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Case Study
Wayne's story
Hello. My name is Sarah Alexander and I am Wayne Brown's social worker.
Wayne is fourteen years old and the subject of a care order. He was brought into care when he was seven due to neglect, and prior to his admission, lived with his mother who is addicted to heroin. Since being in care, he has experienced several foster home breakdowns but is now settled in a supportive foster placement.
Wayne attends the local secondary school but is regularly in trouble with teachers and other pupils because of his withdrawn, hostile and aggressive attitude and behaviour.
Care Order
A child or young person can be made the subject of a care order if he or she is not receiving the sort of care it would be reasonable to expect a parent to provide, and if this lack of care is considered to be causing the child significant harm. The decision to take out a care order is made in court and will depend on whether the child or young person in question is thought to be child is suffering harm in this way.
Neglect
'As at March 2005. there were 27,900 children on child protection registers in England and Wales, with around 600 more boys than girls. Neglect was the most common reason to be placed on the register, for 45 per cent of boys and 42 per cent of girls. Emotional abuse was the second most common reason, with around one-fifth of both boys and girls on the register because of this.' (Social Trends 37, 2007: 111)
Heroin
Heroin is a member of the family of drugs called opioids. This includes natural products, such as morphine that comes from the poppy and synthetic products, such as methadone which is used to help the withdrawal symptoms of heroin.
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Case Study
The impact of adversity and difficult life experiences on behaviour
We have heard that Wayne is in care and is experiencing difficulties at school. Given these experiences, and the limited information available, please take a moment and use the notepad to jot down:
- the kind of behaviour you would expect to find if you were Wayne's social worker?
- what points would you consider when planning and preparing to meet with Wayne if you were his social worker?
When you are ready, compare your answers to our suggestions, by using the following links, and see if you identified similar types of behaviour and points to consider as we have.
Compare your answers to our suggestions. Did you identify similar behaviours and points to consider?
Behaviour
The kind of behaviour you would expect to find if you were Wayne's social worker
On the limited information available, it would be difficult - and misguided - to assume that Wayne will behave in a particular way. However, the impact of adversity and painful experiences - whether intentionally or not - can often leave people feeling guarded, particularly with strangers. Wayne may be a highly resilient individual but given the difficult life events already experienced, he could come across as:
- silent and withdrawn
- mistrustful and difficult to engage
- hostile
- aggressive
- angry
- bitter
On the other hand, Wayne could communicate that he is:
- worried
- scared
- confused
- hurt
- despondent
- distressed
- depressed
- someone who lacks confidence, has poor self-esteem and low sense of worth
Resilient
'When the individual's self-system is under stress, resilient people are able to maintain psychological integrity; they remain able to draw on a range of personal strengths to cope with adversity and life's ups and downs. They continue to be purposeful and focused problem-solvers. Other people continue to be seen as a resource and not necessarily part of the problem. Resiliences include self-esteem, self-efficacy, self-reflexivity, social empathy and autonomy.' (Howe et al 1999: 30)
Points to consider
Points to consider when planning and preparing to meet with Wayne
- How do you think Wayne may feel about seeing you today (positive, keen, apprehensive, indifferent, worried, scared, resentful, angry, etc.)?
- What are his expectations likely to be - both positive and negative - and how will you elicit these?
- Where will you meet with Wayne and how will you organise the setting/room?
- How will you welcome him?
- What situations are likely to trigger negative reactions and how can these triggers be avoided?
- What will you do to defuse the situation if Wayne becomes 'difficult'?
- From your point of view, what is the purpose of the session and how do you plan to communicate and negotiate the requirements or expectations that you have to meet?
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Case Study
Working with silence and withdrawn behaviour
Here we'll explore the different communication skills you might use, and options you might choose, if you encountered a similar situation.
For example, imagine you are Sarah and you have arranged to meet with Wayne who arrives late for the appointment and is refusing to speak. Ten minutes have passed and Wayne has said nothing and refuses to answer any questions.
What would you do? Click on your chosen option to see how it might work in this situation
- Option 1 - end this session
- Option 2 - Sit with Wayne in silence, hoping that in time he'll feel able or feel prepared to respond?
- Option 3 - Sit with Wayne for 5 - 10 minutes but then use your capacity for empathy to put forward some ideas as to why Wayne may not be able to speak?
