Paper Review: Ethical considerations in social work research

Ana M. Sobočan, Teresa Bertotti & Kim Strom-Gottfried (2019) Ethical considerations in social work research, European Journal of Social Work, 22:5, 805-818, DOI: 10.1080/13691457.2018.1544117

Introduction

This is a paper whose aim is to place is looking at the ethics of research through a specific social work lens. What is it that might make social work research and the ethical considerations of it, different from other types of research in other fields. Although there are books devoted specifically to this (Morris, 2006, D’Cruz and Jones, 2013, Hardwick and Worsley 2011 and many others) it is a useful introduction to some of the key tensions and considerations which exist in the field. Not least, for me anyway, because it comes from a perspective of authors from Slovenia, Trento and the United States where most of my reading has been UK-based.

Methodology

In terms of methods, this is more of a piece combining literature relating to research ethics with some of the literature about social work research. Referencing BASW (British Association of Social Work) Code of Ethics and the IFSW (International Federation of Social Workers) Statement of Principles, it pulls apart from of the considerations that make social work research ethics different from research ethics, by adding an additional layer of professional responsibilities and values rather than by removing anything.

It does this with two case study examples illustrating where the values of a social worker as a professional may be at odds with the purity of the research process. In these two examples they are focusing on two particular ‘research values’ and explaining where the conflict could potentially arise.

Context

The examples they give as ‘case study’ type relate to the principle of nonmaleficience. This basically means that the researcher should not cause any harm, obviously not intentionally but unintentionally as well through their research with people. The authors draw on this fundamental principle of bioethics where there may be medical treatments involved and extrapolate to social work where there may be ‘harm’ that isn’t easily identified.

In their example, they refer to research in the field of child protection where there were potentially sensitive issues discussed but the research was around understanding the quality of services delivered from the view of families who received services.

This research was carried out in a focus group and this presented some stresses regarding the role of confidentiality and the use of a group setting where sensitive issues were discussed.

The dilemma identified stemmed from the formation of self-help and support group between people who were the ‘research subjects’ during the focus groups. Should the professional stop these conversations where those who were using services were providing advice and support to each other, talking about how they ‘managed’ poor services and provided useful help within the group? Or should they return the conversation and the group focus to the research questions?

The researcher in question moved the focus back to their research and away from the emergent discussion about how participants may help each other, but the authors leave us with the question about whether this was a misuse of power on the part of the researcher who is also a social worker?

The second case given relates to a social worker/researcher whose roles potentially overlap. On the one hand, the social worker is the ‘agent of change’ but the role as a researcher is to document what is.

In this case, the social worker was researching same-gender parented families. The researcher had personal experiences in this area which is what had led them to the research and in order to aid conversation and discussion, told the participants, so they knew they were speaking to someone who intrinsically supported their families and relationships.

In some conversations, the researcher, on listening to some of the challenges and discrimination faced, was faced with the dilemma of whether they advocate for the families who are ‘research subjects’. Would that change the focus of the research so that some stories became stronger if they were to give a view that might help the family?

These were some of the dilemmas that the authors saw as stemming from the dual role of social work practitioner and researcher.

Key Learning

By presenting case studies, the authors invite us to ask questions about potential ethical dilemmas across social work research, and to explore how these issues may be addressed in writing about social work research, for example, in papers that are published. How do we establish that the research has benefited the participants and social work itself rather than provided a professional stepping stone for the author? This is a useful challenge to reflect on as I make my way through research in the field.

The authors looked at the role of social justice in social work research which had taken place and how often it may have been referenced in studies over the years. They are particularly interested in the role that virtue ethics may play in research with researchers, particularly in social work, exploring their motivations behind the research and ensuring the research is beneficial to participants who are not seen as a means to an end.

The paper asks that universities who train novice researchers from the first steps, engage with ethics by ensuring the language is ethics is central because language feeds attitude.

They present models they have considered about how to review ethical impact, particularly looking at some generic ones which they transpose to a social work framework. The authors then demonstrate how the dilemmas presented in the case studies might work through these frameworks.

Reflection

I enjoyed reading this paper as it was clearly written and easy to follow. I enjoy reading about ethics anyway and placing research ethics within a social work context was immediately useful to me so it may have made my perception of interest stronger.

Some of the issues raised about ethics are specific to research. How do we choose research and subjects? Sometimes this is an individual decision, sometimes it relates to funding availability but it should have a purpose that serves the aims of the profession in terms of growth.

I enjoyed the case study examples as well, they were easy to follow in any context and not specific to social work in a particular area but they made the examples clearer.

Use in Practice

As I am increasingly moving into a different stage of research, this has provided practical contexts for me to reflect on how I design research to ensure that social work principles and standards are embedded in the design from the start, but it is also providing me with a template, through the models given, to review the research but also some of the work we might do on a day to day basis when we try to gather feedback or run QI-type projects, of being aware of any potential harm that may be caused.

It also reminded me of the need to look beyond some of the UK texts I usually turn to and broaden my understanding of professional literature internationally.

Conclusion

This was a useful paper both in terms of research ethics, where it is most relevant but also worth considering some of the points in a more general exploration of social work ethics and how we make decisions about priorities in a work role.

Reflection: On Linking Practice, Research and Writing about It.

After a month or so of writing on this site, after a couple of false starts over the years, I thought I’d reflect a bit on what I’ve learnt through writing and how my research work, day job and additional writing are coming together.

I have tried to develop more of a discipline with the writing. Whether this will see me through the next three years (or so) to completion of my doctorate or not, I don’t know but what I do know is that writing is easy when you are on a roll, but it needs to be a discipline in order to make it a habit. I have never been one for self-help books, especially, but it was a book I read that emphasised the point which, thinking about it, is obvious (which I guess is the same for many self-help books) that to write when you don’t feel like writing, is the toughest part.

It’s also incredibly easy to stop writing. Yes, it’s about creating a habit but it doesn’t always develop naturally through habit and just a day or two of a lapse, makes it much harder to re-start.

I tend to work towards deadlines. One of the hardest things I’ve found about moving to a research aspect of a degree rather than a taught part is the flexibility of deadlines and knowing this in my head. I’ve bought myself (I did this last year as well) an A4 day to view diary with monthly plans at the front and while I’m a big fan of digitalisation, this diary sits on my desk and I make notes about what I have done and am planning to each day. I have the next few months mapped out and whilst that may and is likely to change, I have set myself clear expectations.

My ‘research diary’ as such sits on OneNote but having a paper version allows for other notes and is particularly helpful for setting myself deadlines. The problem with deadlines is the disappointment when you fail to meet them but while trying to build a discipline, I’m also trying not to be too hard on myself.

