Thoughts on Practice

Choosing an independent assessor 

Andrijana Vidovic, Director and Psychologist, Spots & Arrows Pty Ltd , November 2019

There are tools available to casework staff today that were not so readily available when I was caseworking in child protection. I remember those days of good intentions but hasty decisions – decisions informed by scant information, pressures from many corners and a lack of accumulated practice wisdom to practice differently. Quite simply, as a new caseworker, you don’t know what you don’t know. Even after my casework initiation phase, I remember the ongoing challenge of needing to make sense of very complex, often conflicting information, in a timely way. I remember trying to make plans, and action those plans for the safety and wellbeing of kids amidst competing priorities, emotionally taxing content and interactions, and shifting organisational sands. Doing this on your own and relatively unaided rarely yields the best possible decisions or actions – but we did the best we could.

Child and family work in child protection and out-of-home care is complex in more ways than most people will ever grasp, so tools that help clarify the decision making landscape and possible options are absolutely necessary.

What is an independent assessment?

One tool at the disposal of child and family professionals is the independent assessor. A person external to the agency or family whose role is to provide a holistic, impartial and rigorous appraisal of a situation. Independent assessors can help where internal capacity is limited due to time, experience or geographic location.

In our sector, independent assessments can be used to answer all manner of casework, Children’s Court or Family Court related queries – standard or customised. Here is just a sample of some of the queries and circumstances referred to us for independent assessment:

  • Parenting capacity and realistic possibility of restoration
  • Contact arrangements that will serve the child and their identity and connection needs and wishes now and into the future
  • Foster or kinship carer authorisation and carer development planning
  • Therapeutic needs and opportunities for children and young people who have experienced abuse and neglect and how these can be incorporated into case planning
  • Assessing permanency options to inform permanency decision-making to meet the best interests of the child or young person
  • Potential for a carer and guardianship order to be sufficient to meet the needs of the child or young person without case management oversight and support
  • Assessing behaviours of concerns and developing Positive Behaviour Support plans, with support for implementation of strategies
  • Which household or caregiver is most likely to meet the needs of the child or young person (comparative assessment)?
  • Understanding the contact frequency, duration and participants that will best meet the child’s needs for continuing connections with family 
  • Which placement circumstance is most likely to support this child or young person’s development, and sense of connectedness and permanency? 

What do I need to look for in an independent assessment provider?

There are a range of independent assessment providers and services the likes of which seem to abound in the current world of child and family practice. The NSW Government Family and Community Services agency have sought to help child and family staff select providers through establishing a vetted panel of independent assessors. Whilst helpful, it is still necessary to remember that not all independent assessments or providers are created equal. 

Having a less than ideal independent assessment can leave a referrer wading through cloudier water than when they started. These assessments often present in the form of tick and flick style reports, or long-winded narrative accounts of one person’s self-report responses to standard questions during a home visit or 1 hour clinical interview. It can be disappointing, unhelpful and costly in terms of time and money.

So what is a good independent assessment? Drawing on our own experience and referrer feedback, here is a list of some of the technical and practice aspects that referrers can expect in a good independent assessment:

  1. the rigour and robustness of the assessment methodology clearly stated in the approach section of the report 
  2. clarity of purpose and scope 
  3. sensitive, engaging, collaborative and curious interviewing and information gathering 
  4. internal consistency supported by quality review processes for every assessment
  5. information gathering that is holistic, triangulated and cross checked between: 
    • file information
    • self-report during interview conversations
    • views from others 
    • response patterns on any relevant standardised measures administered (yes, even for casework assessments)
    • observations of interactions and engagement
    • research and literature 
  6. holding the child at the centre of analytical statements in precise and applied terms, in ways that consider them now and into the future
  7. analytical statements that make sense of information for the reader, grounded in the assessment questions and purpose; and not merely restate the information gathered nor superficially sort the information into a strengths and weaknesses list
  8. pragmatic and precise recommendations for direction that can be used by decision makers to facilitate, monitor and review progress and change 
  9. all the above summarised in a clear, objective, written report that is self-evidently defensible.

