not have space to play. According to neumans model this will affect jodys stability and

The absence of ill health and disease is not solely dependent on health. Robinson et al (1996) explains this as only one determinant of health. Health is the state of an individual’s optimal well being (WHO,). There are wider determinants of health. Factors such housing, having a safe physical environment, lifestyle, health beliefs, cultural norms, education, socio economic factors employment, emotional and mental state of an individual affects health ().

The author found the child assessment to be holistic. Assessing infant development holistically has never been so important (Cowley, 2008). Robinson (2010) purposes having this holistic approach of assessment allows an understanding of a child within the context of their family, community and culture in which they grow up in. Cowley et al () suggests that the framework should not be used as a checklist to assess needs. A needs assessment should include a client centred approach.

The framework used for the holistic assessment did not consider the cultural beliefs of an individual or have space were their beliefs could be recorded. There were no prompts of what information was required if an individual had low income or housing that was not adequate.

Apply neuman and weaknesses and strength of model! Marmot?

http://www.aifs.gov.au/institute/pubs/fm2011/fm88/fm88d.html

“Reflection is central to good social work practice, but only if enhanced action result from that reflection” (Williams, 2006: xi)

The underlying principles for this assignment are to critically evaluate my professional development in a practice placement setting and record reflections for future learning. Within this essay, I will include my reflections on the social work process of assessment, planning, intervention and review, and will critically analyse what I feel was successful and unsuccessful in each process, with efforts to identify what could be changed to enhance future practice. I will also include my knowledge, skills and values incorporated into my practice with two service users and my group work, while explaining my efforts to promote anti-oppressive practice. Throughout my assignment I will endeavour to portray my learning journey from the beginning to the end of my placement and conclude with future learning needs, to enhance my practice as a social worker.

Introduction:

The practice placement I acquired was a Court Children’s Officer (CCO), based at the Belfast Family Proceedings Court. It forms part of the Belfast Health and Social Care Trust. My role as a CCO, formerly known as a Child Welfare Officer, was to use my training and experience to ascertain the wishes and feelings of children and their families in private law matters. The role falls within family and child care services and determines that the child’s interests remain paramount in court proceedings. As a CCO my role was to deal with cases where assistance was needed to help parties focus on the needs of their children, as opposed to continuing the incriminations as to who was responsible for the breakdown of their relationship. As a CCO I was then asked to present the information to court in oral or written report format. The CCO is used if other efforts to get the parties to reach a decision in the interests of their children have failed. This is to prevent the court process itself contributing to a lengthy breach in contact before it reaches a decision. As a CCO I was also responsible to act as liaison officer between the court and HSS Trusts, or other agencies (e.g. NSPCC etc) in respect of the court’s decisions. Although employed by the Trust, I was responsible to the court.

Before commencement of this placement I had limited understanding of the court process, and the legislation involved in private law cases. I was excited about the prospect of the experience I would gain having undertaken law and court modules, and attended court for certain flexible learning days, but I was also anxious about identifying the social work role within such a specific placement. “I feel nervous and uncomfortable. I’m finding the role intimidating being surrounded by legal professionals and legislation (being just a student). I’m worried about having to provide oral and written evidence to the court, and perhaps having to disagree with the legal representatives views in court. I feel deskilled and anxious” (PPDW: 21/01/10). After this initial anxious stage I began researching private law and knowledge, and used my practice teacher and on site supervisor to ask questions.

Having completed a practice placement last year I already knew of the benefits of using reflection as a crucial aspect of my practice and learning. Thompson (2005) explains that it is important that practitioners use not only established theories, but use their own knowledge and experience to meet the needs of service users. He claims that “reflective practice should help us to acknowledge the important links between theory and practice and to appreciate the dangers of treating the two elements as if they were separate domains” (Thompson, 2005: 147).

I was anxious to identify the social work process within my placement, as it was not evident on commencement. I was already familiar with the process of assessing, planning, intervention and review having had a previous placement with adults with learning disabilities. Within a court, however, this was very different, as a direction of the court determined my involvement with service users. Schon (1987) identifies that more than ‘a process’ is needed with service users – practitioners need to incorporate experience, skills and intuition for outcomes to be successful. The knowledge and skills that I identified, within my Individual learning plan, were skills in working with children, assertiveness skills, report writing and presenting skills, organisational skills, and group facilitation skills. I also wanted to enhance my value base as my previous placement helped me challenge issues around learning disabilities and the current placement is a very different setting. I wanted to develop my values around children’s feelings about parental separation, and also working in partnership with children to ascertain their wishes and feelings about contact issues.

I have outlined below the three cases I intend to use that will help identify my professional development within my placement setting. I will use these to provide an analysis of how my knowledge, skills and values have been developed through the social work process.

Family C: Polish origin

Child C (Age 7) currently resides with her father. The parental relationship lasted for seven years. Mother (Ms C) moved out of the family home to gain alternative accommodation when the relationship broke down. Ms C and the child’s contact have been very sporadic since. Contact has not taken place since December 2009. Mr C is concerned with Ms C’s new accommodation being unsuitable for the child’s safety staying overnight – claiming alcohol misuse and the child coming home “smelling of smoke”. Ms C requires an interpreter and is seeking a Contact Order.

As directed by the court I carried out an assessment of Ms C’s home, and also used mediation and counselling when meeting with the parties to focus on the child’s best interests. The child’s wishes and feelings were also ascertained.

Family E:

Child E (14) currently resides with his father (Mr E). Mother (Ms E) is seeking a Residence Order. Father currently resides with the child in a family hostel provided by the Belfast Housing Executive, which Ms E is concerned about. Court direction stipulated me to ascertain the child’s wishes and feelings about residence with his father and contact with his mother. In addition to this I used mediation as an intervention to try to help the parties reach agreement about the child. I concluded my work with the family using a Person Centred Review with Child E to determine if the plans implemented earlier in my practice were working, and what he would like to change when his case was due for review in court.

Group Work:

My group work consisted of working with teenage girls at a high school in North Belfast; they were aged 14/15. I worked alongside the Health for Youth through Peer Education (HYPE) team who regularly visit schools to promote sexual health awareness. I co-facilitated this group and worked to educate the group about sexual health and relationships. This was to promote the need for the provision of accurate information to prevent teenage pregnancies and STI’s, which have been highlighted as statistically higher in this area of Northern Ireland.

Preparation of placement

As indicated above, to prepare for this placement, I began by developing my knowledge base around the court setting and private law, so that I could be accountable to the court and the Trust for my actions. Trevithick (2000:162) claims to be accountable denotes ‘professionalism’ – by using knowledge, skills and qualifications, and adhering to values and ethics when serving a client. I began to tune in to the placement setting using knowledge, skills and values, with legislation such as The Children (NI) Order 1995, The Family Law Act (NI) 2001 and The Human Rights Act 1998.

I tuned into the court setting and the rights of the service users who used it. Article 3 of the Children (NI) Order 1995 claims that the court should act in the best interests of the child, and I was interested in seeing if this occurred or if parental interests were considered higher. I tuned into the effects that divorce and separation have on children, and focused on gaining knowledge on how to minimize the negative impact this may have on children. The issue of contact in private law proceedings is a complex subject which raises questions of rights, responsibilities and ‘ownership’ of children (Kroll, 2000: 217). I was initially interested in researching if children knowing both parents were in their best interests, and why.

Having had a placement with adults and learning disabilities last year I had reflected on the medical model versus the social model of disability, this placement was very different in that it would be the a legal context versus the social work role. I found this initially difficult as the legal obligations of the court over-shadowed the social work process. Court directions dictated the aspects of work to be done, which I found difficult as service user needs were not necessarily established and met.

Assessment:

Ms C’s assessment required me to meet with her, discuss issues regarding contact with her child, and investigate her living environment to determine if it was suitable for the child to have contact in. Prior to Ms C’s assessment it was necessary for me to tune in to contact disputes between parents. I recognised that there is significant animosity with both parties, but that having contact with both parents is in the child’s best interests to promote for attachment, identity and positive relationships. To initiate Ms C’s assessment I had received court directions, a referral and met with her legal advisor. I was at this time I was informed that Ms C was Polish and required an interpreter. The Human Rights Act 1998 and the Race Relations Amendment Act 2000 both stipulate that an interpreter should be provided for health services to promote anti-discriminative practice and equal opportunities.

