Reflective case study

The assignment is intended to discuss a case I worked on whilst on my final placement and use an analytic stance to discuss the interaction and interventions used with the service user. In order to maintain confidentiality and anonymity of the service users in this case study I will be using pseudonyms for all people involved and mentioned in relation to this case. The assignment will demonstrate professional judgement, accountability of a social worker and the statutory requirements of protection and intervention when working with vulnerable adults. The case study will focus on my work with Sarah throughout my time on placement and assess my principal interventions as well as locating my work within the wider discourses around risk deploying both recovery and exchange models. It will also highlight the strengths and limitations within the process of recovery. Within this case study I will aim to describe and analyse the practice, theories and values that have emerged by carrying out this piece of work.

The assignment will critically evaluate my practice with specific reference to the social work skills used. By reflecting on my practice I hope to demonstrate how I have considered issues such as power imbalances and social injustice and how this consideration has assisted me to work in an anti-oppressive, non-judgemental way with the service user involved. With reference to this particular case study I will also demonstrate to the reader the power imbalance that existed between the professionals in terms of their approach. This was clearly evident in relation to the social model approach versus the medical model approach. Drawing on my observation and the experience of working within an inter-professional team I will provide critical appraisal of the issues and barriers that existed. I will also compare, contrast and evaluate the medical and social model of mental health and mental disorder by referring to appropriate literature and research.

This will demonstrate to the reader how it can inform a social work practitioners understanding and practice. In terms of the interventions used the assignment will not be structured in a chronological order, but will focus on the salient parts of the work with the service user involved. I will examine and recognise the concepts when considering risk and explore the theories associated with risk. Due to the nature of this case study and the involvement of Children and Family Social Services (CFSS) current adult and children’s legislation and policy informed much of my practice with the client. Through my work with this client I faced many challenges; I hope to demonstrate to the reader the issues I faced in relation to risk management. It will be made evident to the reader the fundamental dilemma I was faced with, balancing the individual’s autonomy and choice with the need to protect the client and her baby from perceived risks. The placement agency was part of a large organisation, and was managed through a pyramid scheme of hierarchal systems.

During this assignment I will demonstrate the impact of the organisation structure, policy and management on the team and the service provided. I will explore in detail the impact of multi- disciplinary teams and the culture it creates within an agency paying particular attention to the differing perspectives of professionals and the dynamics of power and how this impacts on practice. I will also demonstrate to the reader my role within the organisation and how my practice was developed and influenced by legislation and policy. The following case study is based on a 29 year old British Asian woman who was under the services of our team which is an assertive outreach team. The team is a multi- disciplinary team that works with clients in the community who suffer from severe and enduring mental health problems often complicated by drug and alcohol misuse and a chaotic lifestyle. Sarah came under the care of the team as a result of repeated hospital admissions, difficulty to engage with services due to unsettled accommodation history and also her vulnerability and issues relating to her relationship with her partner and her family.

She has a diagnosis of bi-polar disorder. I became involved in Sarah’s case initially when I accompanied my supervisor Kate on a visit to Sarah’s home. When I first met Kate she was 4 months pregnant and was living with her partner in rented accommodation, the accommodation was in a poor condition and they had no white goods or domestic facilities. Sarah was married to her partner Tom; they met while they were both inpatients on a psychiatric ward and moved in together when they were discharged from hospital. Sarah had previously alleged that her father had forced her to marry Tom. This was an Islamic wedding so therefore they are not legally married under English law. Sarah also alleged previously that Tom had financially and physically abused her. A POVA (protection of vulnerable adults) was instigated however Sarah withdrew the allegation so therefore this was not pursued. Sarah’s family life is complex; most of the family suffer from mental health problems. Sarah and her siblings spent time in care when she was younger when her mother experienced a relapse in her mental health.

