Using research in practice with children and families

The Guardian recently published a commentary piece entitled “Is misused neuroscience defining early years and child protection policy?” which, at the time of writing, has received over 300 comments. For an article involving child protection and / or neuroscience, this seems a relatively high degree of engagement (by way of comparison, at the time of writing, three other neuroscience articles linked to from this one have received 96, 91 and 36 comments and two relatively recent pieces on child protection have received 2 and 5 comments). In other words, this article has attracted some attention (and not only on the site itself – twitter was also fairly busy in response to the article, at least amongst the social work academics, practitioners, commentators and policy makers that I happen to follow).

What if I told you that the application of neuroscience in social policy is over-baked?

Wise words from Morpheus.

The thrust of the article – for anyone who has yet to read it – is that neuroscience has had a significant influence on early years thinking in England and that the resultant social policy changes have (or soon will) “justify the removal of children (from their homes)”, as well as providing the basis for such interventions as the Family Nurse Partnership scheme. The article goes on to ask – what if the application of neuroscience is ‘over-baked’ and what if, in fact, “the claims made for neuroscience are so extreme that most neuroscientists would disown them”?

Unfortunately (for me at least), I am in no position to judge the relative merits of the various claims being made for or against neuroscience although I do accept there is always a risk when government policy is made on the basis of inexact science – although, having said this, it’s almost axiomatic that the science will be inexact to some extent due to the nature of scientific enquiry, which is ultimately not about ‘truth’ and ’certainty’ but about degrees of probability and confidence (I don’t think the article is arguing any differently). However, my concern is not with this debate per se but what it might suggest about practitioners in the field (not least because I am one) and although the article title refers to ‘early years and child protection policy’, the body of the article also refers to practice.

A glass of Alka Selzter

A glass of Alka Selzter

As an example, within the article it is said that some family nurses have reported “On their visits, they get a glass of water and put Alka-Seltzer in it, and say, if you do what you’re supposed to do, ‘That will be your baby’s synapses firing.’” The implication seems to be that this is something the family nurses should not be doing, as it is not based on any ‘objective science’.

An MRI scan of a baby's brain

An MRI scan of a baby’s brain

My reflection on this is – doesn’t it depend, not on whether it is based on ‘objective science’ but on why the family nurses might be doing this and how? In other words, doesn’t it depend on what the family nurse is trying to demonstrate or communicate to the carer and what they mean by ‘what you’re supposed to do’? If they were trying to give a general idea that a baby’s brain is ‘alive’ with activity and that babies are (usually) very responsive to their environments, then I would have thought it could be – for some – a useful analogy (regardless of what an actual neuroscientist would think of it – after all, they’re not the ones sitting in the family’s front room). If by ‘what your supposed to do’ is all of the ‘typical’ things that babies need, such as food, cuddles, some level of stimulation, then again, I am not sure what would be so wrong with using the Alka-Seltzer analogy (although I have to say, when I visit families, I generally don’t take medication with me, not even over-the-counter stuff).

Everything a growing baby needs

If, on the other hand, the family nurse is using the analogy to say that unless the carer does something ‘special’ – such as baby massage, maintaining eye contact at all times whilst breast-feeding exclusively for 12 months, giving the baby an exclusive diet of organic produce from Waitrose – then the baby’s brain will be more like the glass of still water than the glass with the Alka-Selzter, then that could be much more problematic. As I say, I think it depends.

Sometimes when I visit children, I ask them to draw a picture or write a story about how they feel when they are at their most vulnerable or scared. Sometimes the child might draw a picture (or write a story) of themselves in bed at night with monsters and demons all around them. Other times, the child might draw a picture (or tell a story) about how their carers always seem to be nearby when they feel afraid. Sometimes I tell the children that by doing this activity, it can help them to get their emotions out onto the page and turn them into something they feel less afraid of and more able to talk about with an adult they trust whether that might be a carer, an older sibling, a teacher or even me (I’m also using attachment-related ideas related to mentalization and of what the child expects from their carer during times of heightened anxiety). But of course, I am only using an analogy when I tell the children this. I do not really think ‘an emotion’ is something so easily defined or so easily managed but I use these kinds of techniques based on my (fairly vague) understandings of narrative therapy, even though I am not a trained narrative therapist and do not have a particularly good understanding of the research base (other than to know there isn’t much of one). However, I still use it because I find it sometimes works for me and sometimes seems to help the children and families that I work with.

