By Richard Devine, Consultant Social Worker for Bath and North East Somerset Council
As I was packing up at the end of a long day in the office on a dark, rainy evening, I received an e-mail from the hospital. A child subject to a child protection plan and for whom I was the allocated social worker was treated for a facial injury in an Accident and Emergency Unit. The report noted Joanne returned home and found her 3-year daughter, Jessica, covered in blood while in the care of her new partner, Paul. Joanne had told the nurse that Paul had told her that Jessica had fallen over and bumped her chin.
I arrived at the family home unannounced at 6 pm. I had been working with Joanne and Paul for several months, but they had not been receptive to social work involvement because they disagreed with the concerns that professionals held about them and their children.
Joanne and Paul reluctantly allowed me into the home after I explained the reason for the visit. Paul was a short, broad man with long, shoulder-length hair. His sleeves were rolled up, revealing numerous self-harm scars, some of which were fresh, evidenced by the stained blood on his arm. He was angry, intoxicated and said to me, ‘you are supposed to come here every two weeks and you think you can just f**king turn up when you like’. Joanne, a slim and tall figure, nervously told him to stop ‘because this will be used against us’. I sympathised with his predicament and Joanne’s fear that his behaviour might be viewed negatively.
I spoke to Joanne and Paul and spent a short time speaking with Jessica about the injury. Despite the alarming nature in which the information was initially presented, I concluded that this injury was probably not suspicious and was caused by a lack of supervision. I had sought to be understanding, asking about the visit to the hospital in a non-judgemental way. Despite this, I left the home with Paul and Joanne unhappy and shouting that I had I accused them of abusing their children.
In what ways should I measure the impact I am having on outcomes for Jessica?
Should I evaluate the degree to which I can build a therapeutic alliance? Can I use my relationship-based practice skills to cultivate a relationship with Joanne and Paul that can then be used as a vehicle for facilitating change? Under such fraught conditions, this seems unlikely.
A key outcome that I was measured against was compliance with statutory processes. I had to: visit every two weeks; see Jessica alone and check her bedroom; ensure my case recording is up to date; complete the child protection conference 5 days before the conference; have an up-to-date single assessment on the file; hold core groups every 4 weeks; update the Child Protection Plan after each core group meeting, etc.
While these tasks are essential, effective social work practice is not limited to these tasks.
It raises a question about whether we measure what makes a difference or only measure what can be easily measured.
I could comply with all those metrics yet not do much in the way of helping the family. Or, my approach in dealing with Joanne and Paul could be oppressive. Surely, being helpful and anti-oppressive are important issues we would want to evaluate as well.
Another important outcome was to reduce the risk for Jessica. One key element of this was to ensure that Jessica was protected from significant harm. How to achieve this?
Our involvement with Jessica’s family wasn’t neutral. Joanne and Paul found our involvement stressful; therefore, did our involvement amplify the issues of concern, increasing the risk? Should we end our involvement because that could reduce stress and lessen concerns? Or was the stress-inducing experience of social work involvement necessary for a greater gain, for example, in reducing parental substance misuse?
Perhaps, the impact of statutory involvement should not be considered if that is what is required to safeguard Jessica. Surely, however, to help Jessica, the most effective way would be to help Paul and Joanne. In helping Joanne and Paul, we must consider individual and systemic factors contributing to distress and unhealthy coping mechanisms. What if Joanne and Paul weren’t ready to change? Should we escalate our involvement and consider Jessica being placed in alternative care?
The case example and questions posed highlight the challenges in measuring outcomes, and how we evaluate whether our social work is effective, humane and proportionate.
Research into outcomes
Surprisingly, there has been little research into outcomes for children and families, or rather, what outcomes we should measure and how these outcomes should be measured.
This is a critical issue; how social work is conceptualized and what outcomes are measured determines to a large extent, how we, as social workers, are evaluated both internally and externally. In addition, how social workers are evaluated affects how we practice.
Therefore, we should think carefully about outcomes because changing what is valued as an outcome (and thus, measured) can change our practice.
Professor Donald Forrester has written a paper called ‘Outcomes in Children’s Social Care’ (2017). It is one of the most important papers I have read. I will summarise some of the key ideas before concluding how to apply them to practice.
Outcomes in Children’s Social Care
Forrester points out that Children’s social care aims to help children and families. However, that is not all children’s social does, and a concentrated focus on that excludes the fact that social work has other important functions worthy of consideration and evaluation.