When you have viewed all options click 'Next' to continue.
Case Study
Option 1 - end this session
If Wayne comes across as unable to communicate, perhaps because he's upset, or unwilling to speak, it may be appropriate to end the session. It would be helpful to explain your reasons and at the same time make another appointment, thereby leaving open the possibility - and the hope - of a better rapport being established at some future point.
Try another option.
Case Study
Option 2 - Sit with Wayne in silence, hoping that in time he'll feel able or feel prepared to respond?
If you decide to sit with Wayne in silence, it would be important to decide how long you are prepared to do this and what you hope to gain from this course of action. Any period of complete silence can seem a very long time so it's important that you can see a clock/your watch without being too conspicuous. Remember that some people can find silence very disturbing and may be silent because they're distressed so this may not be the best course of action. However, if, during this period, you decided that Wayne is deliberately and belligerently blocking your attempts to communicate, you may decide to confront this behaviour.
confront this behaviour
There are times when it is important to confront certain kinds of behaviour, or where we find discrepancies or a 'lack of fit' in the details presented, but it can be difficult to know when and how to confront in ways that help to move the situation forward (Trevithick 2005: 237-9). The ability to confront people - without giving rise to more defensive and guarded reactions - is a skilled activity that involves insight, judgement, courage, understanding, tolerance and patience, remembering that the ultimate goal is 'action and change' (Lishman 1994: 121).
Try another option.
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Option 3 - Sit with Wayne for 5 - 10 minutes but then use your capacity for empathy to put forward some ideas as to why Wayne may not be able to speak?
If silence has been the mode of communication for several minutes, this does not necessarily mean that you need to remain silent. Instead, you may decide to speak into the silence, using your capacity for empathy to put forward some ideas as to why Wayne is not speaking? (see scripted example of speaking into silence on the next section).
Try another option.
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Case Study
Speaking into silence
Below is an example of how Sarah could have worked with Wayne's silent behaviour to encourage some dialogue.
Practitioner [Speaking in a slow, quiet voice]: You have been silent for some time now Wayne. I'm sure that you came all this way today for a reason - but right now, I can't see what that reason is - or how I can be helpful.
Wayne: [Silence. Shuffling impatiently, communicating indifference]
Practitioner: If you don't want to talk Wayne maybe I should use this silence to communicate what I think is going on - and you can tell me if I'm wrong. These are difficult times Wayne - some of the changes we've hoped to see in your behaviour haven't yet happened. I wonder if you've said to yourself that it's better not to talk - in case you say something you might regret or because you're scared. I think that you are talking but you're talking to yourself. What are you saying to yourself Wayne that you can't say out loud? [Pause] What are you're scared to say? [Pause] You came here today for a reason - and it would be a shame to leave without having said why you came - what you want - Wayne, how I can help?
Wayne [Speaking belligerently]: I'M NOT SCARED! If you really need to know, I came because if I didn't come, I'd get into more trouble - SO THERE!
Case Study
Role play exercise (three roles: service user, practitioner and observer)
In pairs, take it in turns to sit in silence for 5 minutes each way. The practitioner should ask relevant questions in an attempt to engage the service user, but the service user should remain silent throughout.
A third person should act as an observer and make notes of the questions asked, body language and other points observed in the role play.
In the feedback, all should comment on how they felt as the service user, practitioner and observer - and what they noted about how slowly/quickly the time passed, the body language used, their ability to remain silent, to ask good questions, etc.
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Defences
All human beings have defences some of which are unconscious, that is, reactions that for the most part lie beyond our immediate awareness and control. Defences have two key features. First, their purpose is to guard us from further harm - protect us from thoughts, feelings, actions or events that are felt to be threatening, anxiety-provoking and painful - or that signal danger in some way. They are not set up intentionally but emerge in order to help us cope with the anxieties and conflicts that we encounter in everyday life.
A second feature is that defences can distort reality, which can make it difficult to acquire an accurate picture of what's happening. This helps to explain why people can have widely differing accounts of the same situation. It can also remind us that the 'presenting problem' may have some underlying features that warrant further exploration and understanding. We experience life through our history and our defences constitute one element that shapes our understanding and the meaning we give to particular experiences.