Her parents have separated and Sarah has step- siblings. Tom has a history and spent time in prison for domestic violence against his ex-wife. He had two children with his ex-wife however no longer has contact with the children as a result of the abuse in the home. Considering the risks associated with Tom and also the other risks relating to Sarah’s mental health and her parenting capacity, much of my work with Sarah was concerned with child protection issues and risk. Social work in its various forms addresses the multiple, complex transactions between people and their environments. Its mission it to enable all people to develop their full potential, enrich their lives and prevent dysfunction. Professional social work is focused on problem solving and change. As such, social workers are change agents in society and in the lives of the individuals, families and communities they serve. Social work is an interrelated system of values, theory and practice. (International Federation of Social Workers, 2012)

People in our society are categorised according to their social position in relations to class, age, religion, gender and sexual orientation. The social structure plays an important part in the distribution of power, status, resources and opportunities; this is known as social stratification. Consequently, people in positions of power can discriminate systematically against vulnerable people. Marsh and Keating (1996) It is crucial for professionals to be aware of the implications of discrimination and oppression in order to become an effective social worker and become valuable practitioners. Considering the fact that in Britain, we now live in a multi-cultural, multi-racial society social workers need to have the skills to work towards combating any forms of discrimination and oppression. Theory is the fundamental ingredient in practice that informs the way in which social workers view and approach individuals, groups communities and society.

It is the bedrock for practitioners that help them to predict, explain and assess situations and behaviours. It provides the rationale for how the social worker should react and intervene with clients who have particular histories, problems or goals. Teater (2010) In relation to my work with Sarah my role was ultimately to support her to live in the community and offer her advice and guidance on ways of dealing with and coping with her current situation. I aimed to assist Sarah in becoming more independent and support her to realise her ambitions in a realistic and pragmatic way. I used social work theory to understand varying explanations of difficulties she may experience in doing this, and social work methods to work creatively in achieving this. Howe (2009) explains that theory provides us with an understanding of behaviour that offers us the ability to create strategies and solutions that are ‘relationship responsive’.

While it can be unavoidable for the social worker who has practice wisdom and theoretical knowledge to make assumptions about the origin and solution of problems experienced by the client, I was careful to let Sarah take the lead during my initial visits. Social workers come across a variety of complex situations that may challenge their value base however making assumptions could be considered oppressive practice so instead I adopted the feelings of Stepney (2002:25) who considered that ‘a good working knowledge of different models and methods, and the theories that inform them open up opportunities for progressive practice’. As Sarah is under a secondary mental health service she is required to have an enhanced CPA and it is reviewed regularly, this is audited by the Trust. The care program approach was developed and introduced by the department of health (DOH) in 1990, it identified the essential need for regular care reviews involving all professionals and non- professionals to meet with the service user to ensure assessed needs were being met.

It actively promotes clients to be involved in their care and feel empowered, it also encourages inter-professional collaboration. DOH (2008). During the placement I found the CPA was a very useful tool in terms of inter-professional practice, it enabled me to gain a holistic over view of the client. By using a single assessment process through inter-professional working the result is a comprehensive care plan which included a coordinated path that connects various services required. Cook. et al (2001) In the early stages of my engagement with Sarah I entered the relationship by being open and honest and demonstrated a willingness to listen. This was combined with a genuine commitment to promote Sarah’s rights and wishes. I adopted a person centred approach, this is an influential model that ‘strongly informs our use of counselling skills’ (Miller, 2005:22)

In order to practice effectively in an anti-oppressive way it was useful to consider the humanistic psychological view of Carl Rogers (1951) and his ‘person-centred’ approach, this has helped to shape social work values and practice in an anti-oppressive way. My initial work with Sarah was based on and followed the three main concepts of Rogers (1951) approach; congruence, empathy and unconditional positive regard. The first of these was congruence; this refers to my willingness and ability to be genuine and open. By being clear about the questions I was asking and the reason I was gathering information about Sarah without a hidden agenda it helped to form a healthy relationship. In terms of counselling (Mearns and Thorne, 1988:17) suggested that practitioners ‘putting up a professional front or personal façade’ can be a barrier to forming positive relationships and also obstruct progress and change for the client.