For example, a significant part of social work involves deciding whether we should be involved with a family or not. This pertains to whether we are involved on a statutory basis and thus over-ruling a fundamental right, the right to freedom and liberty from state intrusion. Therefore, we should scrutinise how we undertake the assessment and come to a decision. Is the process by which we decide whether to be involved done fairly, proportionately, and ethically?
Forrester identified two challenges with defining and measuring outcomes in Children’s Social Care.
Firstly, there is a diverse range of responsibilities assigned to social work, and the law and legislation underpinning this work are, by design, broad.
A second challenge is deciding on outcomes.
For example, removing Jessica from her parents might allow her to have a life free from exposure to domestic abuse or substance misuse. However, it also incurs the devastating cost of separation from her parents. In addition, Joanne, and Paul, might feel their family has been destroyed and their precious child taken by uncaring, punitive social workers.
As pointed out by Harry Ferguson in Child Protection Practice (2011)
‘the fact that are often no outcome that satisfies everyone, and that people feel destroyed by what social workers have to do is a painful truth that is at the heart of the ethical complexity…in effectively performing child protection practice’ (p.150)
Different stakeholders (parents, children, social workers, academics, charities) have different views on what matters (see Fox-Harding’s work on this) creating challenges for deciding on which outcomes to measure.
Deriving outcomes from the wrong models
A key argument pursued by Forrester is that social work has, to a large extent, modelled itself and sought to evaluate its effectiveness as if it were a therapeutic intervention.
A therapeutic intervention can evaluate whether a particular approach in a specific context works for a certain individual with a clearly defined problem.
For example, an alcohol service measures its ability to help those suffering from alcohol problems reduce or abstain. The challenge in applying this to social work is that our role is more than simply helping someone (not that that is simple).
To illustrate the complexity of this, Forrester references his research examining the relationships between social workers’ skills and outcomes. Mostly, social workers’ practice skills barely made any difference. A couple of explanations are given for this.
Firstly, in most cases, a social worker only visits a family a few times. Realistically, what impact is this likely to have? Especially when this is considered in the context of everything else that happens in their life.
Secondly, there needs to be a problem identified that allows the social worker to intervene or assist with. In many cases, families reach a crisis point resulting in a referral, but then they experience substantial improvement within a few weeks. Rather than being a consequence of social work intervention, however, this improvement occurs due to the family resolving their difficulties. Or it turns out the initial concerns are not as severe as initially suspected.
Therefore, a large part of social work entails deciphering which families have problems that warrant involvement.
Even once it has been decided whether a family will have an allocated social worker, there is much dialogue about the intensity of this involvement and whether it is still required.
To this effect, the role of a social worker is much more akin to a GP rather than a therapist.
A GP deals with a large number of patients and determines whether or not the issue is minor or serious, which requires additional or specialist input. Once the delineation has been established, a GP is a key support for a patient with a severe or chronic problem.
Forrester points out that for those families where social work intervention is required, the relationship between the social worker and the parent can make a bigger difference. Partly because the social worker spends more time with the family.
Involuntary involvement and unclear criteria for deciding how to help
Even once it has been decided that social work involvement is justified, there is a reality and challenge that most parents do not want a social worker involved.
Forrester argues that this fundamentally challenges our understanding of our conceptualisation of social work and what outcomes we should be concerned with.
As pointed out by Lauren Devine, in ‘The Limits of State Power and Private Rights’ (2017),
‘…social work is seen as building a relationship with a family in order to help a child…however, this is at odds with the legal framework and with policy, creating conflict, confusion and difficulties for social work practitioners and families…social work practice aiming to build trust and relationships with families is based on the principles of s.17, but this approach is not able to reconcile the complex and different nature of a forensic, evidence gathering process under s.47 (P.88)
Devine refers to this as ‘the welfare / policing dichotomy’ (p.88)
At the very least, therefore, the idea that we can establish a therapeutic relationship with parents like Joanne and Paul, who do not want to work with us, is unrealistic. To believe that this is our role sets us up to experience a sense of perceived failure when this isn’t achieved.
Social work also comes up against another challenge, unlike other public services. For example, education, health, and housing have clearly defined roles with service provision and eligibility.
Social workers, however, must enter into a dialogue with parents to discuss what they need and their understanding of the problem (or even if there is a problem).
