Recurrent Care Resource Pack: Section 3

Section 3: Workforce development. Understanding ‘non-engagement’, attachment and complex trauma

The section covers:

• What we mean by engagement and non-engagement, and the underlying factors that may contribute to each.
• The concepts that underpin attachment-informed practice.
• The concepts underpinning trauma-informed practice.
• Tips from practice experts on taking this learning into the development of your recurrent care service.

This section includes three learning modules, comprising films and exercises. These can be used flexibly to set out a programme of shared learning for your team or workforce. Use them to build and enhance understanding in relation to complex trauma, non-engagement, and trauma-informed approaches.

Exercise 8: Understanding non-engagement and attachment through a case study

Time: Allow 30 minutes for the exercise

What you’ll need: The case study of Tina, flipchart paper and marker pens or Post-its.

What to do: Working in pairs or small groups (for 20 minutes), read the case study carefully. Then consider and discuss these two questions:

• How an attachment perspective might impact on your understanding of this mother’s interaction with services?
• What might you do differently?

Come back together for a whole-group discussion in the final 10 minutes. Note down any key points on flipchart or Post-its.

Learning Module 1: Reconceptualising non-engagement (attachment)

Allow 40 minutes to watch the four short films on non-engagement and attachment (Films 2, 3, 4 and 5). You may also want to allow a further ten minutes for whole-group discussion immediately after watching the films, or you can move straight into Exercise 8.

• Film 2: ‘Reconceptualising non-engagement in the context of recurrent care proceedings’ Speaker: Claire Mason, Senior Research Associate, Centre for Child and Family Justice Research, Lancaster University. Claire shares messages from the Vulnerable Birth Mothers and Recurrent Care Proceedings study (Broadhurst et al, 2017) on ‘non-engagement’ and other research relevant to this (8 minutes and 57 seconds).
  
  
• Film 3: ‘Attachment and social work practice: Part One’ Speaker: Danny Taggart, Lecturer , School of Health and Social Care, University of Essex. An introductory talk on developing attachment-informed social work practice (11 minutes and 17 seconds).
  
  
• Film 4: ‘Attachment and social work practice: Part Two, The Strange Situation test’ Speaker: Danny Taggart . Danny explains the experimental condition known as the Strange Situation Procedure and how it is used to identify young children’s patterns of attachment (3 minutes and 2 seconds).
  
  
• Film 5: ‘Attachment and social work practice: Part 3, Applying attachment theory to understanding “non-engagement”’ Speaker: Danny Taggart . Danny’s presentation focuses on attachment-informed practice with adults who have experienced trauma in their early lives (14 minutes and 14 seconds).

Learning Module 2: Reconceptualising non-engagement (complex trauma)

Allow 23 minutes to watch Film 6 in which Sheena Webb gives an introduction to complex trauma, followed by the theory underpinning trauma-informed approaches in practice.

You may want to allow an additional 10 minutes for a whole-group discussion, or you can move straight into Exercise 9 once you have finished watching.

• Film 6: ‘Explaining complex trauma and its impact on families’ Speaker: Sheena Webb, consultant clinical psychologist and service manager of the London Family Drug and Alcohol Court team. Sheena describes complex trauma and its impact, and introduces the theory underpinning a trauma-informed approach to practice (22 minutes and 31 seconds).

Exercise 9: Understanding non-engagement and complex trauma through a case study

Time: Allow 30 minutes for this exercise

What you’ll need: The case study of Amy, flipchart paper and marker pens, Post-its

What to do: Working in pairs or small groups (for 20 minutes), read the case study carefully. Then consider and discuss:

• How a complex trauma perspective might impact on your understanding of this mother’s interaction with services.
• What might you do differently?
• Come back together for a whole-group discussion in the last 10 minutes. Note down any key points on flipchart or Post-its.

Learning Module 3: Trauma-informed approaches in recurrent care

Allow 32 minutes to watch the presentation by Danny Taggart (Film 7) about trauma-informed approaches. You may wish to allow an additional ten minutes for discussion, or you can move straight into Exercise 10 below once you have finished watching.

If you’re working through these modules on different days, you may find it helpful to start this session by also watching the presentation by Sheena Webb (Film 6) about complex trauma. This would mean allowing 55 minutes for the films before moving onto the exercise.

• Film 7: ‘Trauma-informed approaches in recurrent care services’ Speaker: Danny Taggart, Lecturer School of Health and Social Care, University of Essex. Danny on designing a trauma-informed service to work with parents who have experienced recurrent care proceedings (31 minutes and 21 seconds).

Exercise 10: Thinking about trauma-informed approaches in your work

Time: Allow 30 minutes for this exercise

What you’ll need: Flipchart paper and marker pens, Post-its

What to do: Working in pairs or small groups for 20 minutes, discuss how the information about trauma-informed approaches (presented in this film and in the film about complex trauma) might inform your work with parents involved in recurrent care. In particular, try and identify:

• Any wider practice implications
• Practical steps for taking the lessons about non-engagement and complex trauma into practice.

Come back together for a discussion in the last 10 minutes. Note down any key points on flipchart or Post-its.