I was then required to make a referral to the Trust interpreting service, and they informed me that they would make initial contact with Ms C. I found this unnerving, as the interpreter would be making first contact with the service user, and I would have liked the opportunity to explain my role. Having carried out previous assessments, I knew that communication was essential for the assessment and central to the process of gathering information and empowering service users (Watson and West, 2006), therefore to not be able to make initial contact with a service user I found to be restrictive and stressful.

On initial contact with Ms C (and the interpreter) communication was difficult to establish. I found that by communicating through an interpreter I was limited in gathering information. I found it difficult to concentrate on Ms C, especially observing body language and tone of voice; instead I focused on the interpreter and actively listening to her. Ms C came across as frustrated and disengaged, showing signs of closed body language. I felt empathetic to Ms C because of the court process she was involved in, and the fact that she had to go to court to gain contact with her child. I felt the initial meeting with Ms C was not as successful as I had hoped, I was not able to discuss the issues affecting her, and unable to establish an effective working relationship due to the barrier on an interpreter. I left the meeting feeling deskilled and questioning my practice. On reflection, I should have provided more time to Ms C due to the language obstacle and gathered more information on her issues. I should have focused on Ms C and not the interpreter, and used the interpreter more effectively to establish a relationship. For future learning I will endeavour to use these reflections.

The next part of Ms C’s assessment was her home assessment. I was initially reluctant to carry out a home assessment, as I had no previous experience, and did not know what was classed as an “unsafe” environment for children. I began tuning in and identified that a home assessment required strong observational skills for child protection concerns. I also discussed the home assessment with my practice teacher and on site supervisor for aspects I should be concerned about within the home. It was indicated that a safe environment for a child did not have to be overly clean, just safe considering where the child sleeps, fire hazards, is there evidence of drug or alcohol use, or smelling of smoke (as Mr C alleges).

On entering Ms C’s home, as the interpreter had not arrived yet, I was reluctant to try and converse with Ms C. Ms C spoke limited English, and I did not want to confuse or alarm her by trying to discuss the case issues. However, I did try to use body language and facial expressions to reach for feelings and try to build a rapport by asking general questions about weather and work etc. I feel this helped our relationship, and helped me empathise about how difficult it must be to not be able to communicate effectively. By the time the interpreter had arrived I felt more at ease with Ms C, and addressed her (as opposed to the interpreter) with non-verbal cues such as nodding and body language. I felt more comfortable talking with Ms C, I felt more able to understand her frustrations at the court process, her ex-partner and his allegations.

Prior to the assessment of the home I had gained stereotypical perceptions about Ms C’s home. I thought that the house, as it was in a working class area, would be unclean and neglected. However, the assessment of the home, using observational skills, indicated no child protection concerns, a clean environment for a child, and Mr C’s allegations unfounded. On reflection of my perceptions I feel I was oppressive to Ms C having been so judgemental, and I felt guilty about my opinions having been class discriminatory.

Throughout the assessment with Ms C I found that by using an interpreter Ms C was able to stay informed and in control over her situation (Watson and West, 2006). I feel that by working with Ms C has helped my challenge my future practice with individuals who are non-English speakers. It will help me consider the needs of the service user, before judging them solely on language or their country of origin to provide equal opportunities. I now feel interpreters are required for a balance of power between the worker and service user, and promote anti-discriminatory practice.

Planning:

According to Parker and Bradley (2008: 72) Planning as part of the social work process is a method of continually reviewing and assessing the needs of all individual service users. It is based upon the assessment and identifies what needs to be done and what the outcome may be if it is completed.

Prior to the beginning of placement I had limited experience of planning, or group work. It was important for me understand the facilitation and communication skills needed for successful group work, and help to develop my understanding of group dynamics, group control, and peer pressure for this age group.

The key purpose of planning the group was to enable the young people to develop their knowledge and skills to be able to make informed decisions and choices about personal relationships and sexual health. I began preparing for the planning stage of the social work process by meeting with the HYPE team and researching their work. I was interested in the sexual health training for young people at school, as my own experience at school showed that the information was often limited, and I was interesting in finding out if it had been challenged.

I then began by tuning in to how I wanted to proceed through the planning process, and researching the topics of the different sessions as I considered I had limited knowledge on sexual health awareness. As I had to plan every week separately it was important to tune in to each and use knowledge, such as group work skills to inform my practice.

During initial sessions I noted how group members were quiet and withdrawn, this was important to note as the subject of sexual relationships may have been embarrassing for them to discuss. I too felt uncomfortable discussing the material, as I had limited understanding of sexual health, but it was important for the group to overcome these anxieties and work through them together. I identified that ‘ice breaking’ techniques were required to facilitate trust and partnership.

As the sessions progressed, one of the main challenges found was that peer influence was a major issue, with some of the participants controlling other quieter members. I felt it was necessary to include all members and encouraged participation using games. However, it was important not to push individuals when they became uncomfortable, as this could cause them to withdraw and disengage, disempowering them. Another challenge was that despite time management of the sessions, inevitably there had to be flexibility. Some of the group monopolised more time than others and it was necessary to be able to alter the plans according to time restraints.

I also needed to be aware of my own values when planning sexual health awareness training, as it is still regarded as a controversial issue, especially in Catholic schools with teenagers (www.famyouth.org.uk). I considered sexual health awareness to be a great benefit in schools, but obviously due to religious considerations many Catholic schools continue simply to teach abstinence as the only form of contraception. This was important to consider as the group was facilitated in a Catholic school and many of the members or their teachers could have had religious views and opinions on the sessions, creating tension or animosity. Reflecting on this parental consent had been provided for the group, but the group itself were required to take part during a free period. I consider this to be an ethical dilemma as the children’s views weren’t regarded as highly as their parents. If undertaking this group in future, I feel it would be necessary to ask the group if they wish to take part, and give the opportunity to withdraw – promoting anti-oppressive practice.

Intervention:

Prior to this practice placement I had limited experience using intervention methods. My previous placement focused on task centred work with service users, but in the court children’s service this could not be facilitated due to the time restrictions of the court. I had also previously used Rogerian person centred counselling which I found I could use some of the theory and apply it to this setting.

After gathering a range of information from the court referral, C1 and other professionals, I began to tune in to E’s case. I had been directed by the court to ascertain his wishes and feelings in regards to residence and contact arrangements, and mediate between his parents to find agreement about the child’s residence. As Child E is fourteen, I felt it was necessary to research levels of development for this age group and understand, according to psychologists, what level Child E would be at emotionally, physically and psychologically. I found that Child E should be at a level of becoming more independent, having his own values, and being able to make informed choices.

One of the most important issues, through mediation, was challenging my own values and becoming aware of my own stereotypical views on adults who have separated, and the effects on their children. I had to challenge the idea that Child E just wanted to reside with his father as he was the less disciplined parent, or that Child E would most likely be playing his parents off against each other to get his own way. However, by challenging these views, and working with the parties through mediation, I came to realise that E had strong views about living with his father and had a stronger attachment to him. By reflecting on my values I realised that it was oppressive to consider the child as manipulating and could have affected my work with him.

I found that having to be a neutral ‘third’ party in mediation was difficult, I found myself having a role as a witness, a referee and a peacekeeper trying to find common ground. Despite this I feel a ‘third side’ was necessary to help the parties work through issues. I found the most difficult aspect of this role to be impartiality as I found myself empathizing more with the mother (as the child refused to live with her). However, I also understood the child’s reasons behind his decision.

During mediation, and in court, I also challenged my judgements on gender and the notion that the mother is the ‘nurturer’ or ‘primary care giver’ in the home (Posada and Jacobs, 2001). The child clearly stated that he wanted to reside with his father, and when using questioning skills to probe about this, he claimed he had a stronger bond with his father, and that his mother was continually ridiculing him. I found myself having to alter my views about attachment and mother being the primary care giver and focus on what the child wants.

As the intervention progressed I used family mediation session to work through issues. I found that effective communication was principal in ascertaining Child E’s wishes and feelings, and helping the parties consider his views, as opposed to their own relationship incriminations. This not only empowered E by promoting partnership, but also gave him the knowledge that the court would be considering the information he provided. Within the meeting I felt I could have paced the meeting better and made better use of silences with E, as I dominated the conversation.

I consider mediation to be successful as it helped the parties focus on the needs of the child, and helped them realise that they had a child’s feelings to consider instead of the adversarial relationship built from court.