The second concept is empathy, to become an empathic social worker it requires us to see the world as another person sees it. After building up a good rapport with Sarah I found it challenging not to take her feelings on board. In the social work profession people see clients who are living with a wealth of problems and in extreme conditions. It can be argued that empathy is a skilful activity as it ‘involves having a degree of control over our own feelings while remaining open and sensitive to the other person’s feelings.’ Empathy is not only a social work value we should aspire to have, but a practical necessity to avoid intense emotional pressure and burnout. (Thompson, 2000:137) The final concept is known as unconditional positive regard. This is about working positively and effectively with clients. Regardless of the situation this means accepting people and having a non-judgement approach. In the case of Sarah and Tom, I had to be aware that my feelings of disapproval towards Tom did not influence my work in a negative way.

Reflecting and supervision relating to this experience was an essential part of practice, it provides us with the opportunity to make sense of what has happened. Good practice often stems from one’s own reflective work. In relation to a non-judgmental approach which is encouraged and regarded as a high priority on the social work agenda and across all health professionals recent studies suggest that clients continue to experience prejudice. Griffiths et al (2012). Anti-discriminatory practice developed during the late 1980’s to challenge the inadequacies of the prevailing system and the concern many societies had with racism and ethnic conflict. According to Thompson (1992) anti-discriminatory practice involve three different phenomena; psychological, sociological and political. It is therefore essential that social workers practice a holistic approach which aims ‘to empower users by reducing the negative effects of social hierarchies in their interaction and the work they do together.’

Dominelli (1994 cited in Burke and Harrison, 2004:134) Referring to this particular case study as mentioned Sarah originated from an Asian background and also had a diagnosis of Bi-polar disorder. The diagnosis of mental health conditions among Asian clients can be a challenge and also detrimental to the client. During my contact with Sarah she disclosed that she feels a spirit around and within her known as the ‘jinn’. I now know this is a spirit which is a prominent aspect of the Islamic culture and is often referred to in the Qur’an. Keynajad’s (2011) study demonstrates that there is distrust amongst the Muslim community of the psychiatric system. Consultants are not culturally sensitive which impacts negatively on clients. Coming from a western culture using the dominant white cultures psychological norms resulted in my lack of understanding and unfortunately a perception of this belief being abnormal. I reflected that the relationship can be a double-edged one involving elements of care and control. Social work intervention can lead to empowerment or hinder people by oppressing them and their beliefs.

Thompson (1992) The western psychiatric model traditionally excludes spiritual dimensions and overlooks the significance of religion in people’s lives. Indeed, in many cases, it has been found that faiths attribute what British society would describe as mental illness to “spiritual sickness”. (Petit-Zeman, 2001) Good practice involves social workers gaining the knowledge and understanding to enable them to mediate between their clients and the wider society, it is essential that social workers are in a pivotal position in terms of the relationship between the state and its citizens and act as the agents for change. Ferguson and Woodward (2006) Using person centred approach and working in partnership with Sarah enabled me to identify her immediate needs and the best placed intervention to use in her situation.

Task- centred practice is regarded as a contemporary intervention in social work today and has had a steady growth since its emergence in the 1960’s, as part of a shift from psychodynamic explanations of social work towards alternative models. It is essentially an active intervention with a clear and practical model which can be used in a wide range of situations. Doel and Marsh (1992). The rationale for using this intervention was that it would focus on the important issues that Sarah needed to deal with promptly; housing, benefits and her tenancy, furthermore this would be carried out in a planned, structured way over a short term period. It would also support, empower and facilitate Sarah to reach an optimal level of mental health and work towards recovery. In relation to bi-polar disorder it is essential to prevent stressful situations. According to Mind (2010) being organised and taking things step by step can prevent a relapse in mental health. This coincides with the basic structure of task centred practice.

Ford and Postle (2000) set out four phases of this intervention; Problem Exploration-this is based in mutual clarity between the client and social worker on what issues to focus on. Agreement- Acknowledging and selecting the tasks that need to be prioritised. Formulating an objective and motivation –Details of what is required, discussions with the client about the potential outcome and achievement. Planning and agreeing the details to prevent obstacles and encourage success and also reviewing the progress regularly. Termination- End process of task centred work, reflecting and clarifying on what has been achieved. With reference to Sarah, the issues with her housing and benefits were dealt with however there were limitations regarding her tenancy concerns as some issues were complex and given the time limit of this intervention, it could not be achieved. On reviewing the intervention with Sarah it was an overall success Historically in social work many clients received long term interventions and there was a focus on feelings and therapy rather than action.

