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Introduction

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

Methods of obtaining research

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

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

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

Method of obtaining papers for literature review

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

Definitions

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

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

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

Prevalence of Sexual Abuse

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

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

Vulnerability

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

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

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

Lobbying the Government and changes to policy

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

Behavior modification in the learning disabled adult; empowering the victim

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

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

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

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

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

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

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

Education of teachers, health care providers and caregivers

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

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

Community awareness

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

Advocacy

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

Recommendations for social work practice at local level

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

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

Conclusion

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

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

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

Methods of early Intervention

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Bibliography
Articles

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

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

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

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

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

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

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

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

Text Books

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

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

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

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

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

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

Statutes

Crime and Disorder Act 1998

Children Act 2004

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

Websites

www.communitycare.co.uk

www.publications.parliament.uk

www.Homeoffice.co.uk

Top of Form

1

Presenting Problem

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

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

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

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

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

Proposed Intervention

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

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

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

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

Evaluation

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

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

Keywords: drug abuse, adolescents, prevention and intervention

Introduction

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

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

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

Three Models for Drug Abuse Prevention

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

Information Model

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

Affective Model

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

Social Influence Model

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

Treatments for Drug Abuse

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

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

Prevention and intervention plan of adolescents’ drug abuse

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

Macro level

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

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

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

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

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

Mezzo level

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

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

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

Micro level

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

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

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

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

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

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

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

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

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

The following is a quote taken from Laming inquiry:

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

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

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

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

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

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

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

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

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

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

Critically evaluate the strengths and weaknesses of interprofessional working within social work
Introduction

During the last thirty years there has been a lot of debate over community care. Policy in the 1970s and 1980s brought significant changes to services for people with disabilities, people with learning disabilities, and older people (Kirk, 1998). Many institutions were closed due to financial constraints and care was increasingly focused on the community. In 1988 the Government commissioned the Griffiths Report (1988) which advised that local authorities should be ‘enablers’, organizing and directing community care. Local authorities would have budgets with which to purchase care from the private and voluntary sector.

The 1990 NHS and Community Care Act established that provision of care was no longer the sole responsibility of the state. Care packages would be organised by local authorities with input from voluntary and charitable organisations. Care packages generally consist of one or more of the following; provision of services in a person’s home, residential care, respite care, day care and family placements, sheltered housing and group homes and hostels. The introduction of the 1990 Act increased the burden of care for the social work profession who had to make initial assessments and then refer clients to the appropriate services. This meant that social workers who had previously been quite autonomous in their practice (Challis, 1991). The introduction of new working practices and the necessity for a greater degree of inter-professional working has meant that this autonomy has been increasingly eroded. This paper will examine the strengths and weaknesses of inter-professional working for social workers in the health arena.

Since the introduction of the 1990 Care in the Community Act legislative and policy requirements have focused on health and social care agencies working collaboratively with service users and in July 2005 the Government produced a white paper on the delivery of integrated health and social care.^[1] The main thrust of this paper is to establish effective inter-professional working and the means of evaluating working practice. This is probably in response to the fact that much of the literature concerned with inter-professional working concentrates on the difficulties surrounding successful working relationships between people of different professions and how these problems might best be resolved (Molyneux, 2001).

Molyneux’s (2001)^[2] research into successful inter-professional working established three areas that contributed to the success of such partnerships. Staff needed to be fully committed to what they were doing and personal qualities of adaptability, flexibility and a willingness to share with others were high on the agenda. Regular and positive communication between professionals was seen as endemic to good working relationships and service delivery. This communication was enhanced (in the study) by the instigation of weekly case conferences which allowed professionals to share knowledge and experiences (2001, p.3). Creative working methods, where professionals responded to what was happening in non-traditional ways was also seen as a crucial element of good inter-professional relationships.

In order to be able to work successfully across professional boundaries people need to be confident of their own professional role in order to be able to step outside their professional autonomy and work successfully with others. It helps in inter-professional working if all members of the team are particularly focused on the needs of the service user. In this way people reach ‘professional adulthood’ (Laidler, 1991). Hudson (2005) found in his Birmingham study that inter-professional working went well provided it was based on a parity of esteem, mutual respect and a re-orientation of professional affinity i.e. team members first loyalty was to the team rather than to their individual professional bodies. Hudson also identified communication between members and creativity in working patterns as vital to effective inter-professional working. While Hudson (2005) maintains that there are grounds for optimism as to the future of inter-professional working, he nevertheless points out that it is not always easy. In some areas such as acute services, mental health services or services for older people inter-professional working can be problematic because it is not always easy to decide where one set of professional responsibilities end and another begins. These areas, along with learning disabilities, reflect tensions in integrated working because it poses a threat to established practices. Peck and Norman (1999) found that mental health professionals working within teams were reluctant to obey decisions taken by others because it threatened their own professional judgement. It does not help matters when the Government stresses the need for inter-professional working and then sets separate performance targets, rather than integrated group ones. At the same time as it emphasises collaborative working the Government is now intent on prioritising choice and competition and this leaves professionals with an unstable infrastructure (Hudson, 2001). As Hudson argues:

It would be a cruel irony if, having achieved the holy grail of local integrated working, the government, with Sedgefield’s local MP at its head, now puts in place measures that result in its dismantling (Hudson 2005 no page number).^[3]

Conclusion

Clearly the issues surrounding inter-professional working are not clear cut for social workers. They have lost the professional autonomy that they had in the past and it would seem that some professionals in other areas of social care also find the issues problematic. Clearly professionals from all filed, including social work, do their best to comply with legislation and policy and to collaborate with other professionals. If the goalposts were not consistently shifting in Government discourse then the problems associated with inter-professional working may eventually be ironed out.

References

Griffiths Report (1988) Community Care; An Agenda for Action, London: HMSO

Hudson, B. “Grounds for Optimism” Community Care December 1^st 2005

Kirk, S. 1998 “Trends in community care and patient participation: Implications for the roles of informal carers and community nurses in the United Kingdom” Journal of Advanced Nursing Vol 28 August 1998 Issue 2 p.370

Laidler, P. 1991 “Adults and How to become one” Therapy Weekly 17 (35) p.4

Molyneux, J 2001 “Interprofessional team working: What makes teams work well?” Journal of Inter-professional Care 15 (1) 2001 p.1-7

Norman, I and Peck E. 1999 “Working together in adult community mental health services”: An inter-professional dialogue” Journal of Mental Health 8 (3) June 1999 pp. 217-230

http://www.dh.gov.uk/PublicationsAndStatistics/PressReleases/PressReleasesNotices/fs/en?CONTENT_ID=4116486&chk=zOTHS/

1

This report will discuss the past and present issues and government policies involved within multi-professional collaborative working as well as discussing how particular training could expand the knowledge of professionals with reference to the various roles of additional agencies. Furthermore it will discuss the various learning theories used to educate professionals in understanding the role of various agencies involved with each service user. In addition this report will discuss exercises that will be used in a training programme developed to deliver inter-professional education to a range of professionals.