Review:

Prior to the review process I had experience of carrying out person centred reviews (PCR) through my previous practice placement. I had previous training on PCR’s and found them to be more effective than traditional reviews, due to the service user involvement. A PCR is an example of a person centred approach and the information from a review can be the foundation of a person centred plan (Bailey et al., 2009).

Within the family proceedings court the purpose of reviews are to reassess interim plans, and either change them, or confirm they are working for the child(ren). In Child E’s case a review was necessary to indicate if living with his father was working, and to discuss if he wanted to change anything about his interim plans, which were introduced three months earlier. Within the court children’s team a review is fundamental to consider what is in the child’s best interests, assess what is working and what is not working, and how to progress (considering the child’s wishes and feelings).

Child centred preparatory work with Child E was fundamental to the review success as it established what was important to him (Smull and Sanderson, 2005). Reflecting on my person centred work last year; I recognised that it was important to have preparatory work with Child E as it promoted choice and options to explore. I had also recognised that the information gathered from the preparatory work could be the foundations of the review itself, especially if Child E felt embarrassed or shy speaking out in front of his family on the day of the review (Smull and Sanderson, 2005)

I conducted the review with Child E and his parents present, but reflecting on this it could also have been useful including his school teacher or other friends to have a holistic approach. Throughout the review I feel I was able to engage the participants successfully using goals to focus on, and we were able to create a person centred plan for Child E. During the preparation for the review Child E had expressed that he felt he was having too much contact with his mother, and would like to limit this, he also expressed that this was an awkward subject to discuss with his mother present. I identified this in the review as child E did not wish to. I used skills such as facilitation and communication to show that Child E felt strongly about this issue, and both parents claimed they understood his view point. The review was also useful in presenting the information in court, as the child could not be present and I could advocate on his behalf.

On reflection of Child E’s review I feel it was a successful measure to determine what was working and not working since plans were implemented from the last court date. I had confidence in facilitating the review, but I did feel I perhaps dominated the conversation as both parents were hostile towards each other, and Child E was shy and unassertive about expressing his feelings. During future reviews I will endeavour to promote communication between parties, while empowering of the child. I will use better use of silences and encourage active involvement.

Conclusion:

“No matter how skilled, experienced or effective we are, there are, of course, always lessons to be learned, improvements to be made and benefits to be gained from reflecting on our practice” (Thompson, 2005: 146)

I feel this PLO has provided me with learning opportunities and identified my learning needs. It has encouraged me to reflect on my knowledge, skills and values and ensured that I used my reflections to learn from my practice.

At the beginning of placement I was concerned I would oppress the service users by having limited understanding of the court process, and unable to work effectively as a result. However, through training, help from my practice teacher and knowledge, I soon realised that the placement was about providing support, not being an expert. I feel I was able to establish a balance of the legal requirements of court and social work role, which has contributed to my learning experience and future knowledge.

As my placement progressed I used tuning in and evaluations to analyse my practice, and use them to learn from. My placement has enabled me to improve my court report writing skills, presentations skills and legislation knowledge, which I consider to be invaluable for the future.

In terms of future professional development, I will endeavour to challenge my stereotypical assumptions about service users, I will seek advice and guidance from more experienced members of staff, and I will use knowledge and theory to inform my practice prior to meeting service users.

Future learning requires me to continue to develop skills in working with children, to use silence as a skill, as listen actively to what the service user wants. Having an opportunity to work within the court system has been invaluable, but I would also like the opportunity to have more experience working with children to enhance my knowledge, skills and values further.

The Children Act 1989, States that it is the authorities duty to safeguard children and promote their welfare. This is to say that children from all backgrounds that are vulnerable to harm should be protected. Also their general way of life should be shielded from those who threaten to harm or impair it in anyway. To protect the children from such people or events, such as abduction, social workers (sometimes known as child protection officers) have been employed. Their primary goal is to focus on the safeguarding of children and for many years these workers have also provided additional support to families and family members that feel they are vulnerable. CAFCAS along with social work is another agency that is employed in the welfare of children dealing with courts to find solutions to families’ differences when parents separate. Their goal is to reunite parents with their children and also to provide the children with a better way of life. This is either by shielding them from an abusive parent or, by helping the single parent gain access to finances to help support the child.

Another feature of this legislation is to enable the courts to decide on what is best for the child, if that choice is more beneficial for the child in their current situation. This could in extreme cases involve the removal of the child from their parents and be placed into the care/foster care system; this is always the last resort. CAFCAS along with the clerks of the court help support the magistrates or judges in this matter as it is also their responsibility to help provide courts with relevant information as to the best suitable course of action to take. This would normally take place after a number of consultations, observations or a combination of both with the child’s parents. This responsibility could also be delegated by CAFCAS to other organizations such as Pro – Contact who act on behalf of CAFCAS and are obliged to follow strict codes of practice which revolve around all varieties of child protection legislations. This enables CAFCAS to pursue more pressing engagements involving children who are more vulnerable to harm rather than using those resources for a family dispute over something such as access to a child.

Finally, The Children Act 1989 also recommends that in the best interest of the child concerned the court should where applicable not delay in the hearing of a case surrounding the welfare of the child. It, furthermore, goes to suggest that any form of delay could have detrimental effects typical of a long and drawn out dispute. Although the court is responsible for the schedule of the hearing, it does, however, give the judge or magistrate if needed (and beneficial to the welfare of the child) the power to prolong any hearing it deems fit.

The above is an example of one county’s interpretation of The Children Act 1989. Within the UK the legislation itself is full policies for bettering the welfare of at risk children. It, in addition, gives clear guidelines for authorities and agencies to adhere that are involved in any such case of a susceptible child. It should also be made clear that the agency CAFCA workers, mentioned above, are formally trained in social work and/or probation services. (http://www.direct.gov.uk/en/CaringForSomeone/CaringForADisabledChild/DG_10027594,

The Adoption and Children Act 2002 was brought into effect in 2005. It was brought in to replace the Adoption Act 1976 and Children Act 1989 the new Act enabled people who we previously excluded from adopting a child through the likes of sexuality and smokers along with other such things which could pose a risk to a child’s health or wellbeing. The courts and other agencies (the likes of social workers for instance) deemed these examples to be improper and unhealthy for the child to be surrounded by, so a ‘no blanket ban’ clause within the legislation made adoption accessible to all. With this new no blanket policy also made way for another key feature which was to banish selection by area (also known as the postcode lottery) this meant that people from less affluent backgrounds were now eligible to adopt and not just the more wealthier people who would have been one of the main criteria for adoptions as this gave for a better living for a child who previously had nothing.

Another feature within this Act whereby a ‘special guardianship’ law was put into place allowed children to stay in contact with their birth parents, this feature of the legislation is conducted with social workers present and allows for close monitoring of relationships between parents and children, the outcome of these visits would be drawn up in a report and regular assessments would be carried out to check suitability of re-introducing the child back with their birth parents on a permanent basis. The assessments carried out on both the parents who may have had a history of drug or alcohol abuse and child who may have become troublesome because of this environment in which they were living in is essential to ensure that a suitable and caring environment can be sustained allowing the child to grow with the love and care in which every child should be accustomed to. Whilst the child is apart from their maternal parents the child would stay housed with either, foster carers or within care institutions. It is also the duty of the social worker to provide the foster parents with the support they need to ensure the child’s welfare and education is met and kept at a suitable standard.

Suitability of a child to perspective adoptive parents has long been an issue as some children, especially those forced to move, tend to rebel against the authorities’ decision to re-house them. They do this by showing disregard to the temporary carers and in extreme cases by running away from home or possibly stealing and involving the police. To some new foster parents some of these situations can be unbearable and require that the child is removed and re-housed elsewhere this, would be especially true if the foster parents have children of their own and see the bad influence this child may have upon their own children. If this was to be the case then it is the duty of the social worker to put a plan into action to rectify the issue, and also as previously mentioned if the police were to be involved it would be the social worker that would deal with these issues liaising with the police and the courts to find a resolution that would best serve the child. This ‘more information’ policy within the legislation attempts to put an end to these kinds of events from happening and it is considered to be one of the most important parts of the legislation as a suitable pairing of both adoptive parents and child can only best serve and aid the child in the future. (http://www.courtroomadvice.co.uk/adoption-children-act-2002-overview.html)

There have been on-going public and professional concerns about the issue of domestic violence in the world. This interest has resulted in a growing body of research evidence which examine the prevalence and correlates of this type of violence (Archer, 2002; Fagan & Browne, 1994; Johnson & Ferraro, 2000).