Background reading

Here are links to some helpful resources and further reading in relation to attachment, complex trauma and trauma-informed practice:

• Research in Practice Frontline Briefing on Parental Mental Health by Mary Ryan includes a short section on complex trauma.
• Sheena Webb and Tom Borro’s blog ‘FDAC – A trauma-informed service’ offers some examples of trauma-informed practice within an FDAC team. See further FDAC resources available.
• Dr Patricia Crittenden’s Dynamic Maturational Model of Attachment (Crittenden, 2015).
• Lisa Najavits’s manual Seeking Safety – A Treatment Manual for PTSD and Substance Abuse (2002): 
• Narrative Exposure Therapy (NET) is a short-term treatment for people who have experienced multiple trauma. Although NET’s official training centre is in Germany, it is possible to find qualified trainers in England – for example, at the Oxford Cognitive Therapies Centre, or at London Trauma Specialists.

Tips from Practice: Key lessons for setting up and/or developing your service

Below are a series of tips drawn from the presenters of material for this section, participants in the Change Project and colleagues working in a range of recurrent care services who shared their experiences with us. The tips can be used to prompt discussion after watching the presentations above and completing the exercises. They will also help with the planning and development of a recurrent care service.

Tips on staff recruitment

Look to recruit people who:

• Can engage with parents and not give up.
• Have the ability and willingness to work with risk.
• Can be flexible.
• Have empathy, confidence and compassion.
• Are open to learning and development.

When recruiting, put more emphasis on ‘show me what you do’ and not ‘tell me what you do’. You will be looking for a demonstration of values, principles and integrity. Using role play in an interview will be a helpful way of getting a sense of this.

Also consider involving a parent who has used your service, or something similar, in the interview process.

Here are links to a Job Description for a newly set-up recurrent care service in Leeds, together with their interview questions and suggested role plays.

Tips on ways of working that have been shown to be effective and are in line with trauma-informed practice

• Work at the mother/father’s own pace and avoid setting timescales if you can.
• Avoid ultimatums. Give parents the opportunity to move forward on their own individual path and at their own pace.
• Parents want to feel in control – they don’t want to feel ‘done to’ – so work alongside them.
• Listen to parents’ concerns and what they want to tackle. One colleague described this as: ‘I’m a passenger in their car and I’ll be there for them wherever they want to go.’
• Work with mothers, fathers, parents to find the key changing point – what do they think will make a difference?
• Don’t be afraid to be wrong and to say you were wrong or made a mistake – and to try again.
• Persevere cheerfully.
• Be open to discomfort, be human.
• Recognise that engagement can take a long time.
• Recognise that women/men will make wrong choices, and that you need to be able to cope with that.
• Bear in mind that asking a woman to leave a violent partner may create more trauma for her, so sometimes you need to work with both parents on this issue.
• Honesty is very important. You will need to be clear with parents that working with you will not automatically mean they get to keep their next child.
• Being hopeful is important. The most ‘vulnerable’ people, given the right support at the right time, can achieve amazing results.
• Think about the impact of loneliness and isolation, and how to help parents overcome them.
• Bear in mind the recent messages from research about poverty, its link with care proceedings and the impact of poverty on families. See Care Crisis Review Options for Change (2018):
• Take seriously issues of accommodation and debt.
• Think about setting goals with parents and working towards an exit plan.
• If your service sets a time limit on its involvement, make sure you are clear what will you have in place to support the parent once you have closed their case.
• Help mothers/fathers/parents to build a portfolio of what have they achieved over the period of their involvement with your service.

Issues to consider in relation to training

• Systemic approaches are important, so systemic training will be helpful. For example, one service working in the area of recurrent care (Action for Change based in Kensington and Chelsea, and Westminster) is located within a local authority that trains all its staff in systemic family therapy.
• Think about providing staff training in relation to trauma and trauma-informed approaches.
• Recognise that all relevant agencies need to understand trauma and trauma-informed approaches better, so argue for suitable training across services in your area.

Issues to consider in relation to managing your service

• Recognise that the complexity of some cases may reduce the overall caseload a single worker can deal with.
• Make use of reflective supervision/group supervision.
• There is now considerable evidence of the effectiveness of multi-agency teams when working with vulnerable parents with complex problems (Care Crisis Review, 2018; Sebba et al, 2017). Recurrent care services can include staff from social work, substance misuse treatment services, domestic abuse services, mental health services (child and adult), health (midwives) and staff from early help services, or third sector organisations with experience of supporting families.
• The advantages of a multi-agency team include the possibility of ‘team formulation’ of a plan, which can then be discussed and agreed with the parent. Team formulation is more commonly used in health settings. It involves a team discussion of the information collected through assessment (or conversations) and of the different risk and protective factors. The team collectively identify of the issue (or issues) that need urgent attention and the sort of help or support that is most likely to be effective. This would include looking at what has been tried before, always bearing in mind what the parent has told you about their experience of previous services.
  • As used in Leeds Futures and more widely across Leeds services, see an example of a team formulation mode.
  • See also the Research in Practice resource on ‘Analysis and Critical Thinking in Assessment’.
• Where there is no co-located, multi-agency team around the parent, but a range of services working with the parent, it is important to avoid the parent being overwhelmed by having to deal with so many different services. This can be done by taking the lead in co-ordinating the work and helping parents to negotiate the system, including helping them with diaries that give them some control over meetings and appointments.

Part of the 'Working with recurrent care-experienced birth mothers resource pack'.