This practice analysis aims to critically reflect on a snapshot of my involvement with a 17-year-old female called Christina, in particular following a Mental Health Act (1983) assessment which was conducted whilst she was in custody.
For the purpose of this assignment I will be focusing on some pivotal points in the case which I feel has had a significant impact on my professional development and led me to question and assess my ability to recognise and accept my capabilities as a social worker and those of other multi agencies when managing complex, high risk.
It is necessary to provide a brief summary of Christina’s case, it’s also necessary to add that at the time of writing this assignment, Christina is no longer open to Children Social Care following her eighteenth birthday – which I feel adds to the importance of utilising this opportunity to reflect on my involvement.
Christina was referred to Children Social care three months before her 17th birthday following a safeguarding referral from Adult Mental Health services that a male inpatient had made threats of wanting to kill Christina if they could not continue their relationship; he was 8 years older than Christina and due to be released from hospital in two months.
Christina was fostered from birth then adopted at 8 months old, several referrals had been made to Children Social Care since Christina was aged 13 with parents seeking support for attachment related behaviours presented, indicators of mental health issues and self-harming behaviours, concerns for sexual exploitation – frequent inappropriate relationships formed with elder/ adult males and disclosure of sexual abuse perpetrated by her half-brother.
There was no evidence of long term involvement with the family, my review of previous referrals unveiled several closure summaries of ‘Christina doesn’t want to engage with the social worker and doesn’t feel CSC involvement is needed at this time, case to close’.
It took me over one month to meet Christina, I pursued her by maintaining regular text contact, communication which best suited her at the time.
Thereafter, intensive social care involvement commenced managing complexity and risk for Christina surrounding: mental health issues and self-harming behaviours, homelessness, breakdown of family relationships, recurrent short term inappropriate relationships with adult males featuring exploitation and domestic abuse, high risk of sexual exploitation, substance misuse and towards the end of her ‘childhood’, intelligence suggesting Christina was being groomed for sex working by adult males.
Given the chaos that continually surrounded Christina, it was remarkable that I managed to engage Christina and we formed a working relationship which was sustained until she turned eighteen. My manager often commented how if nothing else, the contact was a lifeline for Christina.
This led me to consider why I managed to form a relationship, yet for all previous referrals the case was closed due to non-engagement. Professor Eileen Munro (2011) highlights the importance of examining the child’s journey from needing and receiving help and exploring their wishes and feelings to form the provision of services they and their families will receive.
I have recognised that when working with adolescents in particular, where challenges are presented with engagement and trust, to enable relationships to be built I tend to rely heavily on my use of self to be seen as an individual too as well as a social worker.
Goleman (2001) suggests “that the ability to understand one’s emotions and use them effectively is more important than cognitive ability”, he believes that emotional intelligence is a better predictor of success than IQ, now this is not only important to consider when working with service users, but I found this valuable when considering my own professional capabilities and how I present myself. Goleman (2001) breaks down emotional intelligence into four components: self-awareness, self-management, social awareness and relational management. Reflective supervision with my manager throughout working with Christina identified particular strengths I possess as a social worker in self-awareness and relational management, particularly with a desire to practice to develop others, having excellent communication skills and being a bridge between individuals and accessing other services.
There are so many factors for why someone comes to be in the circumstances they are in (Thompson, 2006), as a social worker you have to acknowledge social disadvantage and prejudice (Dominelli, 2002). Anti-oppressive practice involves practitioners being aware of the power imbalance between them and service users and working to reduce that (Dalrymple and Burke, 1995), this informed my approach with Christina and demonstrating to her my want to understand what life was like from her perspective, I wanted her to teach me what was important to her and what she felt able to change/ wanted to change – and adapt my practice around focusing on what she felt possible. Horne (1999, cited in Beckett and Maynard, 2010) states how anti-oppressive practice involves discovering the individual behind a label.
To achieve this, I used a person centred approach, Trevithick (2007) refers to this as an approach “which aims to help create situations whereby individuals can overcome the constraints they feel subjected to”.