Background

Collaborative practice was recognised internationally in 1978 following the Alma-ata declaration which recommended that the work of multidisciplinary teams as well as cost effectiveness and efficiency was of great importance (Allen and Maskarinec, 2008) in order to improve service delivery (Pollard, 2010). Following this, government policies in the UK since the 1980s have insisted that active partnership between the agencies involved within health and social care are imperative and individual reports have since focused on the serious effects that poor multiagency working can have on service users including the Laming report (2003) into the death of Victoria Climbie and the Laming report (2009) into the death of Baby P (Pollard, 2010).

The centre for the advancement of inter-professional education (CAIPE) describes that inter-professional education is imperative to professionals from various agencies in order to come together to understand each role that they will take and what service they can offer with a view to improve quality of care (Barr and Low, 2011).

In order to achieve effective collaboration between the professionals a set of values are instilled which include; the respect by and of each professional, equal opportunities and>>>. Yet Dean and Ballinger (2012) argue that in the case of students many find they lack the time to consolidate the skills of the other professions whilst trying to learn their chosen profession.

Government policies including the green paper Every Child Matters (ECM) 2003 and the children act 2004 include the expectations of the key agencies working together to promote the welfare of children.

Effective Collaboration

Effective collaboration is the coming together of a number of professionals that have a common trust and respect for one another. Together they share the same view in reaching a certain common goal or outcome and work together with a view to achieve that outcome (O’Daniel and Rosenstein, 2008). Rose (2007) argues that working towards a common goal can cause challenging issues between the different professionals such as differing ideologies, cultures and priorities. Rose later suggests that team reasoning theory may help multi-professional working become more effective as the theory proposes that professionals will look more at what is best for the group as opposed to what is best for themselves.

History of failings and barriers in Children’s services

One of the reasons in which children’s services have failed to protect children is due to the lack of information sharing between agencies. In many cases children who are under social services as well as their families are known to a number of agencies such as the police, education establishments and health services such as midwives and health visitors. It is the duty of each professional to share the relevant information with all professionals involved with regards to the child and the family. It is the duty of each professional to share the information in which they have gathered with regards to the child and the family in order to decide on a better outcome for the child. If in any case a professional withhelds the information and the child suffers as a result then that professional will be held accountable.

Services in the past have been criticised for their failure to protect children due to the lack of information sharing between the relevant professionals (Laming, 2003). Following the death of Victoria Climbie services were criticised for missed opportunities and the death of Victoria Climbie was viewed as a tragedy that could have been prevented. As a result of this Lord Laming produced a report into the inquiry of Victoria’s death which contained 108 recommendations and was to later run in accordance with the government green paper Every Child Matters (ECM) (Baker, 2009). Laming believed that it was the role of all involved agencies to protect the child as opposed to a singular agency (Laming, 2003).

The ECM included a framework which sets out key proposals in order to improve services in promoting the wellbeing of the child. Two of the key proposals included were “to develop integrated teams with professionals from all agencies based in and around schools and children’s centres,” as well as to “remove legal technical and cultural barriers to information-sharing and facilitate effective communication” (Hallett, 2004:168).

Following the Laming report and the green paper Every Child Matters the Children act 2004 was implemented which was to include an approach in the way the various agencies shared information to promote the safety and wellbeing of children. Section 11 of the act placed a duty on the significant agencies working with children to understand the necessity to safeguard children (Bokhari, 2012). Whitney (2007) however argues that there are still failings as the duties that are placed on schools are not the same duties that are placed on the other agencies.

The Laming report (2003), ECM (2003) and the Children act 2004 however did not manage to prevent further deaths and again professionals were criticised in their shortcomings when in 2009 Britain was once again left in shock after the tragic death of Peter Connelly (Baby P). Professionals including social workers, doctors, lawyers and police were criticised by BBC news education reporter Katherine Sellgren as incompetent (2010). Sellgren argues in the online news report,

“Baby Peter’s “horrifying death” was down to the incompetence of almost every member of staff who came into contact with him, official reports say.”

The death of Baby P resulted in yet another enquiry into child welfare services in 2009 by Lord Laming. Laming slated social services in the enquiry claiming that “inadequate training” and “poor supervision” were included in the reasons for the failings within the case of Baby P (The Telegraph, 2009).

The reforms made as a result of the death of Victoria Climbie failed to be implemented by social services and the Laming report into the death of Baby P reported that these failings were due to such areas as “impossible targets” (Knapton, 2009) and increased bureaucracy (White et al, 2008).

Inter-professional Education

CAIPE gives the definition of Inter-professional education as,

“Inter-professional Education occurs when two or more professions learn with, from and about each other to improve collaboration and the quality of care.” (CAIPE, 2002 as cited in Gopee, 2011:128)

Howkins (2008) argues that continual collaborative practice between health and social care has taken over 30 years and it is as a result of inter-professional education that has amplified and sustained such practice. In order to adapt to inter-professional education it is important to take into account planning as well as time and apposite teaching. Howkins argues the timing of when inter-professional learning should be included in one’s profession and questions the possibilities,

“Is it better to start in the pre-qualifying period with the hope of avoiding the development of negative stereotypes or wait until after the qualification when the professional should feel more confident in their role?” (p1)

The issue with regards to timing has brought about much debate and conversation suggests Howkins. It is also later suggested by Howkins that although there are government policies in place motivating inter-professional education there is little in the way of indication that service user outcomes have improved.