Along that line, the writing has been on the basis that I will review one paper a week and one book a week. I have deleted one post I published because I was told (and this was correct) that I had fatally misinterpreted an acronym used in the research paper which had completely changed its meaning. This was a very useful lesson to me about assumptions made, on my part and on the part of those who write for us. I am also not sure if I will be able to keep to that pace. I read a lot anyway, and a lot of the books I am reviewing, are books I’ve read over the last few years but having the discipline of trying to write regularly can be helpful, when it doesn’t involve too much pressure. It’s that balance between discipline and self-criticism that one has to walk, especially if you are particularly tired or stressed from work on one day.

While I want to succeed, I often have to prioritise work on a day to day basis and trying not to feel guilty when I spend days doing not-work, not-study things is also a focus.

I write because I want to practice writing. I am not looking at ‘hits’ or developing a loyal readership as I know I am quite selfishly choosing topics which are interesting to me. I choose papers I have found useful, either for my studying or for work. There is a paper that I read recently, that I thought was really poor and a book that I thought didn’t set out what it intended to. Generally, all the papers and books I have written about, I’ve found useful, helpful and well-written. I may need to develop more confidence before confronting the critical although that is a useful skill as well and one I will try to work on.

Often the last few years, I’ve had more division between my part time study and full time work. I had some study days generously granted by my employers and I brought some of the additional reading I had done into the workplace in exchange, including developing some additional mental capacity training which was rolled out. As I moved into a different job, the links are becoming easier to create because I am doing social work and studying about doing social work. It’s not always intrinsically linked because the areas of social work are different (long story) but what it has done is made me far more aware of the breadth of social work and the value in not compartmentalising the profession into ‘mental health’, ‘child protection’, ‘dementia’, ‘learning disabilities’. The ‘social work’ runs deeper and needs to run deeper than the topic. However, it has become more difficult to separate the time between work and study. I’ve had to actively use more leave which has an impact on the time to rest. This, I hope, will improve but it is a worry.

The other area I have become more aware of is the links and divisions between research and practice. Practitioner research happens and is happening. I am evidence of that. But in order for the profession to grow, it needs to happen far more. This isn’t about battle lines drawn between academia and practice. If anything, I have seen those are increasingly unhelpfully divisive, but we need to make space for more conversations and more conversations with the people who aren’t used to having these conversations – about how we can work together and how we can draw in more user and carer voices.

So I will try and continue as far as I can with the writing, as long as it helps me to learn. I keep telling myself that if I stop now, what I have learnt has already been worth the time (and financial) investment. I may move to one review post and one more flexible post, whether it’s posting links, an update on where I am going or how I use the various tools I use (I am currently on my fifth reference manager). Thank you for joining me.

Research in Social Work – January 2020 links (Open or Free Access papers)

When I started writing at the beginning of the year, I thought I’d compile a summary of links each month about news and research, but it became a bit too much to compile, and this is, fundamentally a hobby for me.

So, I’ve decided instead to highlight each month some open access papers that I’ve found useful, interesting or have bookmarked for later, that others might want to read because we all want accessible research information and the more we read, the more we understand what is worth reading. So here are a few for February – they aren’t always new, but they will be new to me!

This paper in Social Work Education (May 2019) looks at how critical reflection is taught in social work courses specifically in relation to working with older people.

This issue (2018) of the British Journal of Learning Disabilities is open access (most aren’t) so is worth browsing and includes (among other interesting ones) this article which is a study on what is it link to move house for people with learning disabilities.

This is a free access review of literature about trauma-informed care in inpatient mental health services (2013) from the International Journal of Mental Health Nursing which is a useful way to get a broader view of the topic at the moment.

On a slightly different tack, Critical Social Policy have an open access article from January 2019 on ‘Raising Critical Consciousness in the struggle against poverty’. Nice of them to make it free! Seriously though, we need to speak about poverty and the impact it has on our work at every level.

And Practice – Social Work in Action, has this article about decision-making of AMHPs which is a useful read from 2019.

Although this is not ‘my’ area of social work, this paper in Qualitative Social Work from December 2019 with birth mothers’ accounts of the impact of the removal of their children on their future lives has impact for all of us in the sector.

This 2017 paper on the role of trustworthiness in social work from Australian Social Work is definitely something I found helpful in my consideration of how we carry out ethical social work.

Book review: Social Work Theory – A Straightforward Guide for Practice Educators and Placement Supervisors

Introduction

This book by Siobhan Maclean and Rob Harrison from Kirwan Maclean Associates Ltd (best ordered directly from the publisher) is a book written with a specific purpose to run through the different models and theories of social work to equip those teaching and learning in placement settings to have a broad understanding of their students’ needs.

Context

Kirwan Maclean have a reputation for producing social work textbooks and materials which are very much focussed on social work practice rather than the idea of social work which can exist in some text books which are written with a university market in mind. I have actively used this book as a practice educator and beyond that in broadening my understanding of social work models and theories as I try to link them in to the work which I undertake on a day to day basis.

I am a big fan of this publishing house and can honestly say I’ve never read anything from them that hasn’t immediately jumped to the top of my ‘most useful’ pile because the books are written to be understood and used rather than studies and the authors don’t care much for using academic language where it is not necessary. I’ve always believed that the best writers are the clearest writers and Maclean and Harrison certainly achieve this.

Summary

The book is set out into eight sections. Each section has a dedicated bibliography and includes some tasks to use with students relating to the topic covered, immediately helping the busy and maybe (I’m thinking of myself here) tired practice educator who needs new ideas.

The first section is background about practice education and the context of teaching social work in a practice setting. Teaching at work is a particular skill set and the teaching part is fundamental. Students are training in skills but they are also learning about practice. The book emphasises the importance of the education role as it includes theories of learning that were mostly familiar to me from my my practice education course. This was reassuring as it allows a refresh, especially after a few years.

The next sections look at different models, frameworks and theories, separated logically and allowing a ‘pick and mix’ approach when the student returns from university with a new theory. It starts with anti-oppressive practice (such as social and medical models, feminist and race perspectives) followed by human development and learning theories (including attachment theory with both children and adults, and models of grief and loss). Then the book covers a section on using theories in the assessment processes – this includes a section on risk assessment and models of assessment including how theories such as strength-based perspectives are used in practical contexts. The next sections are about models and theories which influence ways of intervening and they are split into ‘counselling models’ such as psychodynamic approaches. Then, those approaches and models based on social work frameworks such as systems theory, task-centred practice and crisis intervention. The models that will be very familiar to any social work student. Maclean and Harrison finish with consideration of organisational theories and leadership before covering the use of eclecticism.