Due to the complex nature and the chaotic lifestyle of the clients under the assertive outreach team long term intervention is not conducive to their needs. The clients are more responsive to short term intervention and action so they can see results; according to current research brief directive interventions have a consistent outcome advantage in the treatment of a multitude of disorders. Giles et al (1993) Another ideology that is particularly relevant in this case and also important to social work is the systems perspective. Bronfenbrenner (1994) stated that in order to understand human development we must consider the entire ecological system in which growth occurs. Ecological models and perspectives ‘encompass an evolving body of theory and research concerned with the processes and conditions that govern the lifelong course of human development.’ (1994:37)

The systems theory, which is explicitly a sociological approach provides social workers with a useful framework to focus on individuals, as being part of the wider society and a series of interlocking social systems such as groups, families and societies as well as a biological system. Payne (1991). To apply this theory during my interaction with Sarah, I was required to work holistically. Having built a good relationship with Sarah it enabled me to discuss the support networks in her life that had a positive and negative effects, she could also identify the problems she had experienced past and present because of her environment not meeting her needs. Eco- social work ‘incorporates analysis of structural causes of disadvantages and includes full consideration of wider support networks beyond the nuclear family.’ Jack and Jack (2000 cited in Stepney and Popple, 2008:117) Although Sarah identified her family as a supportive and integral part of the layer in her environment, she began to make the link that change occurring within her family system was likely to have an impact on her home life.

This became undoubtedly evident and relevant during the children and family core assessment, the assessment was completed to determine how to safeguard and promote the welfare of Sarah’s unborn baby. During this assessment three inter-related domains are used; child’s development, parenting capacity and family and environment, this will be discussed further in more details. DOH (2000) The long and contested debate regarding the medical model and social model was very much evident during my work with Sarah and within the organisation. The medical model perceives the individual as a patient that needs to be treated or cured in order to be able to operate ‘normally’ in society today. Oliver and Barnes (2012). It conceptualizes problems as mental illness and defines individuals through the use of labels. It can be argued that the medical model adopts a cause and effect explanation for mental illness, this concept is very much opposed by the social model and the systems theory.

Zastrow (2009) With reference to the ecological model Bury et al (2001) postulates that the medical model operates at a micro system level. The impact of this restrictive practice can inhibit progression and development in the effort to remove barriers socially and environmentally with our clients. Traditionally, the medical model has dominated and decision making power and has been in the hands of the medical profession. This occupation was seen as the elite amongst the professionals. The approach within the placement agency was based on a culture that worked within a medically dominated hierarchy. The main focus was medical treatment and symptomology. The medical model is ‘characterised as focusing solely on individual pathology and ignoring the social factors which impact on people’s lives’. By failing to recognise and ‘counter the structural oppression’ people experience it is ‘argued, medicine and psychiatry further contribute to oppression.’ (Barnes et, al: 566)

Power imbalances are inescapable and within this team, it was evident that the psychiatrist held the power and was a major factor when decisions were being made within the team. There was tension within the agency as it was felt by some practitioners in the team that the psychiatrist dismissed other professions; he was not willing to engage in a discussion with the psychologist regarding alternative diagnosis. ‘Sometime a form of professional arrogance is displayed whereby the professional looks down on others.’ Pereira Gray (1989 cited in Goble 1994:177) ‘Multidisciplinary teamwork is unlikely to become organizationally embedded unless structural inequalities between professions, and between professions and patients, are addressed’. (Shaw et, al, 2007) After a multi-disciplinary meeting where Sarah received news that her baby was going to be removed from her care and placed with foster parents she became extremely upset and expressed a desire to self-harm and was also screaming.