Learning Theories

In order to deliver an effective training plan it is important to include learning theories. Such theories need to relate to adults as they learn differently from children as suggested by Knowles who introduced the adult learning theory, andragogy and argued that as well as adults bringing work and learning skills adults also want to know the purpose of why they need to know something as opposed to children who are presumed to learn what they are being told (Stover, 2006)

Conclusion and Training Plan

This report has discussed the background of inter-professional learning as well as look upon the past failings that have taken place with regards to children as the result of poor collaboration between professionals. An explanation of Inter-professional learning has been deliberated and learning theories have been discussed in order to determine the best approach in order to train professionals to deliver an effective approach to inter-professional learning with a view to achieve the most effective collaboration when working within children and families. Furthermore a plan will be put into place in order to carry out a training session for the relevant professionals with a view to implement the knowledge and importance that interprofessional learning has on children’s services and how effective collaboration between the various agencies can lead to an improved outcome for children

Team Building

Mutual respect and non-hierarchal relationships are the foundations of successful collaborative working. (Kenny, 2002 as cited in Wilson and James, 2007:315)

Inter-professional Education (IPE) occurs when “two or more professions learn together with the object of cultivating collaborative practice” (CAIPE 2002). The benefits, as purported by (Barr 2002) are to have mutual understanding and respect, broadminded attitudes and perceptions and minimised stereotypical thinking. This thinking is informed by the legislative policy requirements of health and social care agencies to work closely and collaboratively together with service user along with professional guidelines (DH 2006, GSCC 2008, and QAA 2008). Communicating with other health and social care professionals, understanding contrasting perspectives, being involved in the seminars, groupwork trigger exercises, and IPE literature has enhanced my learning at the conference and has informed my practice for the future.

The module began with introductions and the team members each described their professional roles. (Dombeck 1997) refers to the importance of knowing your own professional identity and that of others before you are able to be able to form useful IP relationships. As students there was an initial understanding of each of our own professional roles and this was enhanced by discussion. Through this social process of learning we were able to correct each others bias and assumptions. The multidisciplinary group was not universal in its wish to achieve as much from the course as possible; this became understandable later, when it was clarified that the course did not form part of the medical degree qualification. A sense of inequality developed, which led the group to question the value placed on IPE within the medical profession. (Stapleton 1998) refers to open and honest and equal participation being conducive to collaborative relationships between professions. Despite this perceived inequality the group functioned well together. Open and honest discussions ensued although any interactions were superficial given the duration of the conference. Contact was sparse following the conference and there was little use of the IT systems placed on blackboard to assist or cement further learning.

Professor Means (2010) presentation resonated with me, as he spoke of championing one’s own values and ethics, whilst seeing different perspectives and challenging boundaries of roles. He viewed this to be achievable with positive interactions and collaborations and engendering mutual trust and support. This led me to reflect on the nature of this discussion and contribute to the completion of one of our sentences. “Challenging professional boundaries creatively, whilst advocating ones own professions values and ethics.” Pecukonis et al (2008) state that ethics relate to the pursuit of human betterment but these can be viewed and interpreted by different professions and refers to the term profession-centrism.This was underpinned by discussion within the group of the crossover in roles occurring within health and social care for example occupational therapist carrying out some of the duties of nurses and vice versa, whilst also being the ‘eyes and ears’ for social workers. This caused me to consider that social work is done by many professionals and its boundaries are not clear. This, whilst confusing, can lead to more professional fulfilment within roles and lead to a stronger skill mix which, with the service user at the centre, will lead to a better service and resource savings. Social, political and economic elements would welcome this cross over of skills however there is a possibility of a devaluing the value of each profession. (Barr 2004) supports this view and discusses the new flexible worker giving patients a holistic approach but also advocates respect for specialism’s within teams.

The upgrading of responsibility and specialisation of medical tasks to nurses previously in the Doctors domain was discussed and there was a consensus within the group that this was a positive experience as it valued knowledge and not hierarchical structures of power. (Baker et al 2006) discusses the modernisation of healthcare and the move towards a team based model of healthcare delivery. Power has traditionally been sanctioned through authority and has in general been located within the medical profession (Colyer 2004) advises that the last fifteen years have seen a sea change in the medical professions organisation, structure and agency and this has improved the quality of intervention to service users.

The seminar on Intermediate Care by Williams and Drake (2010) increased my knowledge of how the multidisciplinary teams within the Community Health Team and Bristol City Council work together to provide holistic, flexible and client centred services with a single point of access. This occurs despite different IT, communication and reward systems and the challenges for the future viewed as aligning the organisational aims and objectives, recording systems, and professional views to transform consistency, capacity and efficiency. This enabled me to understand the daily pressures of working between organisations and the further challenges that present themselves with the current political and financial changes currently affecting the NHS and how the stereotyping of roles and their responsibilities are changing as are service user involvement.

The terms service user, patient and client were debated by the group and the subtle ways that language inform the discourse. Service user as a term was decided upon as it was the least discriminatory although consensus was not possible and the problematic nature of labels was explored both for service users and carers (Thomas 2010 p.172-3). The National Occupational Standards of Social Work (2006) set out the values and ethics of service users and carers and the importance of inclusion. The carer in the “patients voices” video who expressed her lack of recognition of being an ‘expert by experience’ demonstrated the gaps that as (Payne 2000) defines as the difference between professionals in collaborative working detracting from the empowerment and involvement of people who use services. Service users and carers should have a place in the decision making process.

I was able to appreciate the seminar provide by Adams (2010) which challenged my perception of being different but being compatible with others. Analogies were used of ‘chalk and cheese’ and ‘peas in a pod’; the same components but different .This challenged my own conscious and unconscious views of my own profession and that of others, and the stereotypes that I hold and internalise. In order to combat these feelings I felt a need to have a clear sense of my own identity, confidence, role boundaries, values and ethics and practice and knowledge standards. I questioned my own perceived identity and that of my profession and recognised my own attempts to try to overcome perceived stereotypes and how issues of power and oppression require consideration before action, (Dalrymple and Burke 2006). A discussion ensued regarding conflicts of interest between professionals and I was able to make the links between theory and practice. (White and Featherstone 2005 p.210) explores the idea of story telling about different professions or professional groups and how ‘atrocity’ stories allows one profession to scapegoat another but how stories can also ‘strengthen and confirm identity’, by questioning other professions and thereby strengthening one’s own. (Barnes et al., 2000) state that by developing ones own knowledge base and ‘othering’ of different professions whether rooted in the medical or social models allows different perspectives to be heard and recognised. (Lukes 1974) discusses these views of power and the subtle way that power is exercised and how people can remain powerless and this how service users are viewed within IP practice.

The Childrens Act 1989 and Every Child Matters 2006 are all resulting from the failures within public services to protect children. In reality IPW continues to fail. The Bristol Royal Infirmary (2001) Victoria Climbie Inquiry Lord Laming(2003) and more recent news on the serious case review of Baby P (2009) and the ongoing Mid Staffordshire NHS Trust Inquiry (2010) have highlighted serious breakdowns in multi-agency working and communication. The subsequent media reports have shown increased public mistrust and increased accountability for professionals Davies et al (1999) states that trust is an asset and that its reduction may hamper institutions ability to function.