I think the point I am trying to make is this – whilst there are, of course, legitimate concerns regarding the role of neuroscience in early years policy and of course we should be able to have an open and frank debate about this, the core activity of social work will always remain what happens within and because of the relationship between the practitioner and the family (or the individual, group, community, etc.). Some social workers are better at helping people than others and there does not seem to be a common pattern between those who are more helpful and their use of particular theories or research findings or between those who are less helpful and their use of different theories and research findings (in some ways, this reflects the still relatively poor evidence base for much of what counts as social work activity).

In other words, it appears as if there are helpful and unhelpful ways of using the exact same theories and research findings in practice, that Theory A can be used as the justification for providing more support to a family or as the justification for providing less, depending on who is doing the interpreting, not only of the theory or research findings, but also in relation to the particular family and their characteristics, the characteristics and experience of the practitioner and the influence of the organizational context and policy framework in which they are working.

Via my own research, I have been able to describe what I would consider to be some extremely positive ways of using the theory and research knowledge related to disorganized attachment in practice such as to help understand and make sense of (with a view to changing) the behaviour of ‘neglectful’ carers in order that their children can remain at home and can be well cared for. Of course, in the hands of other social workers, it is possible to imagine how the same theory and research could be used to argue that a child needed to be removed immediately and without further delay (although I have not found any examples of this in practice, which is not to say they do not exist).

At the risk of repetition, the ‘neuroscience in social policy’ debate is well worth having. But I would also like to re-assure myself that many social workers are active rather than passive consumers of research and that whatever the government-of-the-day might like the science to say, there are many, many good social workers (and family nurses) who find ways every day to help and support families, not because any particular theory tells them they should (or even despite a theory or research finding apparently telling them not to bother) but because they want to and because they know the (moral) value of doing so (perhaps that’s why they became social workers and family nurses in the first place).

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Motivational Interviewing: An Evidence-Based Approach to Working with Families

Posted originally via Social Work Helper

Motivational Interviewing (MI) is a form of strengths-based counseling originally developed by Miller and Rollnick with the aim of helping people to change. Miller and Rollnick defined motivational interviewing as “a collaborative, person-centered form of guiding to elicit and strengthen motivation for change”. Proponents of MI tend to argue that it is more than a set of techniques to help strengthen a person’s motivation for change as it also encompasses a particular ‘way of being’ as a practitioner, based on collaboration rather than confrontation, evocation rather than the provision of advice, and on the promotion of individual autonomy rather than a reliance on authority. In the field of substance and alcohol misuse, MI has a good evidence base as being an effective way to help and there has been in recent years an increasing interest in the use of MI techniques and principles in the field of child protection social work, particularly in the UK.

 Motivational Interviewing: An Evidence Based Approach to Working with FamiliesIn addition, MI has many philosophical similarities with strengths-based approaches more generally. A recent systematic comparison between MI and strengths-based practice found that MI practitioners tend to focus on the goals to be achieved (rather than on any problems that may exist), on service users’ current strengths and how to utilise these for future change, on the employment of service users’ own resources, on the development of a positive and collaborative relationship between the practitioner and the service user, and on the provision of meaningful choices.

As such, in my view, MI is both potentially of practical use for social workers in many different fields, wherever the aim is to help people to change, but it also fits well with the broader value base of the social work profession in its’ recognition of autonomy, of expertise by experience and its’ focus on collaboration.

In practice, MI involves changing the way we speak to service users as a way of putting these principles into practice. For example, by asking the permission of the service user to either discuss certain topics or before giving advice, affirming the control of the service user and their ability to make choices, by supporting and encouraging their efforts so far and by asking open questions and reflecting on what they have said.

One would also seek to avoid confronting the service user or directing them as to what they should do. Rollnick, one of the principle founders and developers of MI, provides the following examples of how one might engage with someone about smoking, with the first being an example of ‘the righting reflex’ (the desire to advise and direct solutions) and the second being an example of a more MI-consistent approach. I’ve added some comments in brackets to highlight where the doctor in these examples is either using or failing to use the principles of MI:

EXAMPLE 1:

You: Are you a smoker? (closed question)

Patient: Well, sort of yes.