The consultant psychiatrist disregarded her experience as a reaction to receiving such devastating news, in true medical model style he labelled Sarah’s experience as abnormal and suggested an admission onto a psychiatric ward. Thomas et al (1996) ‘The social model implies that mental health problems exist on a continuum with other people’s experiences and problems.’ By showing empathy and reassuring Sarah that her reaction was understandable given the circumstances, Sarah was open to suggestions and wanted my advice. I suggested that Sarah may benefit from more support and informed her that I could refer her to the crisis team for extra support at home. After discussing some symptoms Sarah was experiencing and normalising the situation Sarah felt in control and empowered to come up her own conclusion that an informal admission to hospital would be beneficial for her support needs. (Williams et al 2001:477)

Risk assessment is the process for gathering relevant information about a service user, which is then analysed and interpreted in terms of knowledge, values, skills and the application of professional judgement. All assessments should be carried out thoroughly to ensure the service users have an appropriate service according to their level of need. It can be seen as a positive tool that provides a basis for the identification of factors that may lead to risk, danger, hazard or threats to wellbeing. It enables partnership working between the service user and the social worker whereby they can identify the protective factors to minimise the risks to enable them to draw up a plan. Loxton et,al (2010) Assessment is the foundation of the social work process with service users. Walker and Beckett (2011)

In critique of this view assessment is also a major intrusion into someone’s personal life and usually done at a vulnerable point in their life. It may have a negative impact on the relationship between the social worker and service user especially if the outcome has not been agreed and action was taken to minimise risk. In this case the service users may feel disempowered and it would have an impact on the power inequality. Parsloe (1999) In particular to the case study it is crucial to work with Sarah using a holistic approach to the assessment. It is important that to gain an insight and access knowledge regarding Sarah’s mental health condition to enable me to understand her better. This would enable a social worker to identify all the risks and strengths as part of the assessment. McLaughlin (2008). As identified in the case study there was a number of complex factors in Sarah’s life, as part of an ecological approach I explored all areas concentrating on culture, strengths, weaknesses and environment.

Barrett (citied in McLaughlin 2008) The priority in this risk assessment is to identify the risks that warrant immediate action. Nancy would need to access more information surrounding the safeguarding issues mentioned. It is essential to assess each issue separately. Sue would need to clearly indicate risk factors in terms of past history and current presenting risks taking into account both internal and external factors. It is crucial at the early stage of the assessment that Sue begins to build up a rapport with Nancy. In order do this she would need to approach this assessment in an anti-oppressive non-judgemental way. Working in partnership is crucial, to gain the trust of Nancy, Sue needs to be open and honest during the process. This should include informing Nancy about the structures of the agency to enable her to make an informed decision. The assessment should involve sharing the different perspectives, values and concerns of the people involved. Dalrymple and Burke (1995)

Reference List
Barnes, D., Carpenter, J. and Dickenson, C. (2000) ‘Inter-professional education for community mental health: attitudes to community care and professional stereotypes’ Social Work Education: The international Journal. Vol.19 No.6 pp.565-583

Beckett, C. (2006) Essential Theory for social work practice. London: Sage publications Ltd.

Bronfenbrenner, U. (1994) Ecological models of human development. 2nd Ed. Oxford: International Encyclopaedia of Education. [Online] [Accessed on 17 July 2012] http://www.psy.cmu.edu/~siegler/35bronfebrenner94.pdf

Burke, B. and Harrison, P. (2004) ‘Anti-Oppressive Practice.’ In Robb, M., Barrett, S., Komaromy and Roders, A. (eds.) Communication Relationships and Care. London: Routledge, pp. 131-138

Bury, M.,Seelman, K.D. and Albrecht, G.L. (2001) Handbook of disabilities studies. London: Sage Publications.

Cook, G., Gerrish, K., and Clarke, C. (2001) ‘Decision-making in teams: Issues arising from two U.K evaluations’. Journal of Inter-professional care, Vol. 15, no. 2, pp. 141-151

Department of Health. (2008) Framework for the Assessment of Children in Need and their Families, London: The Stationary Office

Department Of Health. (2008) Refocusing the Care Program Approach: Policy and Positive Practice Guidance, Cmnd.9148, London: COI

Doel, M and Marsh, P. (1992) Task-Centred Social Work. Aldershot: Ashgate Publishing Ltd.

Ferguson, I and Woodward, R. (2009) Radical Social Work in Practice: Making a difference. Bristol: The Policy Press.