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Section 2

Discuss how you would take what you have learnt about IP working into practice?

Effective IP working (IPW) involves performing within practice situations of cohesion and disparity. Working collaboratively with other social and health care professionals has experientially helped me to reaffirm and develop my practice. I have gained experience in communicating effectively, understanding teamwork, exploring stereotypes and professional identity and how social, economic and political factors will affect my future practice.

As a social work (SW) student working within an education and child protection setting, I understand the need to ensure a holistic and safe care provision in order to protect vulnerable children and adults. The Victoria Climbie Inquiry (Laming, 2003) pointed to the failure of various professions in their ability to work together in a competent and unified way. The Laming report led to the change in social workers National Occupational Standards and focussed on the need to develop clear documented communication, sharing all aspects with all relevant professionals to avoid any ambiguity and uncertainty within teams. (Laming, 2009. p. 61) emphasises that: ‘there is a clear need for a determined focus on improvement of practice in child protection across all the agencies . . .’ I will describe a child protection team meeting and its wider lessons for my practice.

Whilst on placement I met a young girl, who’s younger brother was subject to a child protection investigation. Her mother had limited English and her father was the alleged abuser. The investigation involved a child protection meeting involving a plethora of health and social care professions to jointly assess the risk to both children. The meeting was effectively chaired by a social worker and all were invited to contribute their specific knowledge and evidence on the family, opinion was sought on actions and timeframes.(Molyneux 2001) debates the issue of good teamwork as being dependant on the qualities of the staff and the need for there to be no one dominant force. By communication being inclusive, creative and regular, issues can be debated and resolved. Concluding that teams were successful when members were confident, motivated and flexible and communication channels were clear, frequent and in the same base. (Petrie 1976) discusses a cognitive map where two opposing disciplinarians can look at the same thing but not see the same thing. My experience of working within this multi-disciplinary team was positive with all professionals having a voice. However on reflection and through IPW I am now more aware of the perspectives of others and the need to define and develop my professional identity. (Bell & Allain 2010 p.10) in their pedagogic study allude to SW students being reverential to medical expertise and giving low ratings on their own abilities of leadership. I feel a dichotomy exists between SW railing against the medical model and promoting the social model whilst deferring to the stereotypes of professionalism within health and social care. For the future I need to be aware of stereotypes and continue to develop my critical reflection of both my personal and professional self whilst developing my abilities to be heard within multiprofessional teams.

As a SW student, I am aware that there exists a blurring of edges of what the SW role entails and how the identity of the role may change in the future. (Payne2006) refers to a social worker working within a mental health practitioners’ team which included working alongside nurses and psychologists including high levels of therapy based work, which would not usually sit within social work practice and therefore one’s professional identity could be lost. (Lymbury & Butler 2004) state that whilst it is important to share knowledge with other professionals that are allied to social work it is imperative that the identity of one’s own profession is preserved. (Laidler 1991) further addresses the issues of crossing professional boundaries describing them as ‘professional adulthood’. That IP jealousy and conflicts will arise to the detriment of the team members and more importantly to the service user. Power as exercised may cause some to struggle as power is shared and fluctuates in accordance with whose knowledge and expertise best suits the service user. Envy as discussed by (Schein 2004) identifies ways in which it can stand in the way of good IP learning by creating a collective unconscious resulting in; an attack on colleagues, an attack on learning and failing to learn from each other and or authority figures, and issues of who takes responsibility. Within the Child Protection meeting the chair was a senior SW who co-ordinated the professionals and this caused me to reflect on my abilities, as SWs must deliver safe high quality care but given limited resources , different professional groups will have different priorities and see issues differently. Sellman (2010) concludes that you need to be willing , have trust in others and have effective leadership either acting with your inclinations or action that affords the best outcome however, personal , professional and structural influences can encourage or discourage practitioners. I recognised that for the future I needed to increase my ability to create a dialogue across difference whilst holding on to the dignity and responsibility of every person. (Skaerbaek 2010) purports that by listening to the minority one is able to see the practices that underlie the agenda of the majority.

However the future blurring of health and welfare provision is changing across all sectors. The role of the private sector in the provision of health and welfare practice can provide competitive market forces to drive up the standards and offer greater choice to individuals through direct payments. This in turn can create greater service user autonomy and much more creative solutions. However this can also lead to inequality and a perception that the services are driven by profit bringing the ethical motivation of private sector into question and a blurring of the duties of the state to the service user. (Field and Peck 2003) conclude that the culture of the private and public sector will need to merge and this will result in challenges within roles and organisations. The voluntary sector is one of the fastest growing with voluntary organisations, who, when commissioned, are more accessible to service users and people are more likely to engage with them. They have more freedom acting as advocates and campaigners and are less regulated through targets (Pollard et al 2010). However given the current economic climate and the recently announced budget cuts (Rickets 2010) suggests that the pressure on the voluntary sector to provide more services will continue and if the state retreats from providing services, the voluntary and community sector will fill the gap. Personalisation in which services are tailored to the needs and preferences of citizens is the overall government vision: that the state should empower citizens to shape their own lives and the services they receive. Liberating the NHS 2010 (p3 & 4) states that “We will put patients at the heart of the NHS, through an information revolution and greater choice and control: a. Shared decision making will become the norm: no decision about me without me” and “The Government will devolve power and responsibility for commissioning services to the healthcare professionals closest to patients: GP’s and their practice teams working in consortia.”(Foreman 2008) sees the need to involve IT in helping to improve and reduce the barriers to IPW. The structures of IPW will continue to evolve and change with complexity and ideological thinking however I need to engage with other professionals and service users in a person centred way.

In conclusion, the IPW conference, literature and subsequent research have clarified my future need to be flexible in both my role and that of others and the primacy of the service user at the centre of my practice. Teams and service users are diverse, comprised of people of different ages, from different social and cultural backgrounds with different expectations. (Carnwell et al 2005 p.56) relates collaboration to embracing diversity and moving away from the comfortable assumption that there is only one way to see the world , providing strategies : learn from each other, embrace IP working, and adopt a value position where anti discriminatory practice is central. By critically reflecting on practice I must embrace a degree of uncertainty and unpredictability as a necessary part of the complex micro and macro systems of IPW.

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SECTION 3 – REFERENCES

Adams, K. (2010) What is Interprofessional Education? UWE Bristol, IPE Level 2 Conference.