The most common form of violence against women is domestic violence, or the violence against women in families. Research consistently demonstrates that a woman is more likely to be injured, raped or killed by a current or former partner than by any other persons. Men may kick, bite, slap, punch or try to strangle their wives or partners; they may burn them or throw acid on their faces; they may beat or rape them, with either their body parts or sharp objects and they may use deadly weapons to stab or shoot them. At times, women are seriously injured, and in some cases they are killed or die, as a result of their injuries (United Nations Economic and Social Council, 1996).

The assaults are intended to injure women’s psychological health and bodies, which usually include humiliation and physical violence. Just like torture, the assaults are unpredictable and bear little relation to women’s own behaviour. Moreover, the assaults may continue for weeks, and even years. Some women may believe that they deserve the beatings because of some wrong actions on their parts, while others refrain from speaking about the abuse because they fear that their partner will further harm them in reprisal for revealing the “family secrets” or they may simply be ashamed of their situation (United Nations Economic and Social Council, Report of the Special Reporters on violence against women, E/CN.4/1996/53, February 1996).

Physical and sexual violence against women is an enormous problem throughout the world. The perpetrators are typically males close to women, such as their intimate partners and family members. Violence puts women at risk for both short- and long-term sequel which involves their physical, psychological, and social well-being. The prevalence of violence involving women is alarming and it constitutes a serious health problem. No woman is safe from domestic violence, no matter what country or culture she lives in. According to the latest UN report, one in three women is raped, beaten, or abused during her lifetime. The occasion of today’s world “Eliminate Violence against Women’s Day” focuses on Iran, where abuse largely goes unreported and – officially at least – unrecognized.

Some researchers have argued that violence is equally a problem for both sexes (Gelles, 1974; Straus, Gelles and Steinmetz, 1980; both cited in Dwyer, 1996). However, as Bograd (1988) points out, this argument ignores the disproportionate rate of male violence against women and that most documented female violence is committed in self-defence. Moreover, it also ignores the structural supports for male violence against women. There is abundant evidence which suggests that violence, against women by their husbands or partners, is a historical and current norm (i.e. Dobash and Dobash, 1988; Geller, 1992; Gordon, 1998).

Some of the criticisms of cognitive behavioural therapies are that they tend to ignore social and political factors which affect clients (Enns, 1997). People who are homeless, battered, or poor may not have the financial resources or social support to use some cognitive and behavioural methods. Cognitive-behaviour therapy views that behaviour is primarily determined by what that person thinks. Cognitive-behaviour therapy works on the premise that thoughts of low self-worth are incorrect and due to faulty learning. In addition, the aim of therapy is to get rid of the faulty concepts which influence negative thinking. Furthermore, cognitive behavioural therapies may not attend to client’s cultural assumptions about rationality which are rather implicit in such therapies.

To make cognitive and behavioural therapies more compatible with the feminist therapy, Worell and Remer (2003) suggested changing labels that stress the pathology of people, focusing on feeling, and integrating ideas about gender-role socialization, rather than using negative or pathological labels such as distortion, irrationality, or faulty thinking. Worell and Remer (2003) suggest that clients explore ideas, based on the gender-role generalizations which appear to be distorted or irrational. For example, rather than labelling the thought that “women’s place is in the home” as irrational, the therapist should explore the actual rewards and punishments for living out this stereotyped belief. By focusing on anger, particularly angry ones which arise as a result of gender-role limitations or discrimination, women can be helped to feel independent and gain control over their lives. Therefore, helping women with their social-role issues, gender-role and power analysis can be helpful in exploring ways of dealing with societal pressures which interfere with women’s development. This is supported by Wyche (2001) who believes that cognitive and behaviour therapies are particularly relevant for women of colour because they focus on the present, providing clients with methods to use in handling the current problems.

1.2 Statement of the Problem

Violence by intimate partners has been recognized throughout the world as a significant health problem. For instance, the World Health Organization (WHO) focuses on violence against women as a priority health issue. Violence by intimate partners refers to any behaviour within an intimate partnership which causes physical, psychological, or sexual harm to those in the relationship.

Violence against women is a manifestation of historically unequal power relations between men and women (Declaration on the Elimination of Violence Against Women, 1993). According to this Declaration fear is the biggest outcome of violence against women. Fear from violence is a big obstacle of women’s independence and results in women to continue seeking the men’s support, and in many instances this support results in the vulnerability and dependency of women, and is the main obstacle in the empowerment of women’s potentials, which can bring about the development of their capacities and to use their energy in the improvement of society.

Violence and abuse across the world are a common phenomenon and are not specific to a particular society, culture or mentality. Women in any given country and society are in one way or another subjected to violence in the private (home) environment or public (social) environment. In view of the irreversible consequences of violence for both the human, social and family structure of society, and for women themselves. This issue must become extra sensitive in the world. In fact, gender-based violence against women is the violation of their human rights and fundamental freedoms, the denial of their spiritual and physical integrity and an insult to their dignity. Violence against women is an obstacle of access to equal objectives, development and peace. The term “violence against women” is associated to any violent act that is gender-based that results in physical, mental and sexual hurt and suffering.

The main reason for the separation of men and women is mental abuse. Mental abuse is an abusive behaviour which hurts and damages the woman’s honour, dignity and self-confidence. This type of abuse results the loss of perception, loss of self-confidence, various types of depression, woman’s failure in managing the family, greed at the work environment, the reconstruction of violent behaviour in children, woman’s dysfunction in the family, turning to sedatives, alcohol, drugs, fortune-telling (Mehrangiz Kar 2000).

Violence against women in Iran takes place in a number of ways: 1 – Honour killing; 2 – Self-immolation; 3 – Domestic violence; 4 – Prostitution; 5 – Human trafficking, women and children in particular.

Violence reduces the self-confidence of women in the family. Women, who are abused, usually become depressed, secluded, and withdrawn people. Depression is also one of the most fundamental psychological problems in women who are in domestic violence. (Enayat, Halimeh,2006).

Standards for counselling practice was developed in response to reports from women who were dissatisfied with the counselling they received after experiencing domestic violence, and concerns raised by workers in women’s domestic violence services (Inner South Domestic Violence Service in Melbourne). According to the Welfare Organization of Iran (2006), the rate of mental illness among women victimized by domestic violence is significantly higher than among other women having hospital contact. It was noted that while an established network existed for domestic violence crisis and support services were designed specifically to meet the needs of women, counselling services tended to be generalized, with only a few practitioners specializing in the area. Furthermore, there has been no study to show counsellors which treatment for the mental health treatment of women who experienced domestic violence is better than the others (WBO, 2006).

Family laws in Iran, create inequality between men and women, and these laws do not have the capacity to protect women who live with violent men, and violence has turned into a power tool for men.

As the country progresses into an industrial nation, more academically qualified professionals are in great demand in Iran. Women who have experienced domestic violence are subjected to considerable amount of problems concerning mental health related to domestic violence. In a study by A. A. Noorbala, conducted at the Tehran University of Medical Sciences, the prevalence of mental disorders was shown to be 21.3% in the rural areas, and this was 20.9% in the urban areas.

According to an old Iranian saying, “Women should sacrifice themselves and tolerate.” This shows that many women, if not most women, are involved in domestic violence. It happens in private life and a legal complaint can destroy the life of a woman. In other words, parts of the population have the perception that abuse is done in order to keep with the traditions of the society and out of love. Women, who are victims of domestic violence, perceived that their husbands’ jealous reactions which turn into violence are a sign of their love and attention to them.

