Martin Webber's blog

Musings of a social work academic

Connecting People in Torbay

One of the key issues we are grappling with in the Connecting People study is how local authorities and NHS Trusts can become more community oriented in their practice.

We are investigating how different types of agencies and teams are able to adapt to implement the Connecting People Intervention. Some are better placed than others to do so. But it is clear that in the context of austerity and increasing workloads it is not easy to introduce new ways of working.

I am having conversations about community social work, community development and community oriented practice with senior managers in a number of sites beyond the study. There is definitely an interest in how the Connecting People model can support practice innovation and development.

I came across similar interest yesterday in Torbay, where I spoke to a conference of social workers from across adults services (and a few from childrens’ services). I spoke about the need to evidence our practice to demonstrate outcomes and articulate the unique contribution that social work makes to multi-disciplinary health and social care services. The presentation I used can be found by clicking this link.

In a workshop I led on the Connecting People model I found interest from both senior managers and practitioners. The model appears to provide the opportunity for practitioners to articulate their practice and provide a rationale for how services should be delivered in the future.

We’re a long way from seeing it happen, but the interest is encouraging and a good foundation for future developments.

Social work and recovery

Social workers support the recovery of people with mental health problems. Recovery is a process whereby individuals or families restore rights, roles, and responsibilities lost through illness, disability, or other social problems. It requires hope and empowerment, supported by a vision for a different way of being.

Recovery is a concept at the heart of social work practice, though the profession is frequently following others in articulating and evidencing good practice. Yet despite the theoretical basis of recovery finding synergy with social work, there is limited research informing social workers on how best to intervene effectively and to influence the social factors enabling or impeding recovery.

The term ‘recovery’ has now become part of routine mental health service delivery and policy frequently without acknowledging its social origins. Internationally, recovery is being framed as core to community mental health service delivery, but all too frequently with reference to symptom reduction and service rationing rather than regaining control over one’s life.

Social work theory and practice largely adopts a holistic, bio-psycho-social systems approach, which is central to models of social recovery. Practitioners are working daily to support the recovery of the individuals and families they are working with, frequently using highly effective approaches such as strengths or asset-based assessments, self-directed support or enhancing social inclusion. However, ‘recovery’ is rarely taught as a social theory informing social work practice on qualifying programmes, possibly because it is under-theorised and lacking a well-developed evidence base.

Special Issue of the British Journal of Social Work, 2015

I will be editing a special issue of the British Journal of Social Work on the theme of ‘Social Work and Recovery’ with Associate Professor Lynette Joubert of the University of Melbourne, Australia. It is due to be published in 2015, but I’m gathering papers for it now.

This special issue will publish internationally relevant contributions to social work research and thinking about recovery across multiple social work fields. Social work researchers and practitioners who are researching and working in the field of recovery are invited to contribute their work to make a distinct social work contribution to the growing evidence base about recovery.

We are seeking abstracts of up to 800 words by 9th May 2014 and full papers will be required by 5th September 2014.

If you are interested, you can find full details of the aims and key themes of the special issue on the British Journal of Social Work website.

University Mental Health and Wellbeing day: 19th February 2014

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Tomorrow is University Mental Health and Wellbeing Day. This is an annual event to promote the mental health of those who live and work in higher education settings.

The International Centre for Mental Health Social Research (ICMHSR) and the Department of Social Policy and Social Work are marking the event by sharing ideas about what we do to look after our minds.

ICMHSR have put up a Mindapples tree in the reception of the Department of Social Policy and Social Work in Alcuin College C block. Hanging on the tree are Mindapples: notes about simple day-to-day activities that we do which are good for our minds.

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If you are in York, please come along and contribute to the Mindapples tree. Pens and Mindapple cards are available in the reception area. It will only take a few minutes of your time to fill out your Mindapples and hang them on the tree.

The tree will be on display in Alcuin College C block for several weeks. Please come along and see what others do to look after their minds.