Future posts will explore good assessment practice in more detail but suffice to say that a good independent assessment should demonstrate these aspects as a given. But beyond the technical elements, a good independent assessment really should help the referring professional by providing clarity and sense of direction to guide their decision making. Good independent assessments should leave the referrer feeling a little more confident in planning what happens next,, and support action that encourages the best possible outcomes for children and young people.

We’d love to hear from you – what else would be helpful in guiding your practice around independent assessments?

Trauma-Informed Practice in the real world 

Andrijana Vidovic, Director and Psychologist, Spots & Arrows, August 2019

We hear the phrase “trauma-informed practice” a fair bit. Sometimes it’s with excitement and openness – child and family professionals expressing a desire to make the healing-oriented principles of trauma-informed practice a reality as best they can. These can be uplifting and motivating professional conversations – and is what leads Spots & Arrows to focus on this kind of practice as being trauma-aware and resilience-focused, because that’s what we’re all really aiming for. For practitioners whose professional identity has come to embody  the principles of trauma-aware, resilience-focused practice, it can be beyond frustrating to work alongside other people or systems where these principles are not as evident.

Amidst this nexus, teams can come undone; interagency relationships can become strained. At micro and macro levels, fundamentally different approaches to the safety, welfare and wellbeing of children and young people can have real impacts on team trust and cohesion, conflict resolution and problem solving, quality of decision making, relationships, innovation and most importantly, outcomes.

But before we launch into soapbox speeches about the evidence for why trauma-aware, resilience-focused practice makes sense (which at this stage, it’s fair to say, does abound), we’d like to encourage a Pause.

What if there was something we could first learn from those professionals that have been reluctant to drink so readily from the ‘trauma-informed practice’ cool-aid?

Here are the top 4 reflective questions we have used in our work so far:

  • What if I don’t know as much as I think I do about how the different trauma and resilience principles actually work together and interplay?
  • What am I not understanding about the system that might be getting in the way of these principles being brought to bear? What is in my circle of concern and circle of influence to affect change in this space?
  • Am listening with curiosity and empathy to the challenges I’m getting from others?
  • Have I adopted a trauma-aware, resilience-focused value set that has driven me toward a moralistic high ground in a way that is stopping me from really hearing what challenges we need to problem solve around together?

We have provided these reflective questions with the intention that they might assist you to better understand your own practice and to begin bridging any gaps between yourself and team members or interagency colleagues.

Because when we can take a Pause, we can check our own intentions and biases. We can maybe create a better understanding and we just might be better placed to find not only common ground, but perhaps, more novel and applied ways of making these important principles real for the kids we work with every day. Taking a Pause also assists our own learning and development to progress better decision-making, informed by reflection on actions and considered planning, rather than simply acting on events or experiences.

We’d love to hear from you – what else would be helpful in guiding your practice around applying trauma-aware, resilience-focused principles in your day to day work?

Meaningful Life Story Work 

Beth Murray-Roach Operations Manager and Clinical Psychologist, Spots & Arrows Pty Ltd, April 2019

Life Story Work….there’s a term that has grown to be part of the everyday lingo in child protection and out-of-home care! Clearly this means it is important…right? But how many of the carers, parents or colleagues you work with have you found are able to describe its basic notions, why it’s important, or the multiple and varied ways Life Story Work can be engaged with practically day-to-day? Perhaps even more critically, how many times have you had the same people express apprehension around talking with children and young people about their care and protection history?