In a very traditional and religious setting in which many [in Iran] live, their understanding of religion and the interpretation given to them throughout the centuries is that a man can beat his wife. They believe that it is a religious command and the commentators, who have portrayed Islam in this light as a violent religion, have also contributed to the growth of this kind of culture. The police and judicial system are of little help. If a battered woman calls the police, it is unlikely that they will intervene. Ironically, the traditional attitude towards marital conflict in Iran inclines people to mediate between the couple. In many cases, the woman is usually sent back to her violent home. In the Iranian judicial system, there has been no law established to prevent domestic violence. On the contrary, there are many indicators which encourage violence against women in families in the Iranian Islamic penal code. Some authors estimate that the number of intimate relationships with violent husbands is about 20 to 30 percent (Stark & Flitcraft, 1988; Straus & Gelles, 1986). Broken bones, miscarriages, broken families, death, and some mental health disorders are some of the consequences of battering in intimate relationships. Each year, over one million women seek medical care due to battering (Nadelson & Sauzier, 1989). Victims also experience nightmares and somatic consequences, while children who witness abuse may be symptomatic, displaying a high number of somatic, psychological and behavioural problems (Nadelson & Sauzier, 1989). In addition to psychological scarring for victims, children, and batterers, there are broader societal repercussions of domestic violence. Williams-White (1989) state that “the structural, cultural, and social characteristics of our society continue to perpetuate the victimization of women at all levels.” In a way, violence within familial relationships reflects and helps maintain violence and oppression it widely in culture. Jennings (1987:195) explains this by stating that violent husbands not only contribute to maintaining the level of violence in society, they also reflect “a direct manifestation of socially learned sex-role behaviours.” Moreover, the prevalence of battering has crossed race, ethnicity, and socioeconomic status (Hotaling & Sugarman, 1986). Maltreatment of violence can lead to more violence (Walker, 1984). In systems which do not change, future generations may continue to resort to violence to solve problems. In addition, in many of those systems, violence may become more severe with time. For this reason, it is therefore necessary to work on treating the consequences of violence. However, to date, funding for mental health interventions is still limited, and it often only supports short-term treatment which will not adequately address the long-term symptoms.

In view of the special treatment for the mental health of women, counseling centres and support houses for women can reduce the mental health problem of abused women and also reduce the domestic violence statistics.

At the Welfare Organization’s Counselling Centres in Iran, women who are victimized by domestic violence are treated by social workers and counsellors utilizing the cognitive behaviour therapy. Based on the above discussion, this study also analyzed the comparison of the treatments given to women who have experienced domestic violence, using four different therapies, namely combination therapy (cognitive behaviour therapy and feminist therapy) with cognitive behaviour therapy, feminist therapy and social work skills.

Violence can shatter a woman’s life in many ways. Being a victim of violence is widely recognized as a cause for mental health problems, including post-traumatic stress disorder, depression, anxiety, and panic attacks. Being abused also plays a major role in developing or worsening substance abuse problems. For many women who are affected by violence, their first abuse usually occurred in their childhood or adolescence. Victimized women as children’s mothers frequently end up losing custody of their own children due to allegations of abuse or neglect, and over 50% of child abuse and neglect cases involve parental alcohol and drug abuse.

In addition to institutionalized violence against women in Iran, the majority of the women and young girls are facing domestic violence at home at the time when they are still living with their parents. In most cases, it is the father and the other elder male members in the family are among those who first commit the aggression against the women and young girls. According to the latest statistics, two out of every three Iranian women have experienced discrimination and domestic violence from the father or the other male members of their family. For the vast majority of the Iranian women, married life marks the beginning of horror, pain, and humiliation, i.e. being the victim of their husbands and sometimes the other family members. Moreover, eighty one out of 100 married women have experienced domestic violence in the first year of their marriage (Mehrangiz Kar 2000). Even women with outstanding jobs and prestigious social standings are subject to this violation. In most of the cases, this abuse leaves permanent physical and psychological damages for the rest of their lives. Ironically, without saying even a word and with much pain and yet no support, crimes against women have gone unnoticed. Ninety out of 100 women suffer from a severe case of depression, from which they ultimately commit suicide and 71% of those women experience nervous breakdowns. (Mehrangiz Kar 2000). Their methods of suicide include setting themselves ablaze. For them, this is the only way of escaping from segregation and humiliation. For instance in Ilam (a city in Iran), 15 girls set themselves ablaze each month, fighting against oppression or depression (Welfare Organization of Iran, 2005). Looking at how serious this problem has become, it is therefore the responsibility of everyone to fight the oppression against women. Female victims need to believe that they should not be blamed on whatever happens to them. An active participation in the Welfare Organization of Iran to defend the women’s rights and opposition to the Iranian Islamic fundamentalism is the least one can do to help end the pain and suffering of the victims of violence in both private and public spheres. Violence against women, in human and brutal punishments, such as stoning and complete elimination of the women from the political and social arenas represent some aspects of the modus operandi of fundamentalists leading to institutionalized violence. This also means that the struggle for equality, safety and security cannot be separated from the fight against fundamentalism in Iran.

This study made use of the theoretical framework, combining the cognitive-behaviour theory and feminist theory for the mental health of the women who have been victimized by domestic violence. The present study could provide knowledge on the different types of mental health treatments adopted by counsellors at various counselling centres throughout the country. This research also examined the quality of the treatment by combining two therapies (cognitive-behaviour therapy and feminist therapy).

Armed with this knowledge, the leaders of the Welfare Organizations, the society, families and counsellors can benefit from the consequences of change in the women’s mental health. The suggested theoretical framework would provide a better understanding of the women’s mental health and their performance in the society.

In summery, battered and abused women need a wide range of responses, flexible services, and supportive policies to enhance their safety and self-sufficiency and to restore their self-esteem and welfare. These might include mental and physical health evaluation and referral; relocation services; confidential advocacy, shelter, and other domestic violence support services; educational and vocational training; legal representation concerning divorce, custody and protective orders; evaluation of immigration status and ethnic or cultural issues; and the effective enforcement of criminal laws and court orders to help free them from their partners’ control and to keep them and their children safe.

We know that women who have suffered abuse are more likely to suffer posttraumatic stress disorder (PTSD), depression, and somatization than those who have never experienced abuse; the more extensive the abuse, the greater the risk of mental health disorder.

Women’s mental health treatment is an important area to consider for research because (1) girls and women as a group are exposed to more traumatic stressors than boys and men; (2) the mental health of women may be severely affected, resulting not only in immediate psychological symptoms, but also lifetime risk for self-destructive or suicidal behaviour, anxiety and panic attacks, eating disorders, substance abuse, somatization disorder, and sexual adjustment disorders; and (3) psychologists are not regularly trained to work specifically with trauma survivors, which can reduce the effectiveness of the treatment survivors receive.

Currently there are 22 crisis intervention centres (women’s crisis intervention centre) across the country (Iran), and women can stay in these centres between 6 to 8 months.

As violence causes psychological pressures and uncontrolled stresses on and ultimately depression in women generally, this study was intended to find a better and useful treatment in the attempt to improve the treatment for the mental health of the women who have become the victims of domestic violence. The present study would also provide further knowledge and understanding on the three different types of the treatments used, namely the Cognitive-behaviour therapy (CBT), Feminist therapy and the combination of the two treatments. The results of this study would therefore contribute the theoretical development and practice in counselling.

1.6 Operational Definition of Terms
1.6.1 Domestic violence

“Domestic violence is a pattern of coercive behaviour, which includes physical, sexual, economic, emotional and/or psychological abuse, exerted by an intimate partner over another with the goal of establishing and maintaining power and control.”

1.6.2 Mental health

a state of mind characterized by emotional well-being, relative freedom from anxiety and disabling symptoms, and a capacity to establish constructive relationships and cope with the ordinary demands and stresses of life. Mental Health is the balance between all aspects of life – social, physical, spiritual and emotional. It impacts on how we manage our surroundings and make choices in our lives – clearly it is an integral part of our overall health. In this study, mental health refers to the score which the client gets from the SCL-90-R test.

1.6.3 Cognitive behaviour Therapy (CBT)

A set of principles and procedures that assume that cognitive processes affect behaviour and conversely that behaviour affects cognitive processes. It emphasizes a here-and-now process without emphasizing causation. (D.Meichenbaum) .A treatment approach that helps clients examines and changes the relationship consequences, thoughts, feelings, behaviours and resultant consequences. It incorporates a number of diverse intervention (for example, cognitive restructuring procedures, problem solving, coping skills interventions, stress inoculation training, and self instructional training.

1.6.4 Feminist Therapy

A philosophical and practical approach with certain assumptions; for example, strategies are needed, and therapists must be aware of personal, gender-biased value system in relation to appropriate behaviour. Feminist therapists promote se4lf-awareness, self-affirmation, and personal integration, outcomes that may conflict with the societal norms that were the original source of dysfunctional behaviour patterns of women.

This essay will focus on how EBP and ‘practice wisdom’ should be combined and not seen as opposing opposites as together they have great value for social work practice. Also both should determine the practitioners decision making processes in practice because failing to do so could actually be oppressive to both service users and practitioners. Also this integration could facilitate and encourage the use of research amongst social work practitioners in day to day practice.