Ripon sinkhole: a reminder of our fragility

The national media has descended on Ripon to take a look at the sixth sinkhole to open up in recent days. News vans from ITV, BBC York and many unmarked ones crammed into Magdalens Close to get pictures of the affected house at first light this morning.

House affected by sinkhole in Magdalens Close, Ripon

Our house is adjacent to Magdalens Close so I was concerned about whether our house and garden was affected as well. Fortunately, we’re OK, but I do feel for the owners of the house affected (pictured) and their immediate neighbours. Houses were evacuated last night amidst concerns that further sinkholes could emerge.

Ripon is susceptible to sinkholes as underground gypsum dissolves and eventually gives way. Many have opened up over the years causing concern for local residents, though this is the first that has come to the public attention for over a decade.

The location of the latest sinkhole is adjacent to the old Ripon Auction Mart. Harrogate Borough Council turned down a planning application for building 75 homes on this site last week. I saw the geological survey as I prepared my submission to the Council and there was clear historical evidence of sinkholes on the site.

I didn’t sleep easy in my bed last night and I doubt that others near to, or in, Magdalens Close did either. It reminds me that we should not take our existence for granted and to look after those around us. We don’t know when the ground may open up to swallow us up.

Building the evidence base for mental health social work practice

Mental health social workers make a unique contribution to mental health services. They are respected for their knowledge and application of mental health law, their ability to use psycho-social interventions in complex situations and their integration of social perspectives into medically dominated services.

As I have repeatedly highlighted in posts in this blog, mental health social work practice is not underpinned by research to the same extent as in psychiatry or clinical psychology. This is not necessarily a problem. Social work draws on diverse sources of knowledge to understand and work with the messy realities of life. However, when systematic reviews are searched for ‘effective’ interventions which can form the basis of mental health policy, it is rare to find social work practice being articulated.

Systematic reviews rely on evidence produced by randomised controlled trials. These are commonly used to test new drugs or psychological therapies, but are rarely used to evaluate the effectiveness of social work interventions. Quite simply, social work is too complex and multi-faceted to deliver in a standardised way to enable it to be evaluated in a trial. But if that complexity could in some way be articulated in an intervention model and then measured, would it be possible to evaluate it in an experimental study? This is what we are testing in the Connecting People study (funded by the NIHR School for Social Care Research).

Connecting People study

We have taken a routine aspect of social work and social care practice which is insufficiently articulated and evaluated – enhancing individuals’ social connections – and set out to define, measure and evaluate good practice. Social relationships can be important for recovery from mental health problems and social workers can play an important role in supporting people to enhance them.

We began by understanding existing practice. We wanted to find out how practitioners were already supporting people to strengthen existing social relationships and develop new ones. In a diverse set of agencies in the statutory, voluntary and third sectors we talked to over 150 people about their practice and developed a good understanding about what good practice looks like. We articulated this practice and termed it the ‘Connecting People Intervention model’. We wrote practice guidance and training materials to accompany the model and help practitioners understand what it meant for their practice.

In 2012 we took the intervention model, practice guidance and training to 14 diverse teams in NHS mental health services, local authorities and the voluntary sector to evaluate the extent to which their practice is similar to, or different from, the intervention model. We have also been investigating the extent to which the implementation of the intervention model improves outcomes for people who use the services. To do this we have been interviewing people who had recently been referred to each team and we followed them up for a period of nine months. We are now in the process of conducting the final few interviews of this study and analysing data emerging from it. The results will be available later in the spring.

The data from this study will help us to establish if it is possible to conduct an experimental study to evaluate the effectiveness of the Connecting People Intervention. Grounded in the lived experience of practitioners and service users, the intervention model captures practice wisdom which we think helps in the process of connecting people. Arising out of practice, we think the intervention model could be easier to implement in practice. But we are still in the process of finding this out.