Each theory or model has a roughly 4-6 pages with a brief explanation of the background, some examples of how it happens in social work settings and then some thoughts at the end of how you might ask a student to think of the theory.

The book is very accessible and easy to dip in and out of. It allows a quick refresh of concepts that may be a bit ‘rusty’ but also gives a useful bibliography where more can be explored if necessary.

There is a broad range of theories that should be a good start and cover most of what’s needed in practice but if it isn’t, it allows frameworks to talk about theories in practice settings.

There is a comprehensive presentation of a wide range of theories and models, explained clearly with pointers for further and deeper investigation.

Use in practice

The joy of this book, as with many from Kirwan and Maclean is its immediate practical value and use. From the moment I bought it, it proved its worth ensuring that I was able to catch up and refresh some of the theory and models that I had learnt years before but also allowed me to familiarise myself with the language of social work theories again. While we all know it shouldn’t, practice as a social worker can sometimes struggle, outside a student placement and practice education context, to call back to the theoretical contexts and the ‘why’ of what we do. While this book is very much aimed at practice educators, it has a use far beyond that for the practising social worker whose initial training may be a few years back and who wants to refresh understanding of the why and how we justify what we do within a professional framework.

I’m not teaching students anymore as I don’t take students on placement (I may, in the future but I’m fairly new to my job now). I was out of direct social work practice for a number of years. Picking up this book, which is genuinely a pleasure to read, allowed me to reconnect with the ‘why’. It is perfect for practice educators who like clear and concrete examples, written accessibly by knowledgeable authors who do not patronise their readers by over-complicating unnecessarily. But it also has a use far beyond that, for all who practice or who want to practice social work.

Conclusion

This is one of those books with a purpose, which it states on its cover and it does exactly what it says on the cover. You want a straightforward guide to social work theory and you’ve got it. My only addition would be to say that it isn’t just for practice educators. Although there is a separate version which is adapted for student social workers (which I always recommended to my students on placement), this book suits more experienced practitioners who want to refresh and revise those connections with theories and it can start a journey, with helpful links and references, back to picking up the why as well as the what we do.

Paper Review: Emotional Intelligence, Emotion and Social Work : Context, Characteristics, Complications, and Contribution

This post is about this article:

‘Emotional Intelligence, Emotion and Social Work: Context, Characteristics, Complications and Contribution, The British Journal of Social Work, Volume 37, Issue 2, February 2007, Pages 245–263, https://doi.org/10.1093/bjsw/bcl016 by Tony Morrison

Introduction

This paper looks at the way ’emotional intelligence’ may link to social work practice by aligning it’s use with five core social work tasks ‘engagement of users, assessment and observation, decision-making, collaboration and cooperation and dealing with stress’

Context

The paper starts with a definition of emotional intelligence as

Being able to motivate oneself and persist in the face of frustrations: to control impulse and delay gratification; to regulate one’s moods and keep distress from swamping the ability to think; to emphasize and to hope’

p246 – quoting from Goleman 1996

The author sets up the links between emotional intelligence and social work (specifically social work with children) by explaining different models of emotional intelligence in different settings and applying them to social work. This is a discussion paper rather than describing research so the methodology is based on reflecting on literature relating to emotional intelligence and linking it to social work settings and environments.

Emotional intelligence literature emerged from management and business studies. The author as an academic teaching social work practice, found the literature useful in describing some of the skills and attributes necessary for competent social work. He draws links between literature about emotional intelligence and social work practice and drew this together with a study in the US about nursing practice (Benner 2001) and developing competencies in nursing which found that the emotional state of the nurse could impact on the quality of patient care. It was this ‘intuitive’ aspect of care which the author tries to link with good social work, beyond technical knowledge of practice.

He draws on literature reflecting the danger of social work becoming a series of skills to be learnt rather than a way of understanding to do undertake tasks skilfully. This is linked with the move towards managerialism in social work. Ironic, then, or perhaps not, that there has been the turn to the language and concepts of management.

By presenting emotional intelligence as learnable, it therefore becomes teachable which is key within a social work department in a university.

Learning and gaps

In looking at core social work skills identified by the author, he refers to them in the context of emotional intelligence. With engagement he refers to the lack of choice that people coming into social work services would have and why the initial contact may be filled with ambivalence or fear. Moving to assessment and observation, he relates to the importance on inter and intra-personal skills and the need for sensitive and responsive assessment as poor communication can lead to poor assessment. Part of this process is about understanding and interpreting emotions on both sides of the conversation that is an assessment.

Regarding decision-making, the author refers back to the challenge of objective (or ‘professional’) judgement as if there is a pretence that emotion does not play a role. I’d argue there is no such thing as objective judgement in social work because we have to bring ourselves into every decision we make but that’s more about the research work I am doing and why I chose it. Decisions cannot be made without understanding the place of emotion.

With collaboration and co-operation, he refers to emotion as a representation of the collective experience, including institutional experiences. Social work exists within the institutions in which we work and we need to understand organisational dynamics to work effectively. We also need to work with difference. This is where the author, somewhat tenuously, in my view, brings in the need to work with diverse groups and ensure we tackle and address discriminatory attitudes.

Values and knowledge about discriminatory forces have to be integrated with inter-personal skills, if practitioners are to be able not only to identify, but also challenge, such forces appropriately

p258

Finally, the author turns to the necessarily social work skill of dealing with skill and developing coping strategies. He relates the ability of social workers to seek help themselves when they might be approaching burnout as a key tenet of emotional intelligence. Practitioners who are able to create positive social and professional networks of support will more likely thrive and he links this to relevant research.

Use in practice

This paper is a literature-based study linking the work around emotional intelligence to the attributes needed for social work practice, particularly focusing on social work with children. It is an interesting approach and he has drawn some useful links identifying how the context of writing can be regarded from a different angle to have professional relevance. Personally, I’m not entirely convinced that pulling in management think is always helpful in understanding professional practice within social work. We need to ensure our language and how we describe what we do is not tied up with the latest zeitgeist management talk. However, where there are useful elements to glean it is important that we do not ignore them.

Regarding practical learning from this, there were two aspects that I thought I would take with me from Monday morning. One was about building supportive networks personally and professionally in order to ensure I am looking after my own support and development needs in order to thrive effectively as a social worker and secondly ensuring I have an awareness of the role my emotion plays in my report-writing and assessment as this has an enormous impact on the lives of those I am working with.