EBP in social work has been implemented at a slow pace and has not been greatly embraced and valued by practitioners (McNeill, 2006; Pignotti and Thyer, 2009; Mitchell 2011, Nevo and Nevo, 2011). Epstein (2011) highlights how practitioners have voiced that they resent EBP as it presents as a threat to their autonomy and creativity. This idea of EB knowledge solely determining practice could be perceived by practitioners as disempowering. An approach that devalues practice wisdom and professional judgement in favour of objective, manualised, and empirically supported interventions (Webb, 2001; Nevo and Nevo, 2011) can be seen to undermine professional autonomy as it places authority of science over the authority of the practitioner (Nevo and Nevo, 2011). Furthermore it can actually be seen to oppress practitioners as it seems to be ‘controlling’ their decision making process that may often conflict with their practice wisdom. An approach that alongside EB knowledge also embraced practice based knowledge may be of more use and value to practitioners and may be more likely to be used in practice as it detaches EBP from its solely scientific and thus its oppressive nature.

It is now increasingly being recognised in the EBP literature that social work values and practitioner wisdom need to be integrated with practice; however this integration is often unclear (Epstein, 2009; Mitchell, 2011; Nevo and Nevo, 2011). A shift towards evidence ‘informed’ practice (EIP) rather than evidence ‘based’ practice is now being recognised (Epstein, 2009; Haight, 2010; Nevo and Nevo, 2011). However practice is wisdom is still not acknowledged amongst some EIP advocates for example Haight (2010) but is greatly valued amongst others such as Nevo and Nevo (2011).

Stoesz (2010) argues that the social work profession is too subjective and reflexive and argues that only scientific evidence is acceptable and ethical as anything else could be depriving an individual of effective treatment (Stoesz, 2010; Gambrill, 2010). Randomised controlled trials (RCTs) are seen to provide ‘gold standard’ evidence for practice to be based on. Qualitative research and practice wisdom or clinical judgments are valued the least as are less scientific (Corby, 2006; Epstein, 2002; Dodd and Epstein, 2012). Epstein (2009) rejects the use of RCTs on ethical grounds as the methodology deprives the one group of intervention. RCTs may have value for research findings and in turn practice but its research methodology is unethical to some service users.

Ethics is of great importance within social work as it is of importance that social workers be ‘ethical professionals’ and work anti oppressively. And also be guided by research (Nevo and Nevo, 2011). BASW (2012) code of ethics states that evidence informed knowledge derived from research and practice evaluation is the basis of methodology in social work. However if practitioners are not using EB knowledge and are using only practice wisdom this could be depriving service users from an effective treatment and is not integrating evidence into practice. What would be of more value is to encourage and accept EB knowledge and practice wisdom so that not one or the other, but both are valued and used by practitioners so that research is being incorporated into and informing social work practice as BASW (2012) states. Also BASW (2012) states that knowledge should also come from ‘practice evaluation’ and mentions acknowledging context but does not mention practice wisdom. This evidence informed approach whereby acknowledging being specific to context but that does not mention practice wisdom is similar to EIP advocated by Haight (2010).

To ignore the existence of practice based wisdom and its perceived value by practitioners in influencing their decision making process will only further limit the potential of integrating EB research into practice.

McNeill (2006) highlights how practitioner’s decision making is not driven by research findings, even when provided with evidence of intervention effectiveness. Gambrill (2006) acknowledges how in social work practice a number of unsupported interventions are conventionally used and accepted in practice that are based on professional authority and clinical experience and not research evidence. Pignotti and Thyer (2009) concluded that just because social workers valued and used EBP interventions they also valued and used ‘Novel unsupported therapies’ (NUTs) in practice.

This could suggest that practice wisdom is valued in the decision making process and could be of priority even when provided with evidence of an interventions effectiveness (Gambrill, 2006; McNeill, 2006). It also could suggest that both EBP and practice wisdom are also co-existing in the decision making process in practice (Pignotti and Thyer, 2009). Pignotti and Thyer (2009) highlights how little is known about why social work practitioners choose NUTs. Similar Research could be of value in potentially identifying how Practice wisdom as well as EB knowledge together both are being used and are of value to practice.

Mitchell (2011) illustrates how the sole use of EBP had limited valuable application in real world practice. Mitchell (2011) found that when attempting to implement EB services for young people with complex needs, this was limited without the integration of practice wisdom. As most research focuses on a single disorder or problem it is difficult to implement such research when faced with complex factors that interact in complex ways in real world settings. Also it could be seen as unethical and oppressive to arrange and reduce human beings using solely scientific EB interventions. Corby (2006) states how human beings are too complex to assume a one size fits all approach. In such complex cases as encountered by Mitchell (2001) practice wisdom and EBP were integrated in order to make a decision based not only on evidence but of relevance to the case at hand. Fook (2012) describes how a reflective practitioner situates themselves and their knowledge in the specific context of a situation, looking at the situation as a whole and in relation to their own experiences. Although the term of practice wisdom is not used this seems to reflect some of the nature of practice wisdom and how it can be of use to each individual case. With exclusion of ‘their own experiences’ Fook (2012) also seems to reflect BASW (2012) concerning Evidence informed knowledge.

It seems to be now increasingly acknowledged that practitioners are not passive recipients or implementers of information, however in addition to this practice based wisdom should also be acknowledged as of value. The understanding of the processes of how EB knowledge and practice based knowledge are integrated into practice is of importance to the purpose of research in social work. The integration of research and practice may then be of perceived value to practitioners.

One of Mitchells (2011) main arguments was that the main barriers to implementation and value of EBP in real world practice is the oppositional construction that remains concerning EBP verses practice based wisdom.

Fook (2012) describes the notion of ‘dichotomous thinking’ whereby most phenomena are seen to fit into ‘binary’ and ‘oppositional’ categories, with one being devalued in relation to the other. This ‘dichotomous thinking’ appears to be occurring within social work research and practice in relation to EBP and practice wisdom.

Current research by Social Care Institute for Excellence, (SCIE), suggests that one person in six will become depressed at some point in their lives, and, at any one time, one in twenty adults will be experiencing depression. I will discuss the definition of depression and its interpretation along with the biomedical model, interpersonal, psychological and institutional perspectives. Then discuss the social, economic, environmental and political factors that contribute to the developing of depression and their relation to sociological and psychological theory with particular relevance to black and minority ethnic (BME) groups.

In England and Wales the Mental Health Act 1983 defines ‘mental disorder’ as: ‘mental illness, psychopathic disorder and any other disability of mind’. There is a dual role of legislation: providing for care while at the same time controlling people who are deemed to be experiencing mental disorder to the extent that they are at a risk to the public or themselves. World Health Organization WHO (2001), marks depression as when “Capacity for enjoyment, interest, and concentration is reduced, and marked tiredness after even minimum effort is common. Sleep is usually disturbed and appetite diminished. Self-esteem and self-confidence are almost always reduced and, even in the mild form, some ideas of guilt or worthlessness are often present.”

Mental health is a contested concept which can be viewed from different medical, psychological and social perspectives, which lead to diverse views on what mental health is. Depression is a mental illness and, can affect anyone at different points in their lives, from every background and occupation. Categorizing populations as experiencing depression, involves making judgments by the use of scales of mental health and these judgments determine cut-off points on a continuum of mental health or illness and are socially constructed. A rating scale commonly used to measure the mental health of populations is the Hospital Anxiety and Depression Scale (HADS). A study by Singleton et al., (2001) found that 76 per cent of the participants, who reported symptoms of mental distress, did not receive any treatment from a health professional for their problems. Sainsbury (2002) study refers to a culture of fear within the BME populace. Causation is affected by the practitioners who diagnose and treat depression and the public perception of depression however there are many perspectives.

Biomedical model focus on biological aspects of depression and look for symptoms that relate to diagnostic categories of mental disorder with a view that a sick body can be restored to health. Interpersonal perspectives on depression focus on individual people, experiencing mental distress, together with family and friends, psychologists and counselors also taking account of the views and experiences of service users and survivors. One such perspective is to see madness as a difference rather than an illness, like the social model of disability Oliver (2002). People’s actions can be open to different interpretations which are influenced by the perspectives of those making the interpretation. However there are commonsense perspectives of depression including personal experience with the people in closest contact, a relative or friend, may form opinions of the likely causes of the distress. Their opinions may include aspects of the person’s personality and recognize the impact of external stressors such as bereavement, debt or work demands. Overall they are more likely to emphasize the impact of social, rather than biological or psychological, factors.