Intervention evaluation guidance

An account of the methodology we have used to develop the Connecting People Intervention has just been published by the Journal of Evidence-Based Social Work. I illustrated the intervention development process using this diagram:

framework

If you are familiar with the Medical Research Council guidance on developing and evaluating complex interventions, you will see some similarities. However, this process emphasises the importance of explanatory, practice and local knowledge at the beginning of the process and feedback loops at each step. Learning from each stage should feed backwards as well as forwards in the process to ensure improvements are made on a continual basis. Also, although ‘implementation’ comes at the end of the process, in reality it is happening throughout. Research and practice are evolving in synergy, both influencing each other.

We hope that our experiences can help other researchers to articulate interventions in such a way that they can become amenable to experimental evaluation. In fields such as mental health social work where evidence of effectiveness is becoming increasingly important, the importance of this process cannot be under-estimated.

More information

The publishers of the Journal of Evidence-Based Social Work have made this paper available free of charge to the first 50 people who click on this hyperlink:

Webber, M. (2014) From ethnography to randomised controlled trial: An innovative approach to developing complex social interventions. Journal of Evidence-Based Social Work, 11 (1-2), 173-182

If you are interested in reading the full text of the paper but can’t access it via this link, please contact me and I’ll email you a PDF version of it.

Community Treatment Orders: Effectiveness, Understanding and Impact

Community Treatment Orders (CTOs) were one of the most controversial amendments made to the Mental Health Act 1983. In 2008 England and Wales joined Scotland and around 70 different jurisdictions around the world in obliging people to adhere to treatment in the community. The rationale is usually to prevent relapse or provide a less restrictive alternative to hospital for ‘revolving-door patients’ with severe and enduring mental illness. However, despite their widespread use, the evidence for their effectiveness is limited.

Last year the Oxford Community Treatment Order Evaluation Trial (OCTET), the first major evaluation of CTOs in England and Wales, reported its findings. This randomised controlled trial found that the same number of people on CTOs were readmitted to hospital as those on section 17 leave of absence. The extra restrictions placed on people on a CTO did not appear to reduce their readmission rate, as was originally envisaged when the orders were first introduced.

Running alongside the randomised controlled trial was an extensive qualitative study which explored patient, consultant and family carer experiences. Findings from this study may help to explain some of the results of the trial. We are pleased to welcome OCTET researchers at our next International Centre for Mental Health Social Research seminar on 12th February to discuss these emergent findings.

In three interlinked presentations, OCTET researchers will present findings and research in progress from the OCTET programme of work:

  • Jorun Rugkåsa will present an up-to-date review of the evidence for the effectiveness of CTOs (including OCTET) and OCTET’s main findings, and discuss the implications of these and the wider current evidence base for the future of CTOs.
  • Krysia Canvin will present findings from the qualitative arm. She will juxtapose consultants’ and patients’ interpretations of the CTO’s powers to consider the implications for patients’ experiences and the predictability of CTOs.
  • Francis Vergunst will present his ongoing DPhil research in which he is exploring the effect of CTOs on patients’ longer-term social outcomes by assessing patients’ social inclusion, social networks, and capabilities/quality of life.

The seminar will be held from 12 noon to 1.00pm at the University of York and is free and open to all. Further information can be found on the Department of Social Policy and Social Work website.

Connectedness as a component of recovery

Social connections are important to most of us. We need people around us to share our lives with – the blossoming of online social network sites in the last decade is visible evidence of this.

When people experience mental health difficulties they frequently also experience a shrinking in their networks. People ebb away due to the stigma of mental health difficulties and individuals’ own problems in maintaining their social connections.