A key method used to understand the problem and level of need is an assessment. An assessment incorporates an understanding of the parent’s perspective, balances their rights and the child’s rights (which can compete with another), takes account of the child’s wishes and feelings and the expertise of the social worker (expertise of child development, impact of domestic abuse, substance misuse, mental health, capacity to change).
It is not simply a case of deciding whether someone is eligible for a service, as determined by relatively clear criteria and guidelines. Instead, social workers need to consider what support could help and decide on whether to defend or curtail an individual’s freedom and liberty in pursuit of safeguarding the child and imposing the support upon them.
Forrester (2017) writes, ‘In a profound sense, social workers are practical philosophers, teasing out complex value-based decisions on behalf of society. Wisdom is perhaps their primary virtue’ (p.151).
Street level judges
In this sense, social workers are neither therapists nor GPs but police officers or judges.
Judges tend not to be evaluated on the outcome of an investigation or court case. Instead, a fair process, appropriate use of authority, proportionality and a defensible balancing of rights are crucial elements that are measured.
An important outcome often used in research is reducing children subject to child protection and care. However, it might be wholly appropriate, in some instances, that removal is sought.
If, for example, it was assessed that Jessica needed to be removed, what might be a more important outcome is how I handled the process and whether the decisions made were evidential robust, defensible, and proportionate.
Forrester proposes that social workers are, therefore, like judges, arguing this as a reason for humane, ethical practice not just because it maximises the chance of promoting change but because it is the right thing to do.
With this in mind, we should carefully seek to understand how to provide compassionate, principle-based, authoritative social work that supports change.
Four Essential questions
This formulation has profound implications for thinking about outcomes.
The default tends to be thinking about whether we have made a difference in the same way that researchers might do in medicine or psychotherapy. Or by compliance with process or procedure.
However, as we have now discovered, social work is far more complex than that. Measuring outcomes needs to reflect this complexity.
Forrester proposes four key questions,
1. What is the quality of the service or practice being offered?
2. Are the right families being worked with? And is the involvement of Children’s Social Care proportionate?
3. How helpful do parents and children find the help being offered?
4. What difference is made to specific problems? (p.152)
Implications for practice
The four questions posed by Forrester provide a road map for researchers but also could easily be used by practitioners thinking about their work with children and families. To re-phrase them and expand upon them, with reference to Joanne, Paul, and Jessica
1.What is the quality of my practice?
Am I being clear and transparent about the concerns held by children’s social care?
Am I showing compassion and understanding, for example, for Paul’s antagonistic behaviour?
Can I hold onto multiple perspectives? For example, recognise the impact of substance use and domestic abuse on Jessica and recognise Joanne/Paul have probably developed ways to cope with a lifetime of adversity.
2. Is my involvement with this family necessary and proportionate?
Do I need to be involved with Jessica and her parents? Does the negative impact of being involved outweigh the positive, or is the harm sufficient to justify statutory involvement?
Does the assessment consider Joanne and Paul’s right to private family life and the right for Jessica to be protected from undue harm? Does the assessment provide a clear, evidentially robust rationale for our involvement?
Are we keeping a case open because we are worried instead of questioning whether we are being helpful?
3.Am I being helpful to the parents and children I am working for?
Have I asked Joanne and Paul what they would like help or support with? What areas in their life would they like to be different, and is there anything we can do to support them in that endeavour?
I could ask Joanne and Paul if they could have any type of support, what would that look like? How would I know the support that is being provided making a difference?
Do I recognise the limitations of being a vehicle for change and instead support them in recognising areas in their life they would like to see change and find the right person or support to enable them to achieve change?
4.What difference is being made to specific problems?
Am I helping Paul to reduce his alcohol use? Or having non-blaming conversations that help him understand the reasons for his alcohol use and explore if he would like to address it?
Are there fewer incidents of domestic abuse? Have the home conditions improved? How will I know I am making a difference?
How could I change the context to improve Jessica’s life, especially if her parents are not ready to change? I could look at ways to support the family or professional network to lessen the risks associated with her substance misuse (i.e., FGC and extra-curricular activities for Jessica).
The outcomes proposed by Forrester are much more likely to support social workers in understanding their role more clearly, reduce role ambiguity, reduce conflict with parents, and support them make a positive difference.
By Richard Devine (25.02.23)
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