Baker, D. Day, R. Salas, E. (2006) Teamwork as an essential component of high reliability organizations. Health Services Research 41(4) pp 1576-98.

Barnes, D., Carpenter, J. & Dickinson, C. (2000) ‘Inter-professional education for community mental health: attitudes to community care and professional stereotypes’, Social Work Education. Vol 19 (6), pp. 565-583.

Haringey Safeguarding Children Board Serious Case Review: Baby Peter Executive Summary (2009).[online] Available from:

http://www.haringeylscb.org/executive_summary_peter_final.pdf [Accessed 22 November 2010]

Barr ,H. (2002) Interprofessional Education Today, Yesterday and Tomorrow: A Review. LTSN HS & P: London.

Barr, H., Freeth, D., Hammick, M., Koppel, I. & Reeves, S. (2000) Evaluations of Interprofessional Education: A United Kingdom Review for Health and Social Care. CAIPE/BERA: London.

Bell, L. and Allain, L. (2010) Exploring Professional Stereotypes and Learning for Interprofessional Practice: An Example from UK Qualifying Level. Social Work Education. Vol 1 pp1 -15

Bristol Royal Infirmary Inquiry HM Government (2001) Learning from Bristol: the report of the public inquiry into children’s heart surgery at the Bristol Royal Infirmary 1984 -1995. London: HMSO [online] Available from:

http://www.bristol-inquiry.org.uk/final_report/report/index.htm [Accessed 16 November 2010]

Carnwell, R. Buchanan, J. (2005) Effective Practice in Health & Social Care: A partnership Approach. Berkshire: Open University Press

CAIPE (2002) [online] Available from : http://www.caipe.org.uk/about-us/defining-ipe/ [Accessed 8 November 2010]

Childrens Act (1989) [online] Available from: http://www.legislation.gov.uk/ukpga/1989/41/contents [Accessed 10 November 2010]

Colyer, H. (2004) The construction and development of health professions: where will it end? Journal of Advanced Nursing Vol 48, (4), pp. 408-412

Dalrymple, J. and Burke, B. (2006) Anti-oppressive Practice, Social Care and the Law (2nd edition). Maidenhead: Open University Press

Davies, H. & Shields, A. (1999) Public trust and accountability for clinical performance; lessons from the national press reportage of the Bristol hearing. Journal of Evaluation in Clinical practice. Vol 5,(3) pp. 335-342.

Department of Health (DH) (2006) Options for Excellence- Building the Social care Workforce of the future TSO: London

Dombeck, M. (1997) Professional personhood:training, territoriality and tolerance. Journal of Interprofessional Care, 11 pp. 9-21.

Field, J & Peck, E. (2003) Public-private partnerships in healthcare: the managers’ perspective. Health and Social Care in the Community. Vol 11 pp.494-501

Foreman, D. (2008) Using technology to overcome some traditional barriers to effective clinical interprofessional learning. Journal of Interprofessional Care, Vol 22(2) pp.209-211.

General Social Care Council (2008) Social Work at its Best: A Statement of Social Work Roles and Tasks for the 21st Century [online]. Available at http://www.gscc.org.uk [Accessed 18 November 2010]

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SECTION 4
APPENDIX- 6 AGREED GROUP SENTENCES

Theme 1: Communication issues between Health and Social Care professionals

Clear and concise communication is key to a well co-ordinated transfer within health and social care services.

Health and Social care professionals need to recognise the importance of maintaining privacy, dignity and respect when communicating in the presence of service users.

Theme 2: Contrasting professional perspectives/ values within teams.

Recognise the importance of valuing each health and social care professions perspective.

Challenging professional boundaries creatively whilst advocating ones own professions values and ethics.

Theme 3: Stereotyping, power imbalances and team processes

Positive attitudes to working with other health and social care professionals in a real world environment with the patient/service user at the centre of planning and documenting is necessary to reduce power imbalances.

Recognise and embrace differences to minimise stereotypical views within health and social care.

Interprofessional Collaboration in Health and Social Care is changing the face of service delivery based on government’s attraction to this concept. This essay is an attempt to identify and evaluate weaknesses that affect interprofessional working, using a practice based critical incident (see Appendix A). In order to achieve this, a model of critical reflection, a combination of systematic analytical tools (SWOT, PESTEL) and use of relevant theories are adopted to unearth various assumptions and their sources with a view of engaging the application of theory to practice which will consequently improve provision of services to end users in practice with the added benefit of improving interprofessional working.

The various influencing factors identified from the analysis that conflate in the arena of interprofessionalism makes it a very complex, yet desirable concept to embrace and implement for the effective delivery of service within health and social care.

The case for a Model of Critical reflection

Reflection has been defined as “a process of reviewing an experience of practice in order to describe, analyse, evaluate and so inform learning about practice” Reid (1993). Researching various models of critical reflection (Gibbs reflective cycle (1988), Stephenson’s framework of reflection (1993), Fook and Askeland (2006) indicated a number of variables which are relevant in the evaluation and reflection on practice situation. For the purpose of this particular case study, I have chosen to reflect on the critical incident described in Appendix A by using Fook’s model of critical reflection. This model;

Focuses on identifying underlying assumptions with a specific purpose of fostering improvement in professional practice Fook and Askeland (2006,p),

Highlights power as a critical element of transforming the revealed assumptions with a view to create a positive change in the practice situation.

The concept of power in critical reflection is relevant in the social, cultural, professional and political context with the aim of gaining a sense of personal power therefore more control and choice, through the exposure of dominant assumptions in operation. Fook (2006), Foucault (1983) cited in White et al (2006, p44).

Fook’s model enables reflection on awareness and use of power in the course of performing my professional role. Fook also emphasises the place of emotion, communication, dialogue and learning in this model of critical reflection. This is particularly relevant to the practice situation as it led to competence queries in the light of the ensuing reverberation. This model of critical reflection is a valuable tool, enabling better decision-making, improved ability to work with uncertainty and multiple perspectives, resolve dilemmas, recognising the use and power of emotion, and better ability to learn from practice. Fook and Askeland (2006)

My choice of Fook’s critical reflection model helps me to take a look at what I do, why I do it, unearthing relevant hidden assumptions influenced by my cultural, social, professional and political beliefs (see PESTEL analysis in Appendix C). It also enables me to reframe myself in view of the revealed assumptions behind my thinking that affects my practice. This model seeks to empower by giving choices and creating new knowledge when the process of reflection is practised. It could also potentially reaffirm personal beliefs that may have been previously separated from professional roles which inadvertently create conflict.