Mental health social workers have an important role to play in supporting people experiencing mental health problems to maintain their social connections. On 27th February, Making Research Count are organising a seminar in York for social workers and social care workers to discuss and engage with three research projects which explore the role of workers in enhancing the networks of people with mental health problems:

  • The Connecting People study has developed and is piloting an intervention model for mental health services to help people to enhance their social connections. It is funded by the NIHR School for Social Care Research.
  • The Community Health Networks study has mapped the networks of people with severe mental illness to explore the importance of people, places and activities in supporting recovery and investigate the (potential) role of primary care and secondary mental health services in community network maintenance and development. It is funded by the NIHR Health Services and Delivery Research programme.
  • Connected Communities is an action research programme that explores social network approaches to social and economic challenges and opportunities. It focuses on understanding, mapping and mobilising networks of support and co-producing action with local communities in a way that takes into account what is already there. It is funded by the Big Lottery.

The seminar will provide practitioners with an opportunity to engage with the emerging findings of these studies and to reflect on what they mean for social work and social care practice with people with mental health problems.

A final plenary session will be chaired by Dr Ruth Allen, Director of Social Work at South West London and St George’s Mental Health NHS Trust and Chair of the Faculty of Mental Health at the College of Social Work, which will explore the implications of these studies for mental health practice.

Practitioners will take away intervention models they can use in their practice to help individuals engage with their networks or  communities. They will have an enhanced understanding about the role of communities and networks in an individual’s life and how they can assist recovery. Community and asset-mapping techniques will be discussed to provide practitioners with tools they can use in their practice.

For more information and details about how to book a place, please visit the Making Research Count website.

Stress in social work: A research review

Stress amongst social workers is in the news again. Last week, Community Care reported the findings of their survey of over 1,000 social workers which found that 96% felt moderately or very stressed. The following day the All-Party Parliamentary Group on Social Work published a State of Social Work report which recommended, amongst other things, that a more rigorous way of ensuring social workers’ well-being is introduced.

With media attacks on social workers increasing in both their ferocity and inaccuracy, and with budget cuts reducing services to a bare minimum, practitioners are under intense pressure. Therefore, we chose ‘Looking after ourselves’ as the theme of December’s Making Research Count seminar in York. Its aim was to review the research evidence about stress in social work and explore some strategies for managing it.

I presented a brief overview of the research on social work stress. If you’re interested, the PPT presentation can be downloaded here.

Social work is a demanding job. Amongst human service professions, it involves perhaps the most emotional labour and is probably the most vilified. So it’s not surprising that rates of stress and burnout in the profession are so high. However, it’s important to be aware that rates of stress and burnout can be over- or under-estimated in surveys.

Firstly, the way in which questions are asked will shape the responses received. Subjective self-report questions such as ‘how stressed do you feel at work?’ or ‘how close do you feel to burning out?’ are likely to elicit responses which over-estimate the true prevalence of stress and burnout. Objective self-report questions such as ‘have you taken time off due to work-related stress or depression in the past year’ are more likely to provide an accurate estimate of the impact of stress and burnout on the profession. Additionally, standardised research measures such as the Maslach Burnout Inventory provide accurate assessments of stress and burnout in occupations (though don’t provide eye-catching headlines such as “Social workers more likely to turn to food than to managers as a way of coping with stress“!).

Secondly, response bias can be a problem in surveys about stress. Practitioners are either too busy or stressed to fill it in (leading to an under-estimation of stress levels) or those who are stressed complete it as a means of communicating their distress (leading to an over-estimation of stress levels). Random sampling is rare in workforce surveys, but recruiting large samples can mitigate some of the problems caused by response bias.

Since surveys of local authority social service department workforces began in the 1990s, it has become evident that stress is a problem for social workers. Rates of depression and anxiety amongst social workers have increased over the last 20 years, though levels of job satisfaction remain stubbornly high. Researchers in Canada, the US and the UK have all explored this phenomena and have found in studies of social workers working with children and families that, although levels of burnout are high, quite frequently levels of job satisfaction are high too.

A national survey conducted by Approved Mental Health Professional (AMHP) Janine Hudson last year found that rates of depression and anxiety amongst AMHPs have fallen from 52% in an equivalent survey of Approved Social Workers conducted ten years previously to 44%. This is still unacceptably high, given that the rate of common mental disorders in the general population is about 16%.