Conclusion

This was an accessible paper which drew together strands of literature to extract the core of good social work as separate from the ability to carry out social work tasks or have a good handle on social work skills. In some ways, I see the emotional intelligence as being linked to practice wisdom, as it is sometimes called, the sense of instinctiveness to make judgement quickly and remain open to challenge, learning and change.

The author expresses concern about the growth of managerialism but hope that by capturing the essence of social work in a concept which is basically teachable seeing ways forward for the profession. Personally, I think time and space is needed to develop the capacity for understanding the role emotion and individual subjectivity play in important social work tasks which is why reflection is necessary. Maybe less fast-track and more slow development will build the emotional intelligence necessary for good practice.

Book review: How to Write a Lot – A Practical Guide to Productive Academic Writing

I read ‘How to Write a Lot – A Practical Guide to Productive Academic Writing by Paul J Silva published by American Psychological Association – I have a copy of the 1st edition (2007) which is the one I am reviewing below but I have linked to a more recent 2nd edition (2018).

Introduction

To write well, you need to choose good words.

p61

This is a short and accessible book from the US Psychology Academic. The background of psychology becomes more important through the book and it is intended to be a ‘tap on the shoulder’ type book nudging reluctant academics and people who need to write in academic contexts, towards writing. I can’t remember how I came across it, if it was on a reading list or a recommendation (mostly how I decided what books to buy).

Context

As mentioned above, the author, Paul Silva is an academic psychologist based in the US. He has taken the approach of writing in a conversational manner and the book is intended to spur writers who may not see themselves as writers to ‘get on with it’. It would be of less use to experienced writers who have their own systems in place.

Of course, it also serves as a means to delay actually starting writing because you are writing it but fortunately, it is a short book which does not need a lot of time to cover.

The author covers a broad range of topics at a steady pace, including starting out and just writing as well as, more specifically, writing for publication including journals and books. The book itself is 132 pages.

Summary

Delete very, quite, basically, actually, virtually, extremely, remarkably, completely, at all and so forth. Basically, these quite useless words add virtually nothing at all ; like weeds, they’ll in fact actually smother your sentences completely

p64

The book is divided into chapters that cover the areas you would expect, including knocking down those barriers, including the excuses like ‘I don’t have enough time’ or ‘I need to read more about X before I start writing’ as well as ‘I don’t have any space/working PC etc’. They’ll be all the usual ones you can think of. Silva comes back at the reader with responses, some more helpful than others.

Ultimately, the reason is often related to time or alternative priorities with work or life, to which the answer is, unsurprisingly, just write and allocate protected time to write. This isn’t a wonderful relevation but it is a message which can keep being knocked on the head to make sure it has a difference.

Silva may claim to not always have been a planner but a planner and a scheduler you need to be if you are going to write effectively and productively. Planning your writing, counts in the writing time and setting achieveable goals is important as well and give yourself deadlines if noone else is going to. He also talks about prioritising projects and how those priorities can differ and that needs to be fluid.

He likes monitoring progress by word counts or meeting specific daily goals which might work if reading is writing.

To Silva, ‘writers block’ is not something that happens to academic (as opposed to creative) writers. It is just ‘not writing’ and by ‘not writing’ you have ‘writer’s block’. The way to cure it is to write. This is about approaches, attitudes and excuses. It might be that some writing needs more editing than other writing because of the flow that develops but it can be progress and it can be measured all the same.

There is a chapter specifically about style and the importance of clarity in writing. This includes a good reminder to write for audiences that may not have English as a first language. The best writing is accessible and readable. Use jargon when it is necessary but don’t import it in if it does not add to the understanding of the reader. This may be a good discipline in all writing exercises and tasks. He reminds us, as writers to think of the meaning of the words you use, each one having a function to increase clarity. This is a lesson which stuck to my heart as I often write with excess verbosity.

Strengths and Gaps

Silva writes unapologetically as a psychologist and the book is published by the American Psychological Association (APA) so examples about journals and book are based on psychology. I don’t think this is a weakness or a gap so much as a ‘thing to be aware of’.

As he goes through the different parts of a paper and how to construct them, he includes a section on the importance of references and what the reference section means. I have not seen this in a book of academic writing previously but that might say more about my reading than about what is out there but I found this helpful.

It was useful to see a differentiation in the way writing would be approached when considering papers with empirical research and ‘review’ articles, both of which he covers.

This is, though a small book. It probably won’t teach you information you have not come across before regarding how to start writing and get writing but it is concise, clearly written and accessible. It is quite pricey though so might be worth tracking down in a library or getting a second hand copy (as I did).

Use in practice

This is an eminently practical book which has immediately led to some changes in behaviours and ways I think about writing. While it isn’t about innovative new methods, the point about writing is you just have to do it and the way to get better at it is doing more of it, so the book serves to grant permission to believe in yourself and your ability to improve by doing.

For myself, I tend to schedule writing time anyway. I write and study at weekends because I work during the week but it has made me consider how much time I may be able to add to weekdays before work and how to quantify the writing I do. For example, I am now editing this post at 5.45am when I usually get up for work at 6am. I’m also writing a blogpost instead of academic writing though, so swings and roundabouts. Writing is writing!

Silva makes writing – including articles and books, accessible. It seems like the ‘I can do it and so can you’ attitude prevails to the extent that I almost begin to believe it. More importantly, it is a fun book to read. It wasn’t difficult to sail through it quickly. It wasn’t an effort to read which some texts can be.

Conclusion

This is a useful addition to the toolkit for someone who is new to academic writing. It can also serve as a cheerleader in the resources to give more confidence to do what you do regarding writing and to feel better about writing than not-writing. Style is essential but practice embeds style. I would recommend this if you come across it, particularly in a library.

The link to buy it is at the top of the page – this is not an affiliate link. I bought this book for myself.

Paper Review: Human Rights : Its Meaning and Practice in Social Work Field Settings

This post refers to the following paper :

Julie A. Steen, Mary Mann, Nichole Restivo, Shellene Mazany, Reshawna Chapple, Human Rights: Its Meaning and Practice in Social Work Field Settings, Social Work, Volume 62, Issue 1, 1 January 2017, Pages 9–17, https://doi.org/10.1093/sw/sww075

Introduction

As I have covered Australian and British social work papers, I thought I’d turn to the United States with this one and while I have read and learned about human rights in the context of English mental health and mental capacity legislation, the ability to see where the global human rights debate is, was appealing. It has been useful to look at where research is focused in the US where the role of social work has some distinct differences and the cultural context may not be as similar as we sometimes assume.

Context

The research study which was carried out involved interviews with social work students and and ‘field supervisors’ who are experienced social workers as might be obvious, who are supervising students in their initial training placements.