Interprofessional Concept

Interprofessional concepts that are apparently relevant to the practice situation are collaboration and communication. The key weaknesses identified were due to lack of communication and failings in collaboration between the pharmacy, social services professions and general practitioner (GP) engaged in the care of the older people in the community.

In order to analyse the practice situation, two analytical tools are adopted namely –

SWOT analysis – considers the strengths and weaknesses in the case and also the opportunity and threats embedded in it. (Appendix B).

PESTEL analysis – This tool relates the situation to its external environmental factors with a view to identifying influences and impacts of the environment.( Appendix C)

The two major areas of weakness focused on are:

The gaps in collaboration between pharmacist, social workers and GPs in the community.

Poor communication between Health and Social Care (HS&C) professionals in the community.

Literature Review

The concept of interprofessional collaboration has been defined as working together with one or more members of the health care team where each makes a unique contribution to achieving a common goal. Each individual contributes from within the limits of his/her scope of practice. Broers et al (2009), College of Nurses Ontario (2008), Makowsky et al (2009). The Health and Social care policy on ‘joined up working’ Department of Health (DoH 2000) has been regarded as a major document pointing the way to or representing one of the imperatives for the ‘modernisation’ agenda. Health and Social Care policies has witnessed several changes in the last twenty five years with a shift in focus from institutional to community care with an attendant upsurge in service commissioning, which created an increasing role for primary care. Karban & Smith (2006).

The need for greater collaboration and communication has been highlighted by the recent increase in major enquiries into several aspects of health and social care (Victoria Climbie inquiry report by Laming (2003), Baby P’s case). Loxley (1995) asserted that the recognition of health and welfare within society as an interactive, adaptive process without an end becomes the only creative basis for strategies, policies and practices and as such, the ability to collaborate is thus an essential in this interactive process.

The National Service Framework for Older people DoH (2001) clearly demands that the NHS and local authorities work in partnership to promote health ageing and prevent disease in older people. DoH (2001). Various government policies has emphasised partnership and joint working as the main focus to drive improved care to users of health and social care services. DoH (1998a) Partnership in Action (1998b); Working Together (1998c); First class service; quality in the new NHS)

Leathard’s(2003) review on McGrath’s (1991) study on interprofessional teamwork in Wales found that joint working led to more efficient use of staff, efficient service provision and a more satisfying work environment. Other benefits include the value of knowledge sharing, potential for comprehensively integrated services, efficient use of public funds and the avoidance of duplication and gaps in services. The New NHS-modern and dependable: DoH (1998).

The government’s objective is to build a reliable health service where patients have access to high quality services based on identified need, building on integrated care between health and social care where each have equally important roles to play. The White paper (1998) sets out the framework for the partnership, with the intention to remove barriers to effective collaboration in the existing systems and provide new incentives for joint working across agencies.

The role of Pharmacists in interprofessional collaboration.

The pharmacy profession’s code of ethics is traditionally based on the medical model of health, where duty of care is to the patient and mainly prescriptive and paternalistic. Naidoo and Wills (2009). There are no strong evidences to support joint working between community pharmacy and other health and social professions despite a strong need for collaboration for the delivery of excellent patient care across the primary and secondary interface. Makowsky et al (2009) review indicates that collaborative working relationships between nurses and physicians have been the focus of several researches, but relatively little work has investigated the integration and nature of collaborative relationships pharmacists have with other health care practitioners. The review stated that most investigations into professional relationship between pharmacy and other healthcare profession has been on physician’s satisfaction attitudes or perceptions towards specific aspects of pharmacy practice, pharmacist roles, perceived barriers between physicians and community pharmacists, unmet needs in the medication use process, physician expectations of pharmacist and physician’s receptiveness to clinical pharmacists.

‘Competencies of the Future Pharmacy workforce’ a publication by the Royal Pharmaceutical Society of Great Britain (2003/2004) highlights the need for greater levels of collaboration between pharmacists across all sectors and boundaries as the way forward for relevance within the healthcare workforce. The Pharmacy White paper (year) also emphasised the role of pharmacists in providing services in the present NHS structure and this would necessitate a greater awareness and participatory collaboration with other healthcare professionals.

Barriers to Interprofessional Collaboration

In spite of the laudable and apparently desirable benefits of interprofessional collaboration, in reality there are barriers that limit effectiveness of this concept between health and social care professionals as apparent in my practice situation. Historically, barriers such as professional cultures, different forms of accountabilities between health and social services, political agendas, rigid boundaries, departmental survival existed and still remain to challenge present day twenty-first century health and social care. Hardy et al (1992) cited in Leathard (2003) identified five categories of the challenges facing joint working within health and social care as;

Structural issues such as service fragmentation, gaps in services.

Procedural matters which hinders joint planning through different budgetary planning cycles and procedures.

Financial factors such as different funding mechanisms, administrative and communication costs

Status and legitimacy, for example local responsibilities are based within a democratically elected arena and in contrast, all services are commissioned and centrally run by the NHS.

Professional issues which include problems associated with conflicting views and ideologies about users, professional self-interest, competition for domains, as well as differences between expertise, specialism and skills.

Leathard (2003) noted more barriers such as practitioners isolated with little management support, inequalities in status and salary, differing leadership styles, lack of clarity about roles as damaging to inter professional collaboration.

It has been noted that service users and carers as typified by the examples in the practice situation (see appendix A) often experience frustration and distress in trying to organise the type of care they want or support needed as a carer. This process, involving contact with different agencies and each with different assessment processes, often leave users and carers unclear as to who should be doing what and how it all links together. DoH (1998a)

Joint working has been identified by the DoH (1998) as needed at three levels; strategic planning, service commissioning and service provision. In the practice of pharmacy in the care of the community, service provision must deliver an integrated package that avoids the burden of complex bureaucracy.

Barriers to Joint Working: Communication

Another weakness identified in the SWOT analysis, (see Appendix C) is poor communication. Information sharing in the appropriate context is important in helping to promote informed decision making and aid the provision of user-focused care. On the other hand, incorrect information can destroy or reinforce negative or destructive stereotypes and therefore limit the range of options offered to the user. Hammick et al (2009). Poor communication can be a barrier to effective information sharing in professional practice. The lack of clarity in the process of communication experience in my context can also be down lack of awareness of how the agencies work together. Meads et al (2005) states that poor systems and lack of parity between different professionals can be major risk factors, particularly with regards to effective communication. In the inquiries into the events that led to Victoria Climbie’s death in 2000 and the Bristol Royal Infirmary incident, systemic failures that led to poor communications were highlighted.