We’ve found it’s a pretty regular theme in our assessment and intervention services. All too often, limited conceptual knowledge and practical skills drives apprehension, which in turn drives avoidance of revisiting traumatic (or all past) stories by important adults in the child or young person’s life. Often, the default is reliance on more formal, tangible yet restricted forms of Life Story Work such as:

  • Written narratives, sourced from inconsistent or piecemeal file information
  • Collecting and storing photos and/or personal mementos from the child’s life 
  • Documenting of basic life events in a Life Story Book

So what does it mean if Life Story Work is avoided, or limited in scope, for a child who has experienced abuse and neglect? 

In a nutshell, it means little to no space is held for kids to be supported to make sense of their life experiences in a way that helps the healthy integration of those experiences into a positive sense of self.

Being unaware, unable, or reluctant to identify, be open to, and respond to a child’s natural curiosities about their history is not just about discrete moments in time – the collection of these together has critical implications on that child’s dynamic and continuously developing identity. Their sense of personal continuity, clarity and connectedness can thus be hampered, which gets in the way of being able to effectively navigate ideas about themselves, others and the world, and to develop positive expectations for safety, security and predictability.

Ask yourself the ways we see the ways a child’s sense of self and identity play out in child protection and out-of-home care. The traumatic impacts we see for a child’s identity is arguably the bulk of our work!

Tangible, documented forms of Life Story Work can be valuable in their own right, but there are huge opportunities missed for everyday conversations and activities that help children to make sense of their past and present, as well as engaging in interactions that promote relational repair. When we explore with caregivers the ways they support and promote a child’s developing identity through Life Story Work, often the first step is alleviating their anxiety before launching into the practical, day-to-day strategies they can engage with. Some key messages include:

  1. You don’t need to know all the answers, or all the details of a child’s history to be effective with Life Story Work.  
  2. While a child’s life experiences can be complex and nuanced, the pragmatic aspects of Life Story Work strategies don’t have to be daunting or complicated – they can be simple, incidental and every day skills! 
  3. Your role is to be the safe, predictable adult for a child who can be available in a proactive, confident and consistent way. Your role does not require you to necessarily correct a child’s interpretation of their experiences, but rather to help the child’s sense of security and empower their own meaning making.
  4. Create an environment of openness and acceptance of a child’s questions and curiosities. This is achieved by being present, interested and available when questions arise, but also being proactive in initiating conversations or recognising opportunities for Life Story conversations day-to-day. Being proactive means you’re letting the child know it’s ok to talk about such topics!
  5. Life Story Work is not just about content, but process. The nonverbal interactions with children – the warmth, tone, pitch and rhythm of your voice; appropriate physical proximity; and facial expressions offer opportunities for children to experience important social connection that supports relational repair. 
  6. Life Story Work does not always need to revolve around traumatic experiences. We are talking about a child’s whole life – they are not just the sum of these negative experiences! 
  7. Life Story Work is also about helping a child to understand their continuing connection with their family and kin, their culture and community. 
  8. Being able to hold an emotional space for a child, or displaying a commitment to helping a child be curious and seek answers, are important ways to model openness, acceptance and a capacity to walk alongside the child in their journey. 
  9. Recognising your own personal responses to a child’s ongoing curiosity and questioning, or hearing their stories, is important. It doesn’t mean you can’t be emotionally responsive, but just be aware of how to use those reactions to model appropriate emotional expression and coping to a child. 
  10. Use multiple forms of Life Story Work and engage in them regularly – the tangible, formal, material activities as well as conversational, incidental work. Spreading the work in this way means its less likely that it will fall by the wayside when time or other life events might get in the way. 
  11. Identify practical ways you can access more information for a child if needed, or access further therapeutic support.

We’d love to hear from you – what else would be helpful in guiding your practice around facilitating Life Story Work with your clients?

Working with clinical diagnoses 

Beth Murray-Roach Operations Manager and Clinical Psychologist, Spots & Arrows Pty Ltd, April 2019

Almost inevitably when working in the space of developmental trauma, we are confronted with questions or issues relating to mental health and associated diagnoses, either explicitly or implicitly, with parents, carers, children and young people. For example, it’s not uncommon for referrers to request comment or clarification of diagnoses, or to undertake psychological assessment to clarify diagnoses, when referring for assessments or interventions.