Psychological perspectives on depression explores unconscious thinking, possible past traumas and focuses on helping service users to realize their potential and focus on social support and psychological interventions. This has created the development of psychotherapeutic treatments or ‘talking therapies’, such as cognitive behavioural therapies (CBT) has become the psychological treatment of choice in many NHS-funded services. Advantages of CBT include having some support, someone to talk to and developing coping strategies. Disadvantages of CBT include – The focus being on here and now, when the person might want to spend more time discussing past issues. CBT is a relatively effective way of helping someone deal with their distress that puts the client back in control of their life. Despite the evidence that has been collected to support the use of different psychological treatments, their effectiveness continues to be debated and funding is mainly offered in private practice or within institutions. (McLeod, 2000; Holmes, 2002) By contrast, the prescription route is a commonly referred to and accepted path with no self-criticism or self-awareness required.

Institutional perspectives or psychiatric perspectives on depression hold biological and genetic theories of causation for depression, and prescribe biological and physical treatments. Psychiatric perspectives emphasize the diagnosis of symptoms of depression in order to place people into categories of illness. The influence of GPs and psychiatrists is powerful in determining what is and what is not considered to be a mental health problem. Psychiatrists have powers to detain patients for treatment against their will. Psychiatry, through its association with medicine, tends to take precedence over psychological and social perspectives.

The bio-psychosocial model introduced by Engel (1980) acknowledges the interactions between the person’s biology, their psychological makeup and their social situation as important in understanding their mental distress. It encourages a more holistic approach to treatment. However, it has not provided the hoped-for basis of an accepted multidisciplinary approach. The Social support perspectives believes social factors and the person’s experiences cause depression and social support restores the mentally distressed person to wellbeing and social functioning. However it is also viewed as an addition to psychiatric treatment, where the service user is established on their medication, and social issues investigated.

Puttnam cited in Gross (2005) refers to social capital as a supportive social atmosphere and discusses bridging and bonding ties and the absence of these can lead to social isolation. Cockerham (2007) makes the connection where depression and illness are most likely among those with little or no social capital. There is also a tendency for the individual to, once diagnosed, to play the ‘sick role’, Rosenhan (1975) refers to the stickiness of labels and Goffman (1961) refers to looping and deviancy amplification that is associated with stigmatization and labeling of individuals. However our social standing is not the only element that contributes to our sense of well being. The environment that we live and are brought up in greatly influence our health Ross (2000) cited in Cockerham (2007) compares advantaged and disadvantaged neighborhoods finding that higher levels of depression occur in the latter with individuals suffering psychologically because of their environment although there were links to their individualism – female sex, younger age, ethnicity, low education, low income, unemployment, unmarried with the remainder from living in a poor neighbourhood. The daily stressors of living with crime, disorder and danger all link with symptoms of depression. Those living in clean and safe neighbourhoods showed low levels of depression. Distressing neighborhoods’ produce distress beyond that from individual disadvantage with poverty and single mother households the strongest predictor of depression. However the lack of choice and powerlessness of poverty make the emotional consequences of living in a bad neighbourhood worse.

Poverty can lead to poorer mental health where access to employment and welfare benefits, can be seen as health-promoting activities. For most nations, spending on mental health promotion is low Appleby, (2004), and the resources put into mental health promotion are minuscule compared with those used for treating ill health. Schulz et al. (2000) cited in Cockerham (2007) found high psychological distress highest amongst blacks and whites living in high poverty areas, slum living conditions. Wilson and Pickett (2006) cited in Cockerham (2007) stated that stress , poor social networks , low self esteem , depression , anxiety, insecurity and loss of a sense of control are reduced and social cohesion in enhanced – when income levels are more equal- however equalizing income is inherently political.

Sir Donald Acheson’s Independent Inquiry into Inequalities in Health Report (1998) recommendations will require policy changes to occur with reference to changes in building design, planning and access to health care treatments, although most research data on interventions tend to be tested on white, middle aged well educated men and women therefore the efficacy with black or mixed ethnic BME is not proven. The report also links depression and anxiety with obesity and inactivity and encourages physical exercise as obesity and inactivity is increasing in lower socio economic classes. The media and the NIMBY phenomenon exemplifies the exclusion that often accompanies a diagnosis of depression. This raises issues of complex ethical and political issues along with human and civil rights.

According to Blaxter (2004) health, disease and illness are social constructs; they are categories which have been named, and defined, by human beings. Bowers (1998) argues that diagnostic classification systems are culturally influenced, but involve: – careful, detailed observation, publication and peer review. Psychiatric diagnoses are based on social judgments of behaviour and experiences. These judgments can be socially and culturally influenced. For example, you will automatically ‘get well’ by travelling to a country where your beliefs are widely shared. This obviously does not happen with heart disease. Problems of subjectivity and unrecognized cultural assumptions may complicate the process of diagnosis. ‘Neither minds nor bodies develop illnesses. Only people do’ (Kendall 2001).

Recognition that both physical and mental factors are involved in mental distress could mean that a diagnosis of depression would be no more stigmatizing than having a heart condition.

Foucault cited in Giddens (2006) was a post-structuralist theorist who believed that people’s views on depression are the results of discourse that exists to define and subjugate people in society. He also, through the process of social archaeology, examines how the issues of mental health existed in the past and how they are a modern conception of normal and deviant activity , defining them as a construct built on power in society and how that power operates , this therefore links in to social constructionist theory. Social constructionism is the belief that our understanding of depression as a reality, overlooks the processes through which the reality is constructed. Our current sociological thinking is one of a historic white male centred Eurocentric model with women historically viewed as hormonal creatures and this gender difference is still prevalent to day in the way we use language with gender differences in the way society defines these roles.

Brown and Harris (1974) model of depression drew links with unhappy life events that can lead to depression when mixed with his four vulnerability factors which he identified as ; 3 or more children under 14, loss of mother before 11, lack of employment, lack of intimate & confiding relationships. He established that these factors plus an unhappy life event led to 83% women became depressed with working class women more likely to become depressed. Kasen et al (2010) have conducted a study supporting the effects of enduring earlier stress both in childhood , poor health status and a more rapid deterioration in health and the effects this has on major depressive disorder on women in old age and the need to develop resources to counteract stress exposures in younger generations of women. These factors need to be considered in the understanding not only from a feminist perspective but also from a black perspective as black women are multiply disadvantaged, hooks cited in Giddens (2005).

Immigration has played a major part in the creation of culturally diverse communities in UK society. The majority of the UK population in the National Census (2001) census was white (92 per cent). The remaining 7.9 per cent were from different minority ethnic groups. Karlsen et al. (2002) states that ethnic groups experience significant racism, unfair discrimination and social exclusion. This needs to be considered when understanding their mental health experiences. Social inequalities in education, employment and health disproportionately affect members of minority ethnic groups. This all leads to increased mental distress. Also black male’s lives are much harder as they have to live to a set of unconscious rules written in Westernised psychiatry which leads to their current diagnosis. People from minority ethnic groups find that mental health services are not sympathetic to their particular needs. A report from the Sainsbury Centre (2002) concluded, black people are disproportionately disadvantaged and their experiences of mental health services are characterised by fear and conflict. ‘Delivering Race Equality’ was launched in January 2005 and requires health authorities, and NHS trusts to ensure equality of services. The Department of Health has set ‘action goals’ for the mental health care of minority ethnic communities and service users; these include, reduction in fear and seclusion in mental health services.

Race is a contested concept with the difference between race, having its origins in 18th and 19th century colonial assumptions about the differences between white and non-white people. The concept of race is socially constructed and is now embedded in how we identify, understand and think about people. Ethnicity is an alternative concept to race that is more acceptable to groups in society . Ethnicity refers to a sense of identity that is based on shared cultural, religious and traditional factors. Ethnic identities are always changing and evolving. Approaches to cross cultural psychiatry according to Pilgrim (2005) are either orthodox or skeptical. Orthodox definitions of depression state that culture shapes the expression and prevalence of mental disorder. Cultural sensitivity enables GP’s to read symptoms and translate them into an orthodox, western diagnosis. A sceptical reading questions the validity of applying diagnostic labels from Western culture to other cultures. Cultural differences lead to people explaining and experiencing depression in different ways. Imposing western diagnostic categories leads to misinterpreting the person’s mental distress. It is important to be cautious in making cross-cultural comparisons in diagnosing with different illnesses being stigmatized in different cultures, and so expressed differently.