The issue of communication was further complicated by the fact that I had no prior knowledge of any disability suffered by the patient that would necessitate any form of assessment set out by the Disability Discrimination Act (2004), I assumed that the client’s GP would be aware of the process of referral for patients needing support with their medicines as they are usually their first point of call. Carer’s expectation was that all service providers talked to each other in a way that gets things done smoothly. Reflecting on what I have learnt on interprofessional collaboration, the situation became clearer as I realised that different organisations have different operating procedures which, despite attempts at collaboration, can still be conflicting.

External influences on the practice situation such as legal factors (see Appendix C) include issues such as patient confidentiality and data protection requirements which make it imperative that proper channels of communication are followed to protect clients’ privacy. This raises ethical and legal questions on how much is too much or too little to exchange with other agencies.

I have learnt that the failings in the practice situation described is not a clear cut failing by a single person, but a classic example of how the barriers to interprofessional working can have a direct impact on both the service user and provider.

Systems Approach to Joint Working: A resolve

A systemic approach to collaboration as stated by Payne(1997) in Hammick et al(2009) is relevant to interprofessional practice as it sees individuals as social beings, affected by and influencing others around them, the organisations with which they have contact and the wider society, drawing attention to relationships, structure, processes and interdependence.

The whole systems concept developed by Bertanlanffy (1971) describes the exchange across permeable boundaries between systems and environments. This characteristic of the systems theory is crucial in its application to service organisations, like the NHS and social service. The key elements from the systems theory as concurred to by Loxley(1997) and Willumsen (2008)relevant to understanding collaboration in interprofessional practice is interdependence and interaction, emphasis on management of processes, the recognition of equifinality – the achievement of the same goal from different starting points. Loxley (1997) asserts that it is possible to manage complexity and differences through the recognition and use of common properties which apply to both parts and to a whole when experiences are shared.

For the whole systems approach to work, the right conditions as advocated by Maddock and Morgan (1999) in Leathard (2003) include;

Support for communication between users and frontline staff

Involvement of actively committed staff

Appropriate performance measures supporting change and staff development

Management and practitioners sharing the same agenda on quality and funding issues

A senior management team with a unity of vision.

The benefits of the whole systems approach as shown by the study on delivery of services to older people across health and social care in Brighton and Hove, Sussex Callanan (2001) include; initiatives to identify gaps in services, an improvement in the services provided in the multidisciplinary assessment and review, improved flexibility to meet user’s needs and the enabling of small changes which would result in significant improvements in service provision. The whole systems approach with the theorised benefits is not without its limitations. CSIP(Care Service Improvement Partnership) Older People Team cited in the ‘whole systems approach’ , a document paper by the NHS Wales(2006) concluded that for most places, a whole systems approach is a statement of aspiration rather than a statement of achievement as there are limitations inherent in the approach.

Conclusion

The way forward may be more opportunities for joint learning among health and social care professionals in practice. Integrating joint learning in the whole systems approach to effective collaboration might in some way resolve some of the perceived barriers.

Learning together reflectively will challenge traditional barriers, professional barriers and compartmentalised thinking. Karban and Smith (2006). They argued that a model of critical and reflective practice acquired through learning together will enable future practitioners develop a shared understanding of the world and ways of working together based on creating a shared dialogue within communities of practice that will enhance the experience of service users.

Forming multidisciplinary teams in the care of the community for specific target population may also be effective in closing the gap in collaboration between pharmacy and other health and social care profession.

In order to avoid the reoccurrence of the incident discussed in my practice situation, I will seek to implement the following –

Raise awareness/understanding of referral process among professionals engaged in the management of older people with disability by writing a letter to all agencies concerned.

Organise seminars at local GP meetings with other healthcare professionals involved in the care of older people with the view of clarifying the referral procedures for effective provision of service

This assignment will critically analyse two examples of interprofessional and interagency practice using examples from my current practice placement. Relevant literature will be used to identify what factors support or constrain interprofessional and interagency collaboration (IPIAC). IPIAC is often described as a holistic approach to an individual’s needs. When used effectively, a holistic approach allows for better service delivery to the service user. Hammick et al (2009, p.10) states that being interprofessional is “learning and working or working and learning with others as appropriate, when necessary and sometimes both”. Interagency working concentrates “more on the organisational roles and responsibilities of those involved in collaboration” (http://www.scie.org.uk). Interprofessional is relationships between individuals and interagency is relationships between organisations.

IPIAC was a modernisation agenda introduced in public policy by the New Labour Government. Government recognition suggests that many social problems cannot be effectively addressed by any given organisation acting in isolation from others. That is, when professionals work together effectively they provide a better service to the complex needs of the most vulnerable people in society. New Labour also specified that there was a ‘Berlin Wall’ type division between agencies and professionals and that there was a barrier to co-operation and this barrier should be confronted so that services worked in partnership with service users. However according to research conducted by Hiscock and Pearson (2002, p.11) “several government reports have criticised the lack of coordination between health and social services in the community”. So, in essence when professions work collaboratively the service user gets a better deal. “Willing participation” (Henneman et al, 1995, cited in Barrett et al, 2005, p.19) and a “high level of motivation” (Molyneux, 2001, cited in Barrett et al, p.19) have been stated as vital aspects of effective IPIAC.

My current practice placement is within a voluntary organisation in a domestic abuse service. I am a project worker at a Refuge for women and children who are escaping domestic abuse. My role is to co-link work with permanent Refuge staff and co-ordinate each service users support needs whilst maintaining links with appropriate statutory and voluntary sectors.

INTERPROFESSIONAL PRACTICE ONE

The first example of IPIAC to be discussed and analysed within my practice placement will be a weekly meeting held between Refuge staff, health visitors and the play-worker from Women’s Aid. The aim and purpose of these meetings is to share information so that identified needs of the families in the Refuge can be addressed and where possible be signposted to other services as required. The meetings are designed for professionals to share information and knowledge about the family’s lives but not make decisions on their behalf (except where there are child protection issues). The meetings also aim to provide support to families according to assessment of need using professional judgement. Within these meetings everyone discusses and communicates the personal development and progress of the women and children in the Refuge so that all professions involved are kept up to date with the family’s circumstances and situation. This supports IPIAC and is effective in that it is a chance for everyone involved to gain further advice and guidance from other professionals in relation to their current level of involvement with the families. This in turn supports the families and assists them with their future goals and plans. However these meetings could be interpreted to some as ‘secretive’ as they are held behind closed doors and it is a meeting in which the families are not involved in. This could be construed as an ‘expert power relationship’ to some (Maclean and Harrison, 2011, p.31).