Within my sense of self, I utilise my age, personality and characteristics to transfer from a personal to professional level to engage with others, my specialism is identified as working with hard to engage adolescents. Drawing from previous experience and learning when seconded to the local Police Child Sexual Exploitation team, serious case reviews such as Oxfordshire stated “being more ‘professional’ makes it less likely that the victims will engage” (Serious Case Review into Child Sexual Exploitation in Oxfordshire, 2015).
Alongside this it is imperative that I maintain professional boundaries as set out in HCPC standards of proficiency (2017), often there is a risk with adolescents of presenting as befriending them to achieve engagement, however by following the standards of proficiency I am able to practice utilising knowledge, intervention and skills and ensuring there was always a structured, clear plan under Section 17, Child in Need (Children Act 1989) for actions required to reduce the risk of harm to Christina. Parker and Bradley (2007) identify that using a strengths based approach helps minimise the power imbalance between professional’s and service users.
At the time of Christina being arrested, it was two weeks before her eighteenth birthday, Child and Adolescent Mental Health services (CAMHS) had recently stated that Christina would be formally diagnosed with borderline personality disorder once she is ‘an adult’, she was living at a property with an adult female connected with sex working and class A substance use. This adult female had been given a child abduction warning notice previously for ‘accommodating’ another vulnerable female adolescent who was a frequent missing person.
“Child Abduction Warning Notices can be issued against individuals who are suspected of grooming children by stating that they have no permission to associate with the named child and that if they do so they can be arrested under the Child Abduction Act 1984 and Children Act 1989” (PACE, accessed January 2017). The police were never able to utilise this for Christina as it only applies to Children aged up to 16 if living at home.
The police had a duty to contact Christina’s parents and Children Social Care to notify that they had Christina in custody as she was aged under 18 and vulnerable (“Being arrested: your rights” GOV.uk, 2016).
Before attending the police station, I had a discussion with Christina’s parents to ensure they were aware I had been requested by Christina to attend for interview as an appropriate adult, to prepare I read through the “appropriate adult guidance” (GOV.uk, 2016). I spoke with the custody sergeant and was informed that Christina was withdrawing from substances (heroin, crack cocaine) in custody and they were exceptionally concerned about the property she was arrested at, the adults residing there and her physical, emotional and cognitive presentation.
A discussion followed with my team manager and actions followed to contact CAMHS and custody mental health liaison. I requested that a mental health act assessment is completed whilst Christina was safe in custody and I provided an in-depth analysis of risk and previous attempts for an assessment to be undertaken.
My rationale for requesting an assessment was due to my (albeit potentially limited) knowledge of the Mental Health Act 1983 Code of Practice (2015) which identifies that a person can be detained in hospital for assessment to find out what treatment and care they need: if it is needed for their own health and safety or to protect other people and that the approved mental health practitioner/ doctors must think about what the patient wants now or said they wanted in the past, and whether keeping them in hospital is the only way to treat the patient.
I didn’t know the full circumstances of the arrest, but from the information I was told, I knew this was another plea for help – previously Christina had begged to be in a refuge to escape domestic violence evidenced through injuries and discussed at multi-agency risk assessment conference (MARAC) , to be sectioned in a psychiatric hospital evidencing physical self-harm, suicidal ideation and medication overdose, that she needed to be in a residential rehab to detox from substances evidenced through an ‘accidental’ heroin overdose, and leading up to this arrest that she needed to go to prison because she was at risk of harming herself or others by carrying knives and screwdrivers around with her.
I had always seen the exceptional vulnerability of this child and the need to safeguard her from herself yet every multi-agency strategy meeting I co-ordinated in accordance with the statutory guidance “Working Together to Safeguard Children” (HM Government, 2015) – it seemed Christina just never ‘ticked enough boxes’ for secure intervention from the police, mental health services and Children Social Care included – even to the fact that agencies did not agree for a joint investigation under Section 47 Children Act 1989 (Brayne and Carr, 2010) as it was deemed ineffective given her age and lack of ‘powers’ police and Children Social Care would have.