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Case Study
Here are examples of types of defensive behaviour. Of these defences, denial and avoidance are particularly difficult aspects of Wayne's behaviour.
Projection
This involves locating feelings, actions, thoughts or attributes that are unwanted to other people. For example, in a conversation with Sarah, Wayne stated "You must be fed up with me", whereas it later transpired that what he actually wanted to say was "I'm fed up with you" but felt unable to say this, or to recognise and acknowledge his feelings at that time."
Regression
This can easily be confused with 'child-like' behaviour but as human beings, we all have a tendency to regress at certain times in our lives, that is, when difficult life experiences are encountered we can sometimes slip back to an earlier stage in our emotional development - to reactions that are younger than those of our chronological age. However, for some authors regression is also be seen as opportunity to grow and to develop because it indicates the need to return to point in an individual's development where emotional growth has been stuck or 'frozen' (Winnicott 1965: 286-287). Wayne's tendency to regress is evident in the degree of helpless dependency he demonstrates when he is unwell.
Repression
This is sometimes called amnesia and describes the way that individuals forget or wipe from their memory - and awareness - any thoughts, feelings, actions or events that they experience as threatening, frightening or anxiety provoking. For Wayne, he can't remember any events that happened before he was seven years old.
Denial
This describes a situation where information or events are rejected or blocked from awareness if it is considered threatening, frightening or anxiety provoking. If we relate this to Wayne, he denies any responsibility for the difficult behaviour he's demonstrated at school.
Avoidance
Describes the different ways that people dodge or evade information or events that give rise to worrying thoughts, feelings, etc. Wayne communicates his unconscious desire to avoid difficult issues by being late for appointments, arriving unprepared, leaving early, refusing to speak and by avoiding any discussion of his behaviour.
Distortion
A situation where reality is exaggerated or underplayed to fit into a person's version of events. Serious distortions, where people experience hallucinations and delusions, are a feature of some forms of mental illness. Wayne's perception of events indicates that he can seriously misread situations and people's motivation
Other behaviour that some authors describe as defensive patterns include displacement, reaction formation, idealisation, rationalisation splitting and sublimation.
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Case Study
Dealing with difficult events
We pick up this case study at a point where Wayne has been accused of stealing a mobile phone from one of the pupils and as a result, he has been referred to the Youth Offending Team (YOT).
Sarah is due to visit the school to meet with Michael Greenwood, the YOT worker, before meeting with Wayne. During this meeting, it becomes clear that Sarah and Michael have a different approach to working with Wayne. These two approaches communicate - through action - the different ways that people can be encouraged to change their behaviour.
Click on the two approaches below to find out more.
Case Study
Michael's activity based approach
Michael's view is that Children's Services have been too lenient with Wayne and he is particularly concerned that counseling can be interpreted by young people as condoning and excusing unacceptable behaviour.
Instead, his approach aims at providing a range of activities designed to enhance confidence, self-esteem and a sense of personal responsibility.
Michael wants to give Wayne every chance to change his behaviour. However, Michael is clear that if Wayne's behaviour continues to deteriorate, procedures will be initiated for Wayne to be excluded from school. He quotes a comment from Jacqui Smith (2007) , a UK Cabinet Minister , who stated, 'I've zero tolerance of anti-social behaviour, and zero tolerance of its causes' (Summers et al. 2007).
Zero tolerance
A zero tolerance approach stresses that people must be made to account for their behaviour and that any attempt to excuse, explain or justify unacceptable, anti-social or criminal behaviour will not be tolerated.
Example activities include:
- organising outside activities (e.g. football, climbing, outside visits, etc)
- setting up reward systems to reinforce good behaviour (camping trips, outward bound courses, school privileges, etc.)
- linking young people to positive role models (e.g. peer and adult volunteer mentoring schemes)
Case Study
Sarah's relationship based approach
Sarah's starting point is that in order for people to be able to accept - or to make use of - support that is offered, they have to feel safe and to have a degree of trust in other people. Therefore, Sarah's focus has been on trying to create the kind of relationship and safe and trusting environment that can help Wayne to feel less threatened so that the emotional energy that is currently locked in trying to defend himself can be released and used to enhance his options in life.