The paper starts with a literature review which covers social work and the role of human rights in social work settings. This has the UN Universal Declaration of Human Rights in 1948 as the starting point but diverges by looking at some of the additional principles to cover, what they describe as ‘population-specific’ conventions including the Convention on the Rights of the Child and Principles for the Older Person which grew up subsequently. There is also reference to some of the work which has linked human rights with social work in a broader context and where human rights practice crosses with social work. This includes the role of advocacy in social work and an interesting distinction between case-based advocacy and cause-based advocacy. There is also reflection on the role of community based social work as human rights in practice.

It was interesting reading through a UK lens where obviously the European Convention of Human Rights doesn’t figure but also where the UK-based literature on human rights and social work would not have been as relevant to the article. This is very much my ‘little England’ view and a literature review is never going to be comprehensive. However, it also introduced me to a broader understanding of human rights, encouraging me to read further and put my focus on UK human rights into a better global perspective.

Methodology

One thing I noticed in this study which was helpful (to me, as a novice researcher) was that the authors explicitly stated their research questions which were

“What means do social work students and their field supervisors attribute to the concept of human rights as it relates to their work in field settings?” and “How do social work students and their field supervisors describe human rights practice in their own agency meetings?”

Having the research questions clearly established helps with appraising the research which takes place and helps understand decisions made regarding research design.

In this case, the authors took a phenomenological approach. These terms can sound like a different language intended to detach academic world but it only means that it is looking at the experiences of people who have them from their viewpoint. It is not an ‘objective’ study but that would not have been unsuitable for the research questions which are asking about how the participants experience and understand human rights in their practice and so phenomenology fits well.

The study was carried out through online questionnaires. Online surveys were sent out to students and supervisors and they were open for responses for two months. There were, in the end, 35 student participants and 48 supervisors. There was a mix of students on different programmes (Batchelors and Masters) and mix of gender and race which was established in the results. The average age of students was 20 and the average age of supervisors was 45. I noted this only because I can’t imagine the average age of UK students would be so low. So another notable difference.

The survey contained a mix of open-ended and structured questions.

Results

The researchers divide the outcomes into seven themes in terms of identification of human rights issues relevant to practice and five themes under which they described their own practice or observation of practice.

In terms of the human rights overlap with social work, the most common theme identified was poverty, in addition to this was discrimination, participation, self-determination, autonomy, violence (right to live free from violence where violence is expanded to mean abuse), dignity, respect, privacy (including confidentiality) and ‘freedom and liberty’.

Poverty identified reflected the resources that link to access to housing and healthcare. This obviously has a different context where healthcare is mostly on an insurance basis but presented another layer of the economic and social human rights which occupy the social justice element of social work and embed social work as a human rights profession.

The interesting point the researchers made about discrimination was that students primarily focussed on discrimination faced by LGBTQ+ groups whereas the supervisors more often referred to cultural competencies and gender based discrimination.

The themes of participation, self-determination and autonomy emphasised the right to have the means to determine ones’ own destiny, including refusing or discounting professional advice.

The group of supervisors who referred to ‘freedom and liberty’ were non-descriptive. It is an interesting expression of a more abstract concept as a right.

In terms of practice and how they saw human rights expressed within the agency there were five themes determined. These were advocacy, service provision, assessment and relationships.

Advocacy was reflected in both individual practice with clients and in terms of challenges within organisations. The researchers distinguish themes of case advocacy versus cause advocacy. Cause advocacy was more heavily emphasised by students. Service provision included areas like psychoeduction and providing direct support to groups of people that had specific needs. I’m not sure of case management as human rights but that might be about my prejudices and understanding of the term rather than the way it is meant by the participants.

Assessment was seen as a human rights engaged activity as a process in order for ‘needs and wishes’ to be met. I think this may be a bit tenuous at best because I prefer ‘conversations about needs’ to ‘assessments’ but that might be my issue with the language. Sometimes, assessments need to be assessments. Do they always lead to resources that are necessary? Perhaps not.

The relationship was interesting as it was presented as being key to human rights in practice including the honesty and transparency of the connection. For the purposes of the paper, treating people with dignity, care and in a way that is free from discrimination were part of the relationship.

Key learning for practice

There were a couple of interesting elements that I took from this paper. It was fascinating to read about human rights from a non-European perspective. It made me itch for more exposure to international research. Struggling to match human rights in principle to work that social workers apply on a day to day level can be a challenge and this research addresses this by asking about both conceptual and practical visions of human rights.

The language of human rights was measured in the research and it can make us think about the language we use in practice. Do we talk about assessments meeting wants and needs or about assessments as processes to be completed? Do we distinguish and action both case and cause advocacy? We might not be able to to both but do we recognise it when we do it.

One of the things I thought I could do as a result of this, was self-audit some of the small actions and conversations I have and records I write in each week, meetings I attend and consider how human rights legislation and principles are enacted in practice.

Reflections and gaps

I enjoyed reading this paper and enjoyed particularly seeing the process of a research project including research questions being described. Of course, the study was based on students and practice supervisors. It would have been interesting to see the outcomes if it had been practitioners at various stages of their careers. The different areas of practice were not also clearly differentiated so it wasn’t clear how many worked with adults or children and in what settings, for example. This might have produced further interesting results. It was a relatively large sample (I thought) and the survey was an interesting way of collecting data, particularly large tracts of data but I wondered about how useful (or different) interviews might have been.

Conclusion

One of the things that struck me (and possibly the authors as well) was the lack of reference to race and discrimination on the basis of race and culture particularly by the students who were interviewed. This was something I wondered about in terms of teaching within social work settings as well. The authors speculate that this might align with gaps in the teaching curriculum although discrimination in the LGBTQI+ community was more heavily referenced by students.

Poverty came up as a strong theme in discussion but in practice it wasn’t always clear how this was challenged and addressed. This is more about where some of the cause advocacy might focus, perhaps.

Policy review: NICE Guidance on Decision-making and mental capacity

The guidance referred to is available here.

I decided to branch out from books and papers and look at some NICE guidance and maybe some policy documents too in weeks to come. I present this as very much a ‘non-expert’ but rather as someone working in this area who wants to make sure I am aware of best practice.

NICE and the place of NICE in Social Care

As a brief introduction, it is useful to note the role of NICE. The National Institute for Health and Care Excellence (NICE) was founded in 1999 as an independent body which produces advice and guidance about best practice in medicine and health. After the 2012 Health and Social Care Act, the body was asked to provide guidance on social care and the first social care guidance was issued in 2014. It is a non-departmental government body.