You: How much do you smoke each day? (closed question)

Patient: I don’t know, about 15-20 years?

You: With that chest, I must tell you, it’s going to get worse if you smoke like this (confronting)

Patient: Yes, I know but you see it helps with the stress, if you knew what I go through with that truck and the long roads, it’s enough just to get through the day.

You: But if you carry on like this you might lose even more time at work (confronting and not listening to the patient’s reasons for smoking)

Patient: yes, I am cutting back you see.

You: Well we’ve got some good aids to quitting if you are interested? (advising, directing)

Patient: yes thanks, I’ll give it some thought thank you doctor.

EXAMPLE 2:

You: would you mind if we talked about your smoking? (asking permission)

Patient: Well, OK.

You: How do you really feel about it? (open question)

Patient: I’m trying to cut back, but I can’t say it’s easy with my job, you know it’s stressful driving a truck.

You: It’s not easy for you yet you’d like to smoke less (reflecting, highlighting the patient’s possible motivation to change)

Patient: Oh if I could, definitely, I know it’s not good for my chest for a start.

You: You can feel the effect for yourself and it’s not pleasant (reflecting, highlighting the patient’s possible motivation to change)

Patient: That right, but it’s such a stress reliever it’s hard to let go.

You: It’s difficult for you to imagine being without smoking (reflecting)

Patient: yes, that’s exactly right, you got me.

You: I don’t want to give you a lecture or hassle you about this, but I’m wondering what would be helpful for you? (emphasising patient’s control, seeking their opinion on what might help)

Patient: I just don’t know Doc.

You: Tell me, deep down, how important is this for you right now? (open question, emphasising the patient’s option to seek help or not)

Patient: I feel sick and I’m tired, and this smoking wears me down…

The difference between these two conversations is quite stark and I can easily imagine how the patient in the first example might leave feeling under pressure but without any real motivation to change, whereas in the second example, the patient would (hopefully) feel listened to and may leave thinking about why they do actually smoke and perhaps even thinking about what it might be like if they could stop. I would suggest, and there is evidence to support this, that the patient in the second example is much more likely to come back to the doctor for further help and support, whereas the patient in the first example may not and may even actively avoid getting into a discussion about smoking again with their doctor.

One very simple technique for seeing how well one can put these ideas and principles into practice – of asking open questions, seeking permission, emphasising the service user’s control and choice, reflecting on what has been said and seeking to highlight potential ambiguity regarding the possibility of change – is to record a conversation with a service user (with their permission, of course) and simply listen back, noting down when you have asked open or closed questions, when you have advised without permission, confronted or directed and where you have been able to reflect and emphasise the service user’s autonomy. Personally, I have found this to be a powerful learning technique in my own practice and this in turn has allowed me to develop my own skills of MI, which I believe has made a difference for how productive my conversations and discussions are with services users.

For More Information

Miller, W. and Rollnick, S. (2002). Motivational Interviewing: Preparing People for Change. Second edition. London: The Guilford Press.

Miller, W. and Rollnick, S. (2009). Ten things that Motivational Interviewing is not. Behavioural and Cognitive Psychotherapy, 37(2), 129-140.

Forrester, D., Westlake, D. and Glynn, G. (2012). Parental resistance and social worker skills: towards a theory of motivational social work. Child and Family Social Work, 17(2), 118-129.

Manthey, T., Knowles, B., Asher, D. and Wahab, S. (2011). Strengths-Based Practice and Motivational Interviewing. Advances in Social Work, 12(2), 126-151.

‘Thinking the unthinkable’?

“Let’s think the unthinkable, let’s do the undoable. Let us prepare to grapple with the ineffable itself, and see if we may not eff it after all.” (Douglas Adams)

The phrase ‘think the unthinkable’ seems to have suddenly become a feature of discussions of Serious Case Reviews (SCRs). This is somewhat surprising given how little the phrase actually appears in SCRs but perhaps this is because it is thought to capture so much of what has been said before (in this regard, it is similar to the phrase ‘the rule of optimism’). However, my concern is that by reducing a somewhat complex argument into a reductive phrase, we risk overlooking the very complexity that gave rise to it. In other words, like the phrase ‘if it’s not written down, it did not happen’, if practicing social workers only hear the phrase and not the argument, there is a risk of unintended consequences in the way they (potentially) adapt their practice. Given that a significant minority of social workers do not read SCRs, this appears to me to be a very real possibility.