Giles, T.R., Prial, E.M. and Neims, D.M. (1993) ‘Evaluating psychotherapies: a comparison of effectiveness’. International Journal of Mental Health, Vol. 22, No.2, pp. 43-65

Goble, R. (1994) ‘Multi-professional education in Europe: An overview.’ In Leathard, A (eds) Going Inter-professional: Working Together for Health and Welfare. London: Routledge.

Griffiths, J., Speed, S., Horne, M and Keeley, P. (2012) ‘’A caring professional attitude’: What service users and carers seek in graduate nurses and the challenge for educators’ Nurse Education Today, Vol. 32, no 7, pp. 121-127

Howe, D. (2009) A Brief Introduction to Social Work Theory. Basingstoke: Palgrave MacMillan

International Federation of Social Workers (2012) Definition of Social Work. [Online] [Accessed 18 July 2012]

Loxton, J., Shirran, A and Hothersall, S.J. (2010) `Risk.` In Hothersall, S.J and Mass-Lowit, M (ed.) Need, Risk and Protection in Social Work Practice. Exeter: Learning Matters Ltd. pp.21-35

Marsh, I. and Keating, M (1996) Sociology: Making Sense of Society 3rd Ed. Essex: Pearson Education Ltd

McLaughalin, K. (2008) Social Work, politics and society: From radicalism to orthodox. Bristol: The policy press.

Mearns, D. and Thorne, B. (1988) Person Centred Counselling in Action 3rd Ed. London: Sage Publications.

Miller, L. (2006) Counselling Skills for Social Work. London: Sage

Mind. (2010) Understanding Bi-Polar Disorder (Manic Depression). [Online] [Accessed on 17 July 2012] http://www.mind.org.uk/help/diagnoses_and_conditions/bipolar_disorder_manic_depression#sort

Oliver, M and Barnes, C. (2012) The New Politics of Disablement. Hampshire: Palgrave MacMillan

Parsloe, P. (1999) `Introduction`. In Parsloe, P. (ed.) Risk Assessment in Social Care and Social Work. London: Jessica Kingsley Publishers Ltd.

Payne, M. (1991) Modern Social Work Theory. Basingstoke: Palgrave MacMillan

Petit-Zeman, S. (2001) Restored Faith: Sophie Petit-Zeman on how a spiritual dimension has been adding to treating people with mental health problems. The Guardian. [Online] 21ST February. [Accessed on 17 July 2012] http://www.guardian.co.uk/society/2001/feb/21/socialcare.mentalhealth?INTCMP=SRCH

Rogers, C. (1951) Client- Centred Therapy: Its current Practice, Theory and Implications. London: Constable

Stepney, P. (2002) ‘The theory to practice debate revisited’ In Stepney, P. and Ford, D. (eds.) Dorset: Russell House Publishing Ltd.

Sepney, P and Popple, K. (2008) Social Work and the community: A Critical Context for practice. London: Palgrave Macmillan

Shaw, M., Heyman, B., Reynolds, L.,Davies, J. and Godin, P. (2007)
‘Multi-disciplinary Teamwork in a UK regional secure mental health unit a matter for negotiation?’ Journal of social theory and health, Vol.5 pp. 356-377

Teater, B. (2010) An Introduction to Applying Social Work Theories and Methods. Maidenhead: Open University Press.

Thomas, P., Romme, M. and Hemmellinjk, J. (1996) ‘Psychiatry and the politics of the underclass.’ British Journal of Psychiatry, Vol 169 pp.401-404

Thompson, N. (2000) Understanding Social Work. 3rd Ed. Hampshire: Palgrave MacMillan.

Thompson, N. (1992) Anti-Discriminatory Practice 5th Ed. Basingstoke: Palgrave MacMillan

Walker, S. and Beckett, C. (2011) Social Work Assessment and Intervention. Dorset: Russell Housing Publishing

Williams, B., Cattell, D., Greenwood, M., LeFevre, S., Murray, I and Thomas, P. (2001) ‘Exploring ‘person-centredness’: user perspective on a model of social psychiatry.’ Health and Social Care in the community, Vol 7No. 6, pp. 475-482

Zastrow, C.H. (2009) Social Work with groups: A comprehensive workbook. 7th Ed. Belmont: Brooks/Cole, Cengage Learning.