Background to this guidance

The guidance on Decision-making and mental capacity was published in October 2018 as NG108 . As part of the process of writing guidance, NICE committees will involve experts (including experts-by-experience). Alongside the guidance itself, NICE publish the methodology which is useful as a new researcher to understand how to write up scoping literature reviews as well a methodology although it is in a lot more depth that would usually be necessary. It includes which databases were used for searches and what phrases and words were used, which studies were included and which were excluded. They also detail the expert testimony included and who was consulted and inputted into the formation of the document.

Context

The guidance was written in the light of numerous reports and studies (which are detailed in full on the NICE website) which pointed to a mismatch between what the legislation and Code of Practice say about assessing capacity and making decisions about capacity on behalf of people when they may lack capacity to make those decisions in the context of health and social care. Of course, the Mental Capacity Act (MCA) and its scope move far beyond the health and social care sphere but for the purposes of NICE, that is where their scope lies. The guidance was actively commissioned by the Department of Health to help people using the Act in practice to engage with it.

The guidance is used alongside the primary legislation, Code of Practice and growing case law and provides practical assistance both to both health and social care professionals and organisations that employ them and those who commission these services regarding duties, expectations and best practice goals.

As the Code of Practice is being updated now, until it emerges, this is the most recent guidance that practitioners can turn to. Personally, I have found it enormously useful in my work, not least making me more aware of expectations. I know colleagues who have been more critical but for me, it’s been a useful tool.

The guidance specifically excludes reference to deprivation of liberty safeguards and areas of decision-making and mental capacity for under 16s which have different legislative frameworks.

Summary of key recommendations

The guidance divides along the lines of key recommendations and divides them into recommendations for individual practitioners, for service provides and for commissioners. So reading this, one can choose the parts that relate most to the area that impacts.

Regarding individual practitioners, as that is where my interest lie, I was disappointed that some of the key ‘know the law and apply the principles’ has to be stated. It shouldn’t need to be part of formal guidance. Some of the guidance is stuff that shouldn’t even need to be said but perhaps reflects where some of the drive has come. Areas like, ‘make sure you document past and present wishes, beliefs and preferences’ may seem like they don’t need to be said but by expressing, them it ensures expectations are clear. When we are writing records, we are not just writing for tomorrow, but also for 10 years in the future.

The guidance also emphasises the importance of sharing information including information about accessing advocacy services. Obviously I won’t list all the recommendations here as a lot of them are ‘do what the Code of Practice’ says but there is a stronger emphasis on recording reasons for decisions and involvement.

The other area that I saw was strongly emphasised was the importance of advance care planning. By nature a lot of work in a busy organisation happens when it needs to and perhaps this is more focussed on social care staff who may be working in a more preventative capacity to think about and document advance care planning and give people the opportunities to understand and make advance decisions.

When explaining the process of actually undertaking an assessment of capacity, the guidance emphasises the need for collaborative approaches to be taken and refers to particularly difficult situations where someone may have a brain injury which affects executive functioning which may call for a more structured assessment.

The guidance is clear that a documented assessment of capacity must exist before a best interests decision is made. Some research has reflected that this has not always been consistent in practice. There is also a specific section of the guidance devoted to involving family members and those who are involved when best interests’ decisions need to be made. Although this might be obvious for people using the Act and Code of Practice, it strengthened the clarity of challenge when these steps are not taken.

To organisations that provide services and employ health and social care staff, there are specific guidelines which are highlighted. These include ensuring that staff have access to better training (they talk about more investment in training). They should also ensure there are robust monitoring procedures in place including outcome measures which involve people who have been assessed and the level of collaboration in decisions being made.

They are also tasked to ensure that the systems they have in place have a clear way of recording preferences and advance care planning including advance decisions.

Commissioners have recommendations which vary in strength from asking them to ‘consider’ increasing the scope of Independent Mental Capacity Advocates (IMCAs).

There are some areas of oversight that are emphasised and recommendations about systems being in place to ensure good practice is followed but there has to be a will to change in order to do this and that is probably not the priority of some who commission services.

Thoughts on the recommendations

Generally, I’ve found the NICE guidance helpful. Although I hope it doesn’t tell people using it anything new, it is a clear representation of some of the ‘how’ in terms of carrying out a mental capacity assessment and taking best interests decisions.

Recommendations, like all NICE guidance, are just recommendations in the end. The call on commissioners and service providers to provide more investment in training is something that requires analysis of the training which has taken place and why it hasn’t been useful. I have my own theories but this probably isn’t the place for them.

Given what the scope of the project, I think the recommendations remain unambitious. Yes, we should involve people but investing in training needs outcomes of training to be measured. Having key people in place to push mental capacity as a necessary knowledge set is key and shouldn’t rely on champions who have been picked because no-one volunteers. For me, work around capacity and best interests is a fascinating area of power dynamics, control and push between state and individual which needs to be explored in more depth and given more life in practice. If it is presented and trained through online tick boxes as if it’s just another burden to complete rather than a way to work with an individual and their family or people important to them in a collaborative and exciting way, it can influence attitudes to the processes.

But that’s probably outside the scope of the guidance!

Use in practice

I have found this to be eminently useful in practice, from the clear examples given about how to involve people in decision-making to the retelling of the legislation with recommendations about how they can be used better. Some of the recommendations can be completed by individual practitioners today, others need financing and systems to be changed but anyone who is involved in assessing capacity or working with patients and service users to build pictures of individuals through care planning and incorporating advance care planning can find the guidance immediately useful.

Conclusion

I have probably not explored relevant NICE guidance as much as I should have and this is the first guidance I have seen which directly influences my day to day practice. It has been useful to read through and I have a copy on my desk at work which I direct people to. One of the key uses for NICE guidance, particularly when there are recommendations for organisations, is to highlight through management when they are not being adhered to (I’m terribly popular with my managers!).

However, even for the key steps of assessing capacity, there is useful, clearly written and up to date guidance and for that, this is worth both accessing and using actively.

Book review: Research and Evaluation for Busy Practitioners : A Time-Saving Guide

This is a review of Research and Evaluation for Busy Practitioners by Helen Kara first published by Policy Press in 2012. I have a copy of the first edition so I have reviewed that but there is a second edition available.

Introduction

This book is written by an independent researcher and writer, Helen Kara, who has written a number of books about research. This book fills a space because it is very much aimed at practitioners who are employed in ‘non-research’ roles, like, well, social workers but by no means only that, who are thinking of starting research and/or evaluation projects in a work setting. Through writing the book, Kara interviewed 20 different professionals who contribute. The writing is interspersed with key ‘advice’ quotations which stand out from the text. I have to say my favourite one was

You don’t have to read the unreadable

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Research is useful, doing research is an important professional skill and using research evidence is necessary to stay current in work environments. However, not all research is good research and critical analysis needs to accompany the reading/writing/doing of research, just as it does in practice environments.