The statutory duties of AMHPs are not the prime reason for such high levels of stress, though they are certainly a contributory factor. High caseloads, not feeling valued by their employer, and feeling less satisfied about the non-AMHP duties which social workers undertake were all associated with higher rates of depression and anxiety. AMHPs also cited the lack of available and appropriate resources; the high emotional labour of their jobs; their role not being understood or supported; not feeling valued; feeling vulnerable; and the general high pressure of their workloads as contributing to their stress.

Clearly, systemic changes are required to reduce stress amongst social workers. Peer support, good supervision and a supportive working environment can help to alleviate stress and promote well-being. Practitioners can practice mindfulness techniques, as we explored with Mike Bush in the seminar yesterday. But the standards for employers introduced by the Social Work Reform Board need to be enforced. Relying solely on the the resilience of practitioners to provide safe and effective social work services, without changing the hostile environment in which they are practising, is clearly untenable. Now is the time for the Chief Social Workers to act.

If you’re interested in debating the issues around stress in social work further, the College of Social Work is hosting an online debate on this topic on 18th December at 12.30pm. Also, if you’re interested in finding out more about yesterday’s seminar, the tweet trail can be found below:


Connecting People on Film

The NIHR School for Social Care Research has funded the creation of short films to accompany training materials for the Connecting People Intervention.

The films have been created by Trafford Community TV, a social enterprise spun-off from the Trafford well-being centre blueSCI who are participating in the Connecting People Study.

The films have been developed to assist training sessions about the Connecting People Intervention model. They feature practitioners talking about aspects of their practice within the context of the model. The different opinions expressed by them are certain to provoke discussion in training sessions when workers explore what they think about the practice involved in supporting people to develop or maintain their social connections.

All the films can be viewed via the menus on the Connecting People Study website.

An introduction to the films can be found by clicking ‘training‘ in the website’s menu.

Drop-down menus from this link take you to the following 12 pages:

Question 1. How should I view the person that I am working with?

Question 2. How can I manage boundaries with an individual?

Question 3.How can I keep building on my own community knowledge?

Question 4. How do I overcome barriers faced by working in this way?

Question 5. How do I identify in what areas I can best help an individual?

Question 6. How can I get someone to try something new?

Question 7. How can I help someone to move on?

Question 8. How can I link an individual to someone new?

Question 9. How can I help the individual to overcome barriers?

Question 10. What kind of environment works best?

Question 11. How does this fit with our existing practice?

Question 12. How can our agency form better links with our community?

Each page has a short film and a PDF document with some suggested exercises for use in the training session. They can be used in sequence or dipped in to as required.

Additionally, we created videos, animations and case studies to illustrate what the Connecting People model is all about. These can be accessed via ‘the model‘ link in the Connecting People website menu. For example, the film below features workers talking about their thoughts about the model:

Finally, the research team talk through what the model is all about:

Click this image to watch the connecting people intervention model

(Click image above to watch the Connecting People Intervention model video)

We are keen to hear what you think about the films. Please leave us a comment on the Connecting People website to let us know your thoughts.

NIHR School for Social Care Research Insights from Research on Mental Health

The NIHR School for Social Care Research held a seminar to discuss some of the mental health research it funds on Thursday 5th December 2013 in London.

The seminar heard presentations from:

  • Jerry Tew on family approaches to reablement
  • Julia Stroud on service user and practitioner experiences of Community Treatment Orders
  • Eva Cyhlarova on direct payments for people who lack capacity
  • Rich Watts on employment supports for people with mental health problems

Slides from the event will be posted on the NIHR School for Social Care Research in due course. However, in the meantime here are the two presentations I gave on the Connecting People Study:

Presentation #1: Developing a social capital intervention for people with psychosis: an ethnographic study of social capital generation and mobilisation

Presentation #2: Social care interventions that promote social participation and well-being: A mixed methods study

To get a flavour of the discussion during the event, please see the twitter stream below: