By Denise Carroll and Mark Smith
Dr. Denise Carroll is Looked After Children Nurse at Kibble Care and Education Centre and Dr Mark Smith, is Senior Lecturer in Social Work, at the University of Edinburgh and a member of the editorial group of the goodenoughcaring Journal.
On the borders: residential care workers and mental health professionals working together
by Denise Carroll and Mark Smith
This paper reports on the research and professional development activities undertaken over the course of a three-year EU Lifelong Learning project, which ran from 2012-2015. The project was a Finnish initiative led from the Turku University of Applied Science. The focus of the project was the population of children and young people on the borderlines of residential childcare and the mental health services. All European projects require an acronym, thus RESME for residential and mental health.
The partners involved in the project were from six European countries, Finland, Spain, Germany, Lithuania, Denmark and Scotland. The Scottish partners were Kibble Education and Care Centre and the University of Edinburgh. The participating countries offered a broad spectrum of welfare systems across Europe: Denmark and Finland representing Scandinavian models of a Welfare State; Germany operating within a Central-European model with a long tradition of public health services; Lithuania, a post-communist Eastern European transition stat; Spain representing a Catholic, Mediterranean Welfare State and Scotland being a devolved partner in the British model.
The starting point for this collaborative venture was that each of the countries involved encountered difficulties with that group of children and young people who spanned residential child care and mental health service provision. The main aim of RESME was to enhance mutual understanding and improve inter-professional working between mental health and childcare services through the development of a joint training programme. The programme of work for the project consisted of a literature review, national interview based research projects, the development and delivery of a training programme and dissemination of the findings. This paper is written by the Scottish partners.
The literature review
The literature review and discussions highlighted the different backgrounds of the residential care workforce across Europe. For example most countries operated some model of social pedagogy or social education. In addition across Europe there is differential use of residential care. In Scotland, less than 10% of the total numbers of children in care were placed in residential settings, while in Finland, for instance, 38% of the total numbers of children in care are in residential care and in Spain that figure is around 40% . Moreover, while we might think of Scandinavian countries being more liberal and using locked facilities less than the UK, they actually make far more use of hospital in-patient facilities than we do here.
It is estimated that about 10 to 20 % of children and adolescents suffer from mental health problems worldwide (Braddick et al. 2009). It has been well documented that children and adolescents in out-of-home care are at a much higher risk of mental health problems (Shin 2005, Besier et al. 2009). The World Health Organisation Mental Health Declaration (2005) for Europe highlights the need for comprehensive evidence-based policies targeted especially for vulnerable groups such as children and adolescents. It is generally agreed that collaboration among these two professions can improve the use of children’s mental health services (Bai et al 2009). These issues are not new yet there is little knowledge of what better collaborative practice might look like and there is a perception of inadequate training and lack of knowledge of each other’s respective disciplines
In Scotland, The Scottish Needs Assessment Programme (SNAP) Report on Child and Adolescent Mental Health (2003) emphasised that all agencies and organisations have a role in supporting children and young people’s mental health with three core themes: the right of children and young people to be heard, the importance of mainstreaming mental health and the integration of promotion, prevention and care. In Scotland the SNAP programme saw the establishment of Child and Adolescent Mental Health Services (CAMHS) framework. CAMHS have a tiered system of access/intervention with different models of delivery in different health board areas. Across Scotland meeting the needs of young people is indertaken within the overall context of Getting It Right For Every Child (GIRFEC) a model that is being embedded across all existing policy, practice, strategy and legislation affecting children, young people and their families.
National research projects
In total 59 interviewees participated in this research, 49 individual interviews and 6 focus groups were conducted. All the interviewees had a minimum of five years experience. Scotland contributed 7 interviews and 1 focus group. The information from the six national research projects was collated by the Finnish partners using Qualitative Content Analysis.
The findings indicated that effective collaborative practice is influenced by factors such as a workforce that knows its professional roles and responsibilities, differing professional models and unevenly distributed power and status. Status differentials were evident across all countries; residential workers perceive that their profession is undervalued by society, certainly in terms of salaries. Psychiatrists enjoyed a generally higher professional status than childcare workers. Childcare workers expressed that this differential proved a serious challenge to real cooperation, as they perceive mental health professionals as having the last word and the power to take decisions. Specific manifestations of this status differential were evident in seemingly small things such as the expectation that joint meetings were almost always held in mental health offices, reflecting a belief that psychiatrists’ time was more valuable than that of residential workers. Residential workers complained about the lack of information given back by psychiatrists in terms of discussion, follow up arrangements and reports. In general, they reported an unbalanced situation where psychiatrists requested information from childcare workers but didn’t see the need to feed back in the other direction. In addition care staff stated they felt unable to articulate the concerns they had and could be put off by the professional language/jargon that mental health professionals use.
Meanwhile mental health practitioners complained that residential workers attending appointments with children lacked information about the family background, medical history, and personal circumstances of children. Moreover, when treatment extends over a long period of time it is very common that residential workers accompanying children to appointments with mental health practitioners change, thus compromising any continuity in relationships.
These obstacles to collaboration were similar across Europe and echoed the comments from the Scottish contributors. Mental health staff felt that care workers had unrealistic expectations of what they could do. There was a sense that they “ask for miracles”, “wait for a miraculous medication”, “want very fast results” … .. (mental health practitioner, Scotland)
Psychiatrists and related workers in mental health services had a unanimous understanding of their main tasks as counseling, assessment, diagnoses and treatment (especially medication). By contrast, residential care workers found it much more difficult to define their main role and activities; they spoke about things like everyday life, home routines, preparing young people to become citizens and support for reflection. Their job was sometimes unpredictable requiring a flexible and spontaneous approach. Some of them felt that this reality could make them appear less assured in their position when engaging with mental health staff.
It was noted across the participating countries that good practice between the services seemed to happen when the professionals actually knew each other and worked closely perhaps on the same site or within the same project.
Development and delivery of the programme
Scotland was the lead partner in developing the training course, which reflected the other countries’ reports and research findings. A 15 module course was developed, each module with its own handbook, based on the broad themes: assessment, intervention, inter-professional working and international perspectives. The intention was, originally, for the same course to be delivered across each country at the same time with opportunities for joint learning.
However, there were difficulties across all countries in seeking to implement the course in such a coordinated fashion. In Scotland, while there was broad agreement about the benefit of the course, the wider context of financial constraints, for example resulting in unit closures, and the difficulty in funding staff backfill costs made it difficult to get staff from different agencies to attend. Therefore the Scottish partners narrowed the scope of the project to Kibble in the first instance.
In addition to the difficulties in implementing the course there was ongoing discussion about an appropriate qualification level. The original RESME aim was for a Master’s degree level module, which is not in fitting with the education needs of many of the care staff here, who were working towards a first level degree.
It became unrealistic to keep the European dimension tightly coordinated both in terms of delivery time and content across all partners. The partner countries needed to embed what they were doing in national context. Tailored pilot education courses were delivered and evaluated with an overall of 157 participants across all participating countries. Scotland focused on Kibble Care and Education’s social pedagogy students. We tried to extend invitations to attend the training to mental health workers but they were unable to participate.
The actual course delivered in Kibble consisted of 5 contact days. The content of the course focused on the importance of life-space and everyday care, social determinants of ill-health, diagnosis and interventions An international dimension was supported by visits from American exchange students, input from Danish lecturers and feedback from the staff involved in an exchange placement in Denmark.
The assessment for the course took the form of a presentation, reflective account, and an essay on social and medical models. The module is being validated by the University of Strathclyde for the social pedagogy degree they are developing with Kibble. The project will therefore be sustained as a module in the social pedagogy degree.
Evaluation and Discussion
From the evaluation from the 157 participants across the participating countries, a range of aspects were thought to be particularly helpful, including opportunities to network, to, exchange experiences, discuss case studies with an interdisciplinary perspective, work shadow and engage with relevant research literature.
It was evident across all partners that professions, such as psychiatry, based around what can be thought of as ‘hard’ technical-rational or scientific knowledge are thought to possess a more robust and useful knowledge than professions such as social work and residential child care which operate with knowledge that is harder to pin-down. Residential care workers are generalists or ‘experts in the everyday’ rather than specialist, scientific professionals. There are no ready-made solutions but sharing everyday life can afford residential workers a privileged access to observe and know children in ways that are important in understanding behaviours and mental health. It is perhaps this idea of practical knowledge that converges around a particular set of values that residential care workers need to begin to develop and talk up in respect of their professional expertise rather than looking to other professionals to provide answers to what they experience as puzzling and troublesome.
The project aimed to enhance the mutual understating and improve inter-professional working between mental health practitioners and care staff through the development of a joint training programme. However, this is not straightforward, the project identified widespread and persistent difficulties in the two groups working together. These difficulties included divergences in the status and respective expectations of the two groups but may reflect more fundamental divides in professional knowledge. Nevertheless, the project did spark a lot of interest, suggesting that the topic was one that did concern practitioners. A number of spin-offs from the project remain, such as the module on the proposed social pedagogy degree and ongoing events and discussion between the two groups of workers in Edinburgh.
Bai, Y., Wells, R., & Hillemeier, M. M. (2009). Coordination between child welfare agencies and mental health service providers, children’s service use, and outcomes. Child abuse & neglect, 33(6), 372-381.
Besier, T., Fegert, J. M., & Goldbeck, L. (2009). Evaluation of psychiatric liaison-services for adolescents in residential group homes. European Psychiatry, 24(7), 483-489.
Braddick, F., Carral, V., Jenkins, R., & Jané-Llopis, E. (2009). Child and adolescent mental health in Europe: infrastructures, policy and programmes. European Communities, Luxembourg.
Shin, S. H. (2005). Need for and actual use of mental health service by adolescents in the child welfare system. Children and Youth Services Review, 27(10), 1071-1083.
World Health Organization. (2005). Mental health declaration for Europe: facing the challenges, building solutions: First WHO European Ministerial Conference on Mental Health, Helsinki, Finland 12-15 January 2005.
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