Context

The place this books inhibits is partly about a guide to research for non-researchers and partly taking people who are confident and experienced practitioners and putting them in a ‘research’ space.

I found the most useful part of the book was the tone. Often, and I have read a lot of ‘how to research’ and ‘beginning research projects’ books which are entirely aimed at first year undergraduates or at least, early stage postgraduates.

While I have an MA in social work, and for that, I needed to complete a dissertation, it was entirely using secondary data and as part of a qualifying course, research methods and methodology was not emphasised beyond the immediate need and the push to make things as easy as we could for ourselves in getting through the degree programme.

Kara is able to speak to people like me. I am not new to my subject (in this case, social work) but having qualified in 2000, I have not been used to the language of academia. There is a particularly useful glossary at the back of the book which gives very short, one or two sentence definitions for research terms which will be second nature to those within academia but can increase the distance for those on the outside. Often, in many sectors of work, knowing the language and the terms is such a key part of understanding what is being said and how to say things. Finding the common language is key and that’s where I’ve found a lot of this book incredibly useful.

Key points

This book, as the title says, takes the busy practitioner who has a job alongside research, through the process of defining what project it is that will be undertaken, looking for research questions and better defining the tasks and best way of gathering data to answer the questions, gathering the data, including use of interviews, focus groups and quantitative data sources. Then glances through data analysis and dissemination.

These are all the same key points that would be made in many research texts for those who are new to research. What sets this book apart is that it is not aimed at academics or students. There is a useful pragmatism and an acknowledgement that perfect isn’t possible in a messy world with competing priorities. I had never read, for example, the distinction between a document review and a literature review or thought about why designing a research project on the basis of what is most feasible is not a ‘get out of jail free’ card but an entirely legitimate approach.

Kara touches on all the key parts of research, including research ethics and involving people who use services you might be working in including a breezy nod to the importance of being a practitioner in the development of emancipatory research and action research as well as an explanation of the difference between them.

Use in practice

The whole book is very much built about being able to use its contents in practice but for me, the key take-aways, apart from the additional knowledge of research and the language it uses to sometimes create a veil of mystery around the work of researchers, has been a re-stating of the idea that research doesn’t sit in a box distinct from practice. It is a challenge to integrate research into practice until you realise what you are doing anyway is using a lot of research skills, particularly if you are involved in audits and evaluation work.

As practitioners we have interviewing skills, skills to manage groups, skills to discern quality of evidence provided. These are all research skills.

There are some handy practical tips as well, such as managing information, making notes and keep track of references which has been immediately useful. The book also addresses issues such as funding and allowing time (or not) for research alongside work, often full-time.

One of the areas which is probably a bit outside the scope of the book that I think I’d have liked to see more of, was less about the doing research which is very robustly covered and a bit more about using the research evidence in practice and tying research into practice contexts, particularly when there isn’t time or support to carry out full research projects. Some more examples of the small projects which have to run alongside work would be useful.

Saying that, I found this an incredibly useful resource and it is a clearly written text which occupies a gap in the market and as such I’d definitely recommend it.

Summary

This was a book which spoke to me because it catered to a professional, skilful audience who are just not in synch with the language of academia and some of the skills of research. Although one of the key takeaways that I found particularly helpful was the idea that often use the same skills that are needed to undertake research and evaluation, in a work environment but don’t always recognise them as such. We have conversations (interviews.. ), we write assessments (reports), we analyse information which is provided to us and determine the output based on evidence.

Being spoken to, as this book does, as a skilful and knowledgeable professional who just wants to know more about how to do research in a work environment which may not always be supportive, rather than as an 18 year old undergraduate who is at university for the first time, is a great relief.

I have read a number of Kara’s books, which no doubt I will return to at other times but if you fall into the category of ‘wanting to start research but not really sure of some of the things that everyone takes for granted’ this is a perfect place to start. Even in the third year of the studies, I found it a refreshing.

We need research in practice and we need to undertake research in practice. We need to understand the basis of evaluation work and need to speak the language of evaluation and research to thrive in a professional context and this book is a great start.

The book can be bought here (I’ve linked to the second edition on Amazon – this is not an affiliate link – although I may add some later, I will always state explicitly when I use affiliate links).

Paper review: The Mental Health Act Assessment Process and Risk Factors for Compulsory Admission to Psychiatric Hospitals – A Mixed Methods Study

This post refers to ‘The Mental Health Act Assessment Process and Risk Factors for Compulsory Admission to Psychiatric Hospital : A Mixed Methods Study‘ – Wickersham, A, Nairi, S, Jones R and Lloyd-Evans, B. Published in British Journal of Social Work in April 2019.

Introduction

This paper presents a mixed method study using data from mental health act assessments followed by interviews with AMHPs (approved mental health professionals), s12 doctors and some AMHP managers in a focus group.

A Mental Health Act Assessment is a formal process in England and Wales, which relates to the provisions of the 1983 (as amended 2007) Mental Health Act. It is the process by which a person can be compulsorily detained in a hospital which is registered to provide care and treatment. An application for detention is made by an AMHP (who is a social worker, nurse, occupational therapist or clinical psychologist who has received additional specialist training and is approved by the relevant local authority) and it requires the recommendation of two doctors, at least one of whom should be independent (the other can be the treating psychiatrist or can be a GP) and who has preferably received additional training under section 12 of the Mental Health Act.

This process is commonly known a ‘sectioning’ a person.

Methodology

The study is described as ‘mixed methods’ because it integrates elements of quantitative and qualitative research methodologies. The researchers took a range of data from AMHP reports following Mental Health Act Assessments and the information held on electronic databases within the trust to analyse some characteristics and outcomes of people who were assessed under the Mental Health Act within a specific time period. 150 records were analysed, including retrospective case record audits of which 146 were included. The researchers noted that there were fewer, and less complete records for assessments which had not resulted in detention which meant they covered a longer period in order to ensure some were included.

Only assessments which took place in the community were included and anyone who was recalled on a CTO was excluded.

Some of the characteristics identified or used to differentiate included what, if any, diagnosis the person assessed had, whether the reason for assessment was due to concerns about risk of harm to self and/or others and whether a ‘lack of capacity or insight’ was noted (I’ll come back to this).