To achieve this aim, Sarah's approach focuses on understanding as a key element. This understanding involves helping Wayne to look at how he comes across to other people and how his defences are holding him back and stopping him from making friends and exploring life in ways that could be exciting and enjoyable.
Sarah thinks that Michael's approach has great potential and would complement her work very well. However, she has is a question mark as to whether Wayne has the inner emotional resources, particularly the self-discipline, to take up and benefit from Michael's activity based approach.
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Case Study
Question
In the discussion between Sarah and Michael, it is clear that each of them has a different approach to working with the challenging behaviour that Wayne presents.
Of these two approaches, which one do you find more appealing? Michael's activity based approach or Sarah's relationship based approach
Click on 'Next' to see the feedback.
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Case Study
Both these practice approaches can be effective but a great deal depends on the individual concerned, the issues presented, the context and the particular approach adopted by different agencies or organisations - in this case, school and Children's Services. However, work of this kind is likely to be much more effective if both internal and external factors - barriers and opportunities - are taken into account.
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Case Study
Encouraging people to take responsibility for their actions
During the meeting, Sarah and Michael ask Wayne to explain his version of events about the mobile phone incident, but Wayne refuses to discuss the incident (avoidance) and to deny any involvement (denial) - despite the fact that the phone was found in his bag. Instead, he insists that he is being 'picked on' because of his reputation and the fact that he's in care (a possible distortion of events but further evidence is needed).
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Case Study
Encouraging people to take responsibility for their actions
Think about the different communication skills you might use, and options you might choose, if you encountered this situation where you were confronted with defensive behaviour such as avoidance and denial.
What would you do? Click on an option to find out more.
- Option 1 - take up the issue Wayne has raised (being picked on)?
- Option 2 - take Wayne back to the incidents to encourage a discussion of his version of events?
- Option 3 - make Wayne aware of his behaviour and the fact that he has changed the subject?
When you have viewed all options click 'Next' to continue.
Case Study
Option 1 - take up the issue Wayne has raised (being picked on)?
Depending on the situation, and how Wayne comes across, all 3 options could be an appropriate focus for your communication and intervention.
The concern Wayne is communicating may be true. If so, it would need to be discussed and, perhaps, action taken. Once this has happened, it may then be possible to return to look at other issues. Also, if this topic is foremost in Wayne's mind, it's likely that introducing a different subject will meet with resistance. Instead it might be wiser to focus on why Wayne feels 'picked on'. If, however, you think that Wayne is trying to avoid discussing his behaviour, or refusing to take responsibility for his actions, Option 2 or 3 could be more appropriate.
Try another option.
Case Study
Option 2 - take Wayne back to the incidents to encourage a discussion of his version of events?
This course of action may be appropriate if you feel Wayne is avoiding a discussion of the mobile phone and bullying incidents but it's essential to hear his version of events. Different power dynamics can lead to young people's views being ignored, particularly when these contravene the views of people in authority. Creating a safe and trusting environment could encourage Wayne to communicate - if this fails, you may need to be more challenging but in ways that ensure that the communication does not become stuck.
Challenging
Being 'challenging' describes a low level, gentle yet firm invitation to face service users with 'contradictions, distortions, inconsistencies or discrepancies and inviting or stimulating them to reconsider and resolve the contradictions' (Lishman 1994: 121), where they may otherwise be reluctant to do so.
The timing of challenges, and how they are undertaken, can be as important as what is actually said because challenges should come at a point where it is clear that the person in question is unlikely to pick up on the 'lack of fit'. For example, some people do not understand how they come across and the extent to which some aspects of their behaviour can be off-putting or set people against them.
A well timed challenge should strengthen our relationship, whereas one that is premature or inopportune, perhaps because it is too forceful, persistent or moves too far ahead of a person's understanding, it could damage the relationship and threaten progress, sometimes irreparably. Millar et al. (1992) see challenging as a form of feedback and stress the tentative nature of the communication as a means of aiding further self-reflection and understanding: 'What interviewees need is a chance to consider what behaviours they display, how they "come across". What appear to be less helpful are attempts to present analyses of underlying meanings, interpretations or evaluative statements' (Millar et al. 1992: 97).
Try another option.
Case Study
Option 3 - make Wayne aware of his behaviour and the fact that he has changed the subject?
If it is evident that Wayne is avoiding any discussion of his behaviour, you may decide that your only option would be to confront what is happening. However, before choosing this option it is important to consider whether Wayne can manage to face - and to bear - the consequences of his actions. Depending on his personality, inner resources and the context, Wayne's capacity to accept responsibility for his behaviour could be hindered if he is overwhelmed by feelings that immobilise him, such as intense feelings of guilt, shame or anxiety. If this situation is encountered, there would need to be follow-up contact.
Try another option or click 'next' to continue.
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Case Study
Dealing with hostile behaviour
The interview is not going well. Wayne is still refusing to discuss the incident or his behaviour. The situation is becoming very heated and Wayne has started to swear.
Sarah and Michael think they should assert clear boundaries in response to Wayne's swearing but since this is their first joint interview with Wayne, they need to consider the best course of action under the circumstances.
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Case Study
Dealing with hostile behaviour
The following options explore the different communication skills you might use, and options you might choose, if you encountered a similar situation where a young person begins to swear at you.
A great deal will depend on what swearing is intended to achieve and the form that this takes. For these reasons, the ability to tolerate swearing can vary widely but most practitioners would find swearing that is directed at them personally unacceptable, such as comments about their appearance or competence. On the other hand, certain words are considered to be completely unacceptable irrespective of the circumstances.
What would you do? Click on an option to find out more.
- Option 1 - insist that Wayne stops swearing immediately. Otherwise, you will end the session.
- Option 2 - ignore the swearing and carry on with the issues you want to discuss with Wayne.
- Option 3 - Option 3 - invite Wayne to think about his swearing and the kind of reaction it's likely to produce in others.
When you have viewed all options click 'Next' to continue.
Case Study
Option 1 - insist that Wayne stops swearing immediately. Otherwise, you will end the session.
This may be the best option if the intention behind swearing is to be deliberately hurtful or to sabotage your efforts to communicate and to discuss issues of importance.
Try another option.
Case Study
Option 2 - ignore the swearing and carry on with the issues you want to discuss with Wayne.
This course of action may be appropriate if the intention is to shock you or, again, to take you off course. It involves considerable effort and concentration to be able to ignore persistent swearing but it's important to remember that some households adopt swearing as a normal mode of communication and some people do not recognise swearing as an offensive form of communication. If it proves impossible to stay focused on the interview, one of the other options should be considered.
Try another option.
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Option 3 - invite Wayne to think about his swearing and the kind of reaction it's likely to produce in others.
This is the most risky option because it can be thought to condone swearing and other disrespectful forms of communication. However, if being permissive and non-judgemental is one of your aims in order to establish safety and trust, or if you consider it bordering on discrimination to insist that people change how they communicate, then this option may be appropriate.
When people are allowed to speak openly and freely and given the freedom to say anything that is on their mind, it can uncover issues that they consider troubling or upsetting that otherwise may not be obvious or never come to light. However, in relation to young people, such as Wayne, it is essential to stress that in other contexts, such as in school, swearing is not acceptable and will not be tolerated.
Try another option.
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Case Study
Dealing with aggressive and threatening behaviour
If Wayne's behaviour had deteriorated to the point where he became aggressive or threatening, it would be important to remember the following points:
- Most service users are not violent but some can express their anger and frustration in frightening ways
- Beware of falling into a 'siege mentality'. An excessive preoccupation with self-protection can interfere with our being able to establish a trusting rapport with service users. One of the best ways to defuse the situation is to try to engage the person in a dialogue
- Our best protection is our skill and capacity to avoid and to deal with aggressive and potentially threatening encounters because once we have acquired these skills, they travel with us into all situations.
- The ability to leave without inflaming the situation is an important skill
- It can be helpful to remember that people who are frightened can behave in frightening or threatening ways. In some situations, it can be appropriate to reveal how frightened we feel - and the fact that we mean no harm
- If we feel that we may have played some part, however small, in provoking a hostile or threatening response, this needs to be brought out into the open but in an atmosphere where no blame is apportioned and our actions are seen in context.
In all situations it is important to make sound organisational arrangements.
Organisational arrangements
The importance of sound organisational arrangements, such as:
When working away:
- carry a mobile phone when working away or doing home visits
- work with another colleague when considered appropriate for your safety and the safety of others, including the person who is being threatening
- ensure that your agency are aware of your whereabouts and movements
When working in an agency:
- work out a contingency plan beforehand if someone has a history of frightening, aggressive or violent behaviour
- know the location of alarm/panic buttons
- ensure colleagues are being in the vicinity and aware of the situation
- position yourself within easy reach of the door but ensure that the exit path for the other person is not blocked
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Case Study
Dealing with violent behaviour
If Wayne's behaviour had become violent, different boundaries would have to be considered (Koprowska 2008: 140).
Some research studies indicate that violence against social workers is increasing (Kemshall and Pritchard 1999). For example, it was found that 25 to 30 per cent of social workers have been physically assaulted at some point in their careers (Rey 1996).
Except for situations involving self defence, it is good practice for all violent attacks to be reported to the police because it gives a clear message that any physical assault against another human is illegal and will not be tolerated.
Many of the points raised on hostile and aggressive behaviour are relevant when confronted with violent behaviour.
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Case Study
Unfortunately, events overtook the work that Sarah and Michael had planned when Sarah was informed of the death of Wayne's mother.
In a meeting with her supervisor, Sarah discussed how to communicate this upsetting news to Wayne and it was agreed that the safest place to talk to Wayne was his foster placement. However, who should be present and who should communicate with Wayne was less clear.
Please take a moment to consider who you might think would be the best person - or people - to break this difficult news to Wayne.
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Case Study
Breaking bad news" background
In the discussions that followed, it was agreed that the best person - or best people - to break the news of Wayne's mother's death should be those individuals who have the most sensitive, trusting and open relationship with him.
Various options were considered. Select the option below that matches your thoughts.
Breaking bad news - 6 points to consider:
1. Think about how you might feel if you were to be told this news. What might you need?
2. If known to you, think about what information you have about the person in question and how he or she might feel and react.
3. Think about how best to break the bad news in terms of:
- the setting and where best to communicate this 'bad news'
- who else might need to be present to provide comfort and support
- your choice of words, tone and timing and other non-verbal forms of communication that could be helpful and provide comfort
- how to avoid being interrupted
- if agency based, the role of other staff if e.g. informing the receptionist about the difficult news that you are about to communicate and the fact that the individual is likely to become upset
4. What additional or follow-up work may be needed in order to ensure that the individual is able to cope and to manage the feelings and reactions that they are experiencing.
5. What support you might need. How are you likely to react or be left feeling? Who could provide you with that support?
6. Think about how to tie up any loose ends, including any practical arrangements that need to be dealt with.
When you have viewed all options click 'Next' to continue.
Case Study
Counsellor
Although a counsellor is likely to have important and specialist skills in this area, it was felt that to introduce an person who is not known to Wayne at this point would be inappropriate.
Try another option.
Case Study
Sarah
It was agreed that Wayne felt safe with Sarah and that their relationship was important. A further consideration was Sarah's links with the school, with Michael and the role Sarah would play in helping Wayne to adjust to his loss over the coming weeks and months. Of particular concern was Wayne's attachment history (Bowlby 1979; Howe et al., 1999) and how this might impact on his bereavement (Moss 2008; Worden 2003).
Try another option.
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Foster Parents
It was acknowledged that the foster parents had the strongest relationship with Wayne. However, they felt they lacked the skills and confidence to undertake a task of this kind.
Final decision
After further discussion, it was agreed that Sarah would tell Wayne of his mother's death but with both foster parents also present to provide care and support. Over the following months Sarah spent a considerable amount of time with Wayne to help him to come to terms with his mother's tragic death.
Try another option.
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Case Study
In a three-monthly review, Wayne was asked to identify what he felt had gone well, what had not worked so well and what changes he would like to see happen.
Wayne enjoyed Michael's activities and said he had learned a lot about himself, particularly 'what he was good at and where he was useless'.
What had not worked so well was how Wayne felt about school, where at times he still felt 'picked on' and 'dissed' (put down) for being a 'kid in care'. Also, Wayne still felt sad and upset about his mother's death but felt there was little anyone could do to except that it helped to 'talk about things'.
In terms of the future, it was agreed that Wayne would continue to attend Michael's activity sessions, remain with his current foster carers who would monitor events at school and unless needed, he'd see Sarah again at the next review.
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