This is not the first time I have pondered the effectiveness of the Children Act 1989 being ‘fit for purpose’ for adolescents, I recognise how a child protection plan is more likely to be ineffective for adolescents compared to younger children. The focus is always on the significance of early intervention – I don’t believe attempts were made in their entirety to engage with Christina from her early adolescent years which had contributed to the escalation of risky behaviours, poor choices and further abuse and harm – another case example of many missed opportunities and when involvement had commenced, seemingly it was ‘too late’.
I felt like this was my last chance to try and achieve something for her, to try and get her to a place of safety for assessment, knowing that my involvement was coming to an end.
I attended the police station and met with the approved mental health practitioner (AMHP) and two doctors and we spoke in a room together first, this was mainly for the AMHP and two doctors to discuss information they had about Christina. One of the doctors was from the local CAMHS and he had met Christina on a few occasions previously so was able to share his medical view on her presentation and indications of mental illness leading up to this event.
I felt lost on some of the context of discussions, referring to sections and threshold for diagnosis, the benefit of hospital admission and suitability in light of Christina soon to be an ‘adult’. I didn’t ask for an explanation, I felt the conversations were so fast paced that they were almost in a rush to get the assessment started.
On reflection, I recognise that I felt insignificant amongst the other professionals, that I wasn’t intelligent enough to keep up with their specialism in mental health and conversations, that what I had to share would have been irrelevant.
I’m disappointed that I felt this way as I wouldn’t expect a professional in mental health to understand all the legislation, policies and ‘jargon’ within social care, neither would I doubt their capabilities or intelligence for their lack of understanding for an area which isn’t their specialism – I did have relevant contributions, questionably the most important – I was the one that knew this child.
With the benefit of hindsight, what disabled my confidence was the emotion I felt for urgently wanting an outcome to be that they could place Christina in hospital, voluntarily or under a section for assessment, I wanted them to have an answer… to save her because I felt I had failed her and within my role there was nothing more I could do.
Christina’s presentation shocked me, I hadn’t seen her for two weeks, she had drastically lost more weight, her face and neck were covered in open red sores, her nails bitten down and dirty, her hands grubby with grazes and open cuts to her knuckles.
In all honesty, in a brief moment I had never felt less professional, I wanted to cry. I felt this lump in my throat and immense rush of panic – in that moment I felt like no time had passed from the first time I met Christina compared to the horrifically sad state she was in now and I wondered how on earth this child got to where she is and why hadn’t I, or anyone, been able to stop it.
Christina was seen by us all together, the room was very poor; lacking space with a table against a wall with the chairs squashed around it. This made it difficult to conduct an assessment in a suitable manner – I knew Christina well, she found strangers intimidating and would often disengage and do anything she could to minimise the time required to participate, this was not the right environmental situation to try and encourage her to relax and feel comfortable to talk about what was going on for her.
The AMHP introduced herself and informed Christina of the purpose of assessment, following the code of practice (2015), as did the other professionals.
The assessment was completed, the outcome was that there was no evidence of significant mental health illness and no grounds for detaining Christina or supporting a voluntary admission to hospital.
After the assessment a CAMHS doctor spoke to me away from Christina and said that if she had said she wanted a voluntary admission to hospital then he would have sanctioned it because he knew of the continuous incidents, how she is identified at significant risk of harm and accidental death as well as having an ‘emerging personality disorder’.
So why was this not encouraged? I felt like the assessment had been a waste of time, being able to critically reflect has supported clarity and learning outcomes:
I didn’t fully consider the impact of requesting the assessment at the station from the child’s point of view and what was in her best interest- she was assessed in a police station whilst still under caution, had withdrawn from substances since her arrest and had to wait for the assessment to be conducted before being interviewed – knowing that this assessment would elongate her time in custody. I had gone with my gut instinct for it to be done in a ‘safe place’ and with hope the outcome would have resulted in a hospital admission.