Then the researchers undertook semi-structured interviews with 4 AMHPs, 4 section 12 doctors and ran a focus group with 3 AMHP service managers. These were subject to thematic and content analysis.

My first thought was that it was a small group of interviews and that it might reflect a lack of balance in the importance of each conversation but the number of AMHPs within one trust is small so as a representative sample of 53 AMHPs employed it was a fair percentage.

The paper refers to the outcome of the study being discussed with the AMHP leads and involving ‘a research colleague who has lived experience of using services and working as a peer support worker in the participating trust’ but that just begged a few more questions in my view.

Context

This study took place in one London trust. It is described as an ‘inner London trust covering two local authorities’ which, for anyone who knows London mental health, narrows it down to one trust. I had to try to stop myself being distracted by this because I was an AMHP in one of those boroughs, in that trust, so kept thinking of people I used to work with, but that’s not the best perspective from which to start reading a paper in a neutral manner. However, it does emphasise the truism that we don’t read papers in isolation of our own experiences and knowledge of situations. So while, in one sense, I am trying to move away from that and read the paper as if I had no idea where it was and who might be being interviewed, I am also able to acknowledge the role that self, and background knowledge always plays when we read papers and research.

The aim of the study was to focus on potential increases in the level of detentions and to look at any barriers to alternatives to admission or what might or might not influence decisions to detain someone under compulsion which is an extreme action regarding the deprivation of liberty of another person in the context of state infringement of the human rights of another person.

Key learning points

Some of the themes identified will be familiar to those who have worked in this field for any length of time. One related to the potential difficulties caused by not having three professionals assess at the same time. A doctor may make a recommendation and this can be followed up by an assessment with a doctor and an AMHP attended at the same time. One of the issues identified was that the first recommending doctor may be influenced to recommend detention, as the paper states

‘ one doctor suggested that, as the first to do an assessment, it can feel safe to recommend detention and pass responsibility to the second doctor’

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This was followed by the further discussion that the AMHP and second doctor may be influenced by the first recommendation.

Issues were raised as well about the individual different in attitudes, experience, knowledge and confidence with understanding risk thresholds which can be key to the outcome. Personality and unconscious bias may play a role in the outcomes of assessments.

One of the key themes to emerge, unsurprisingly, was that the impact that lack of alternative options to admission, made on the decisions to detain. If there were no places in crisis houses, capacity in crisis resolution teams, day services that met the needs of the person who required support, family and informal support in place, it could have a significant impact on the outcome and decisions made. Lack of access to substance misuse services may also have an impact on some decisions.

It may also be about the assessing team not knowing what the alternatives are for that person. One of the key pieces of learning the researchers emphasise is the potential difference in outcome when someone has a member of their community team present, or a family member or someone who knows the individual. This can help to identify both options and the lack of suitable options.

There were some issues raised around poor operational processes including the role of inpatient services. This included poor discharge planning which led to hasty readmission and poor continuity of care between community and inpatient teams. There were some additional factors which might be more relevant in the type of area it is, around access to support for people who are non-UK residents. This is an area which may include some people who are visiting the area.

Reflections and gaps

The paper identifies some of the difficulties in identifying data in the assessments considered for inclusion and reflects that out of the 150 assessments analysed, 22% had missing or incomplete AMHP reports.

The identification of ‘lack of capacity or insight’ as one of the categories in which the assessments were sorted, indicates to me a lax approach to the term and use of ‘capacity’. I never want to see the term ‘lack of capacity’ in any document that doesn’t refer to what the lack of capacity is for. I accept this is my pedantry, but is if it ‘lack of capacity to consent to an admission to hospital for assessment or treatment’ it wouldn’t take many more words to say so and these phrases add to the general misconception around capacity and/or insight, that it can be applied broadly, or maybe it’s me not understanding the implicit suggestion that this is specifically capacity to consent to admission.

The sample size is local to one trust so the findings can’t necessarily be used to evidence situations in other geographical areas. The interview sample sizes are small which can attribute far more importance to one or two, what might otherwise be, throw-away lines. That doesn’t mean that the importance of what is said isn’t valuable. It is, but it needs to be recognised in the context of the sample of assessments and the sample of interviews.

The involvement of management staff was key to understanding some of the context in which the study happened and the management team reviewed the data which was prepared for inclusion but that does offer a consideration about any self-imposed restraints that those interviewed might have felt in terms of criticism of the organisation, given that the sample size was so small. However, saying that, there was a fair bit of criticism for the organisation coming through but it may have been a factor.

The study only looked at community assessments because the focus was on avoiding hospital admissions. This meant that the voices of those who are detained in hospital and views of inpatient teams are lost. It is possible, especially with longer admissions, that some inpatient staff may have built up a different perspective about blockages and this aspect was intentionally lost. That is due to the limitations of the study rather than a lack of thought in the process.

This is research which is about the outcomes of Mental Health Act Assessments and the process of completing them. The study was focussed on professional views and records. There was a researcher who was there to review, who had lived experienced and the purpose of this research was to present a professional perspective but I wonder if there are more gaps around involving people who have experienced detention, in the processes of research and using social work research as empowerment. I know there are other studies which have and are doing this so it does feel like an unfair criticism but I felt it would be remiss to ignore it totally.

Use in practice

So what does the paper tell us that we can use in practice? The key headline and of course, this may be increasingly difficult in the face of cuts in services, is the importance of having someone who knows the person being assessed, present as part of the assessment, whether that is the care coordinator, or a family member or person who works with them through a third sector organisation.

It is also preferable to have the assessing team carry out the assessment at the same time. Often this is not lacking because there is an intention to make the process more challenging but due to availability of staff who are more frequently pressed by competing needs. It is useful to point to a study which evidences this as a factor.

The other aspect is to keep pushing for better options around prevention. This isn’t something that everyone can change but we can keep advocating and shouting for improved services which lead to better outcomes . I don’t know how much difference this makes when it is a factor that is far bigger than the individual practitioner, team or even organisation but it always needs to be referred to and having the evidence to do so is helpful.

Conclusion

This was a very useful paper to me in a lot of ways. It helped to show the way that mixed methods can be used effectively and how they can form a cohesive approach to understanding a problem. The outcomes and concerns raised were ones I recognised and I suspect will be recognised by those of us working in this space. Did I learn new things? Possibly not, but I found I have evidence to back up some of the assumptions made and that is key to pushing changes and improvements. If organisations can be presented with evidence linking the lack of capacity in the service, to involve people who know the person being assessed in the assessments and show that this leads to more admissions and therefore more cost, it may be a trigger to change systems.

And even if it isn’t, it allows us to talk about about what we see with more authority.

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