Interestingly, the phrase seems to have appeared only very recently. The Victoria Climbie Inquiry Report makes no mention of it and neither does the first (redacted) SCR regarding Peter Connolly, nor the second, nor the SCR regarding Khyra Ishaq. Indeed, even the very recent SCR regarding Keanu Williams does not contain the phrase although it does say that, ‘In many ways the ‘rule of optimism’ seemed to be affecting professionals. Research evidence shows that “efforts to think the best of families” were found in a 2005-07 study which noted that “There was a reluctance among many professionals to make negative professional judgments about a parent” (p. 42). To me, the meaning of this is quite clear – professionals must be prepared to make ‘negative professional judgments’ about parents and not to operate under the ‘rule of optimism’. This appears to be an example of why the phrase ‘think the unthinkable’ has become common currency so quickly – because it appears to capture so much of what many previous SCRs have been trying to say.

The only example I could find of the phrase itself appearing in a recent SCR is in the one regarding Daniel Pelka. The authors of this SCR use the phrase three times, saying, “professionals needed to ‘think the unthinkable’ and to believe and act upon what they saw in front of them, rather than accept parental versions of what was happening at home without robust challenge” (p. 6). Later on, the same SCR says, “the practitioners involved (with Daniel and his family) were not prepared to ‘think the unthinkable’ and tried to rationalise the evidence in front of them that it did not relate to abuse” (p. 71). Finally, the same SRC says, “When faced with significant and complex concerns about a child’s welfare, it is essential that professionals ‘think the unthinkable’ and always give some consideration to child abuse as a potential cause of presenting problems” (p. 73).

Much of the discussions I have been involved in on twitter and in the ‘real world’ have centered on what this phrase actually means, with various suggestions made such as ‘social workers should trust parents less’, ‘social workers should consider abuse as a possibility in every case’ and ‘it means social workers have been too nice’. This may or may not be what the authors of the Daniel Pelka SCR meant when they used the phrase but my interest is less in what they may have meant and more in how ‘think the unthinkable’ might be operationalized in practice. A question I have posed (on twitter and in the ‘real world’) is – when I am next looking at a referral or undertaking an assessment, what would I do differently if I were ‘thinking the unthinkable’?

This question made me think of the work of Professor Donald Forrester and his study regarding how social workers talk to parents. In this study, a vignette was created involving the mother of a 5-year-old child. In one of the scenarios, there are reports that the mother appeared to be drunk when collecting her child from school. The 24 social workers in the study were asked to conduct a simulated interview with the mother, played by an actor, and the nature and quality of their communication skills were recorded and analysed. Of particular interest is the finding that on average, the social workers demonstrated no empathy towards the client and were obstructive in their communication, although three of the social workers demonstrated empathic listening consistently and communication skills on a par with a skilled counselor. My PhD supervisor, Professor David Shemmings, often refers to Professor Forrester’s research in his training presentations and he asks social workers how they might respond if, when they visited the mother, she claimed not to be drunk but said her anti-depressant medication sometimes gave that impression. Two of the more common responses are:

–       I would ask to see the anti-depressant medication to check for such side-effects

–       I would ask to speak with the mother’s GP.

As Professor Shemmings points out, whilst it may well be the case that the mother is trying to hide her drinking, the thing these responses have in common is the implication that the mother is lying. In other words, they are both good examples of the kind of communication that shuts down conversations rather than opens them up and such responses would probably lead to either defensiveness on the part of the mother or worse, disguised compliance. What neither of them suggests is a social worker operating under the ‘rule of optimism’, of being unprepared to make negative judgments about parents – to ‘think the unthinkable’.

The point I am trying to make is this – there are times when social workers (and their managers) need to ‘think the unthinkable’ but rather than simply turn this phrase into another mantra, to be repeated in team briefings, training days and elsewhere, what we need to do is understand why, in some situations, social workers find ‘thinking the unthinkable’ relatively easy to do and why, in some other situations, they do not.