Beck cited in Giddens (2005) felt that depressed peoples thinking is dominated by a triad of negative schema of, ineptness, self-blame and negative evaluation although this doesn’t take into account any social factors that have impacted on the individual. Freud cited in Gross (2005) thought that people were victims of their feelings. That the psycho-analytical theory with fixation in psycho sexual stages and repressed desires feelings are what causes mental illness as the ego is unable to exert control over our feelings and this inability to express may cause anxiety and depression. He took this further with enforcing the belief of intra psychic loss, loss of sense of self, esteem, loss of job or the loss of a major sustaining relationship. Hayes (1998) links Bowlby’s functionalist perspective in his attachment theory being the loss of significant carer and lack of maternal attachment had far reaching effects. Skinner cited in Gross (2005), believed in radical behaviourism and that learning is conditioned and emphasized the role of environmental factors. Seligman (1974) takes a humanistic approach purporting that learned helplessness is a cognitive psychological explanation of depression, where there is learned helplessness and passivity, people become dependant and unable to make decisions for themselves.

Oakley (2005) remarks on the tendency for women to specialize in mental illness and that many more women in Westernized society are classified as having neurotic disorders and women dominate in psychosomatic disorders. A correlation exists in the study of mental illness being higher in men living alone and higher in married women however women are also suffers of post partum depression which is viewed by society through the biomedical viewpoint. Oakley (2005) places this within the self perception and ideals within a male patriarchal culture where women have been, historically, subject to social, economic and psychological discrimination, as have black people. However we are all damaged in some extent, this being a state of humanity; however, connectedness is not possible without the qualities of vulnerability, weakness, helplessness and dependency. A paradox exists in that all these qualities are seen as feminine, and are, not only negatively described, but are also associated with depression. This also links to learned helplessness as a psycho social explanation that women are gendered and stereotyped into this through socialization Weissman et al (1982). Calhoun et al (1974) established data that indicated a trend for females to hold themselves more responsible for unhappy moods than males.

There are a myriad ways of thinking, behaving and experiencing the world through a combination of care and control using medical, psychological, and social support with interventions done to reduce negative factors such as poverty , unemployment racism etc, and promote social inclusion. Research will play a large part as new factors are established as demonstrated in the recently publicized link between teenagers sleep patterns and depression Gangwisch et al. (2008)

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Assignment Question: The professional-client/service-user relationship is expected to be objective and detached (Storr, 1989). Discuss this statement and other potentially stereotypical assertions we affix to the ‘profession’.

Profession is a vocation or an occupation based on an educational training. It also requires a degree in that professional field. For example, teaching is considered to be a profession because it has both an educational training and a degree. The word profession comes from the Latin word ‘professio’ which means a public declaration with the force of a promise. This means that the profession first presents itself to society as a social benefit and then society accepts the profession, expecting and trusting it to serve some important social goal. In fact, The Australian Council of Professions defines a profession as; ‘a disciplined group of individuals who adhere to high ethical standards and uphold themselves to, and are accepted by, the public as possessing special knowledge and skills in a widely recognised, organised body of learning derived from education and training at a high level, and who are prepared to exercise this knowledge and these skills in the interest of others’.

The professional-client relationship, as Storr stated, is expected to be objective and detached. In fact, theories of the helping process that follows the medical paradigm have presented the ideal worker as an objective, clinical detached and knowledgeable professional. The relationship has to be objective and detached because a professional is someone whose efforts or actions are only intended to attain or accomplish a purpose or goal without any emotional involvement. For example, a doctor’s efforts are to cure the patient’s health without any personal feelings involved. In fact, if a worker expresses his real emotional feelings towards his clients, then he is considered to be unprofessional. The relationship between a professional and a client may be defined by boundaries. These boundaries make the relationship both professional and safe for the client. Paraphrasing Marilyn Peterson, from her book ‘At Personal Risk’, these boundaries are the limits that allow a safe connection between the professional and the client based on the client’s needs. The client’s needs should always come first. The workers’ personal values or biases should be prevented from their ethical decision-making. This is because, if their values enter their decision-making process, their personal views or needs would begin to govern or shape the therapeutic intervention. Therefore, in this situation the needs of the workers will be placed above the needs of their clients and the decisions will not be beneficial for the clients.

Boundary can refer to the line that separates the self of the client and the self of the professional. Professionals should not touch or hug their clients because if this happens, the professional-client relationship would begin to diminish. Regardless of who initiates the touch or hug, the client or professional may then perceive the relationship as one between friends whether intended or not. Professionals should avoid becoming friends with clients and should not socialize with them. The need for professional boundaries is rooted in the power imbalance that exists between the professional and the client. This power imbalance exists because the professional has skills, expertise and knowledge that the clients do not posses and they need. This means that the client depends on and trusts the professional to do only good and not cause harm. In other words the client believes and has faith that the workers, while in their professional role, will fulfill their ethical obligations of beneficence and non-malfeasance. Also, this power arises due to the client’s disclosure of personal information. However, despite all this, professionals are human beings working with other human beings. There are days when they are tired and stressed, and as a result, their ethical decision-making may not be good as it is when they are not stressed. They may cross boundaries inadvertently or their clients may innocently push the boundaries. Nevertheless, it is the professional responsibility to maintain or re-implement boundaries and they must take responsibility for their actions.

Stereotype is a belief or opinion that people in a society create on something or someone. Due to these stereotypes, many societies believe that in order to be a professional, one has to obtain an educational training and a degree in that professional field as already mentioned. Therefore, a professional is perceived as someone who goes to university, studies hard, obtains a degree and enjoys a comfortable salary. Such occupations that are considered to be professions to society are medicine, dentistry, law, engineering, architecture, social work, nursing, accountancy and teaching. However, there are occupations that are not considered to be professions but in my opinion they should be. For example, builders and plumbers are not considered as professionals because they do not have a high educational training like the others mentioned. However, in my opinion they should be considered as professions. This is because to be a builder or a plumber one should have a certain knowledge and skill in order to bulid an entire building or to install and repair pipes. Furthermore, both builders and plumbers are really necessary in society. Therefore, I think that they should be considered as professions even though they do not have a high educational training and a degree. In addition, those occupations that are considered to be professions are not really that professional in my opinion. Workers are considered to be professionals because they have the knowledge and skill to cure their patients, however there are other things that should be considered. For example, usually doctors are not friendly and sometimes, especially in hospitals they have the habit to talk with nurses about patients in medical words. This may make the patients feel uncomfortable because they know that they are talking about them and they may not understand these medical words. In my opinion this is not professional. I think professionals should first make their clients feel comfortable as possible.

Workers are required to choose between their personal and professional self during their work. Obviously, professionals have to choose the professional self in order to be professional. However, in my opinion by interacting the personal and the professional self together, one will develop a real skill. Professionals should help their clients in the most important and meaningful way they can. I think that there is nothing wrong if professionals show their feelings and express them to their clients. Professionals should respond in a personal way but at the same time carry out their professional function. In fact the interactional practice theory suggests that the helping person is effective only when able to synthesise real feelings with professional function. Without such a synthesis the worker appears as an unspontaneous, guarded professional who is unwilling to allow the clients access to the worker’s feelings. Clients do not need a perfect worker but they require someone who cares deeply about their success and improvement. Usually, the clients are more likely to see the worker as a real human person rather than a mechanical. If the worker shows no sign of humanity, the client will either constantly test to find flows in the facade or idealise the worker as the answer to all problems. The client who does not know at all times where the worker stands will have trouble trusting that worker. Another way in which sharing the worker’s feelings can be helpful in a relationship is when the effect is directly related to the content of the work as when the worker has had a life experience similar to that of the client. Self-disclosure of personal experiences and feelings when handled and interacted with the professional function can promote client growth.

The professional-client relationship raises many critical argumments. In fact there are also many films created purposely to criticse the boundaries of the relationship between professionals and clients. ‘Good Will Hunting’ is an example of one of these films. In this film what attracted me the most is the relationship between Will Hunter and the psychologist Sean Macguire. Although Will was unaware, blamed himself for his unhappy upbringing life and so he needed help from a psychologist to find direction in his life. In their relationship, Macguire was suppose to be objective and detached. However, this did not happen. Macguire, shared personal information about with Will about his wife and that he was too a victim of child abuse.