A conflict was that I felt solely responsible for Christina, getting caught up in her trauma and chaos and my professional judgement for a holistic view was impaired by feeling pressured by time constraints as to how long Christina would remain open to Children Social Care. Overall there were occasions I had forgotten that the limits to resources and interventions were not due to my professional incapability, but due to contexts, organisations and legislation which impaired interventions. I’ve also recognised that feeling so pressured to safeguard Christina should not have been just down to me as an individual worker, and further learning is that supervision needs to be more reflective, critical and clinical to relieve the pressure I held for knowing what that child was suffering.
Although I don’t believe I was wrong with requesting the assessment, I do recognise that without careful consideration and planning, the primary driving force and panic for an urgent assessment was because I felt scared for what would happen hereafter. As professionals we have to accept that we cannot take responsibility for someone’s actions or make them choose a different path, we can only try to minimise risk and let service users make their own informed choices. Overall I recognise that throughout working with Christina – I found it very difficult to accept the choices she made and accept that at times, she was making those choices willingly.
I also hadn’t considered the impact of her substance use fully, could it be that a potential barrier to Christina participating with the assessment and voicing her circumstances be through fear of further police involvement? I had police intelligence suggesting the adults connected are drug dealing and exploiting women through sex working – how realistic was it to expect Christina to share any information relating to this, her making any disclosures could have increased a police presence at the property she’s been living at and bring offences to those she sees as ‘friends’– although no-one wanted her living there, it was the only option she felt she had at the time.
Another consideration is if Christina had divulged her suicidal thoughts and ideation, self-harm behaviours and experiences of auditory and visual hallucinations – what would happen? This was unknown to Christina, she didn’t have the skills to ask these questions, if she went into hospital how would she cope without substances? I hadn’t considered the push/ pull factors that would impact co-operation for intervention.
My role was to support Christina and to try advocate for the assessment to be conducted in her best interest however I was unable to do so because of the constraints of Christina being in custody.
A significant learning point is that I should have better prepared for the assessment; afterwards I learnt that the key guiding principles of the Mental Health Act 1983, which are in the Code of Practice 2015 are: Least restrictive and maximising independence, Empowerment & Involvement, Respect & Dignity, Purpose & Effectiveness and Efficiency & Equity. These guiding principles are what AMHP’s have to follow to ensure that the service user is involved, safeguarded and identify the least restrictive option to deliver necessary care in line with the Human Rights Act 1998 and supporting the principles of the Mental Capacity Act 2005.
From the information discussed before seeing Christina and the minimal questions asked in the assessment, afterwards I struggled to see how the information gathered supported exercising the guiding principles in their entirety.
This led me to question the appropriateness of mental health act assessments, particularly for adolescents and from this experience – evaluating the purpose against realistic outcomes achievable and for adolescents when a trusted person is not present and how it must feel as a service user to be seen by at least 3 ‘strangers’ who hold such power over decision making.
The purpose and timing of these assessments can be so crucial to effective, immediate safeguarding of vulnerable people and yet there seems to be so many barriers whereby someone would feel unable to participate fully – there are times where significant mental illness is evidenced clearly in presentation however the overarching principles for the MHA 1983 and detaining ‘patients’ covers many disorders which were evidenced in Christina’s behaviours – just not in that short 25 minute assessment (Clinically recognised conditions which could fall within the Act’s definition of mental disorder, 2.5 Code of Practice, 2015).
This experience has encouraged me to adopt a more open approach with my team manager as I believe due to the extent of involvement with Christina, I have experienced a level of secondary trauma and felt frustrated and powerless to safeguard that child. Since the case has been closed to Children Social Care, I have questioned my skills and effectiveness with working with adolescents and whether I need to adjust my caseload to develop skills and experience with younger children where there is more accessibility to resources and interventions to safeguard.
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