For IPIAC and these meetings to be effective it is vital that all professionals involved support one another and are not be seen as self-interested or see themselves as higher than another profession. This is when problems occur as there is not a logical distribution of power. “Unequal power distribution can be oppressive” (Payne, 2000, cited in Barrett et al, 2005, p.23) and can limit participation for some professionals. Power in IPIAC should be shared and distributed and no hierarchy of power should exist. If some professionals see themselves as more powerful than another they are not meeting the needs of the service user. Sharing of information and knowledge about the families in the Refuge is the purpose of these weekly meetings so as to achieve the best possible outcome for the service user.

A constraint of IPIAC is that some professionals are territorial and do not like to share information and knowledge. Molyneux (2001, cited in Barrett et al, 2005, p20) “found that professionals who were confident in their own role were able to work flexibly across professional boundaries without feeling jealous or threatened”. “Professional adulthood” was an expression used by Laidler (1991, cited in Barrett et al, 2005, p.20) to describe professionals who were confident in their own role to share information and communicate effectively with other professionals. These professionals do not feel territorial about relinquishing their knowledge and understanding to further enhance good IPIAC. Stapleton (1998, cited in Barrett et al, 2005, p.20) suggests that “a combination of personal and professional confidence enables individuals to assert their own perspectives and challenge the viewpoints of others”.

Active listening is an important skill to maintain in order to achieve effective IPIAC. To be able to recognise and respond to what is being communicated is fundamental. Professionals working collaboratively should be able to demonstrate this verbally and non-verbally to each other. This is greatly helped if all concerned put aside the typical stereotyping of each other’s professions in order to hear and listen to what is being said. Effective open and honest communication is vital and probably one of the most important aspects of IPIAC. It requires professionals to take into account each other’s views, be respectful, dignified and to listen to each other without being highly critical of one another. Constructive feedback about the family needs to be undertaken alongside constructive suggestions and encouragement and should take place at a time when other professionals are receptive. However, being receptive to what is being said does not always occur during these meetings. At times, one professional does not like what another is conveying and this can create conflict within the professions. However the need here is to remember that it is the service user that is central to the process and that the goal is to achieve the best outcome for them and their family.

There are elements within this example that both support and constrain IPIAC. To achieve the goal and not result in a poor outcome for the service user it is important for all professionals involved to communicate honestly and openly and for there to not be a significant power imbalance between the professions.

INTERPROFESSIONAL PRACTICE TWO

The second example of IPIAC to be discussed and analysed within my practice placement will be a Multi-Agency Risk Assessment Conference (MARAC). A member of the Refuge staff attends these meetings on a fortnightly basis. A MARAC meeting is a community response to domestic abuse. Cases are referred to a MARAC by the Refuge as a result of completing a CAADA-DASH risk identification checklist (RIC) (see appendix one) with the victim of the domestic abuse. This checklist determines the victim’s level of risk/need. If the risk identification score is 14 or more on the RIC, the MARAC threshold for high-risk has been meet and a referral to a MARAC meeting is made. Cases can also be referred to the MARAC either as a result of a high risk domestic crime/incident recorded by the police or by a direct referral from a participating agency. Participating agencies attending the meetings can include representatives of statutory services such as the police, criminal justice, health, child protection, housing practitioners and Independent Domestic Violence Advocates (IDVA’s). The purpose of the meetings is for professionals to implement a risk management plan that provides professional support to all those at risk and which reduces the risk of harm. The aim is then to produce a safety plan for each victim of domestic abuse.

The MARAC’s aim is to share information to increase the safety, health and well-being of victims/survivors of domestic abuse. They can determine whether the alleged perpetrator poses a significant risk to any particular individual or to the general community. According to Bowen (2011, chapter 5.) “MARAC functions through meetings designed to facilitate multi-agency information sharing, with a view to implementing an agreed-upon risk management and victim safety plan”. Effective communication and information sharing supports IPIAC as it can assist to build relationships between agencies across a much broader range. A MARAC with effective communication and information sharing between agencies can also promote IPIAC in developing much stronger relationships between the voluntary and statutory sector. Barrett et el (2008, p.21) states that “communication competence contributes to effective interprofessional working and enables those involved to articulate their own perspectives, listen to the views of others and negotiate outcomes”. An effective MARAC meeting which supports IPIAC is when professionals work collaboratively to ensure that victims/survivors and/or their children are safeguarded from further abuse. The government’s action plan “Call to End All Violence Against Women and Girls” states that “we all have to work together to achieve our goal of ending violence against women and girls. It is not a task for central government alone”. It suggests that agencies need to work together to meet the needs of their local communities and that agencies are held accountable.

However, a constraint of a MARAC meeting that I witnessed was that not all professionals brought the appropriate information to the meetings which lead to an inefficiency and delay of the case which frustrated others professionals attending. Poor timekeeping was another avenue that at times would frustrate other professionals attending the meetings. This seemed to alienate them as I would hear comments such as “we are all professionals here and should act as such” and “as professionals attending important meetings like this, we should always strive to be on time”. I also found at the MARAC that some agencies only had snippets of information that on their own did not raise any particular concern. It was only when the jigsaw of information was pieced together that the risk factors could begin to be understood.

This example shows that when MARAC meetings support and strengthen interagency working and is effective, it is IPIAC at its best. This approach to working more collaboratively is beneficial as all organisations are coming together for the purpose of a common goal, with that goal being the best possible outcome for the service user. However some of the MARAC meetings that I had attended were not always that effective due to the fact that not all key agencies or organisations attended the meetings when required to do so or did not have the appropriate information to hand. It is beneficial that all agencies have as much information to hand as possible to facilitate IPIAC and have a profound positive impact on the outcome for the service user.

In conclusion, IPIAC has many elements and all these different elements require that the different professions adopt them so that effective outcomes are achieved for the service user. Although IPIAC has been around for many years and is not new, it still needs to be continued, developed and incorporated into the daily work of all professions. When organisations and professions from different disciplines truly understand each other’s roles, responsibilities and challenges, the potential of IPIAC could be fully realised and many of the barriers alleviated. This in turn will contribute to a more successful outcome to the service user which of course is central to effective IPIAC. If IPIAC is ineffective it can limit choice for the service user and also increase risk.

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