While the workforce in the child protection space across Australia have extensive and diverse knowledge, skills, and experience relevant to understanding and working with trauma, the reality is that there are a small percentage technically qualified to formally assess and treat clinical disorders in accordance with government and health legislation and policies.

So what can we do when our work invariably involves consideration of mental health and psychological functioning, while still working within the bounds of such existing limitations? One important approach is to view diagnostic systems and labels as resources for understanding challenging presentations, but not as a means to wholly describe them. Being able to confidently take this approach means being informed about the landscape and context of how and why diagnostic labels are used.

Why are there diagnostic systems and labels?

There are many reasons why diagnostic systems (i.e. the DSM-5 and ICD-10) and labels are used among professionals. For example, they provide a professional and administrative language for communicating about psychological distress, with the aim of establishing consistency in diagnoses. Medical science and research evidence has been depended upon to demonstrate the effectiveness of treatments and intervention, suggesting that practice can be effectively manualised through evidence-based protocols for treatment. A huge amount of authority and legitimacy is thus afforded to systematised diagnoses and treatment from political and financial systems. As a result, formal diagnoses can often be required to access particular support or funding to address mental health concerns; and therefore there is significant investment in the outcomes of treatment and intervention. 

Ask yourself – how often do the children and young people you work with require a formal diagnosis to access funded support or intervention?

What’s the problem with diagnosis?

Diagnosis and evidence-based treatment on some level is attractive – there is a compelling sense of pseudo ‘certainty’ that can come with systems, labels and manuals for addressing complex issues. However, we find that the existing discourse can be alienating for professionals and laypeople alike, leading to apprehension or anxiety about how to understand or work with diagnoses, as well as misunderstanding, discrimination and stigmatisation. Diagnostic systems have been criticised as increasingly medicalised and prescriptive, as though psychological distress occurs in neatly predetermined clusters of symptoms that exist within the individual alone. 

This approach tends to ignore the social, cultural, neurobiological, environmental and systemic factors inherent in an individual’s experience of self, others and the world around them. Reducing psychological distress to symptom clusters and manualised treatment protocols also tends to ignore the important relational aspects of therapeutic practice that, as trauma professionals, we know are critical to repair and healing. The idea that human experience can be labelled with totality is highly structuralist, and leaves little room for alternative perspectives and meaning making.

The realities of trauma

Many of us working in this space recognise that there are significantly more rich, diverse, complex, nuanced and contextual aspects to consider when making sense of psychological distress connected with family, relationships, language, narrative and personal meaning, community and culture, gender, ethnicity, and spirituality. Many of our clinicians approach assessment and intervention with the lens that evolving, multiple understandings can exist in tandem and change over time. There seems to be an almost unspoken understanding that there is no singular, objective way to understand or label human experience. 

It is this sort of pluralist philosophy that influences how we engage in our work conversationally with children and families that reflect a more integrated, systemic understanding of context. This drives Spots & Arrows methodology, where multiple sources of information inform our understanding and meaning making of experiences at a point in time. We have found in our work that there is often a tension between the ethical mind of the clinician, who makes sense of trauma in such nuanced and complex ways, that battles against the constraints of diagnostic systems and labels. 

The future

There are shifts that are evolving in the world of diagnoses around making meaning of symptoms as not solely residing within the individual, but as reactions to the nuanced, systemic, relational and environmental stressors, combined with biological vulnerability. For example, there is some consensus that children and young people with complex symptoms of psychological distress are not able to be adequately conceptualised through standard classification systems. Existing diagnostic labels do not adequately describe the constellation of interrelated symptoms following experiences of severe, cumulative and chronic relational adversity. 

Leading trauma professionals have attempted to better conceptualise such presentations. For example, in 2005 van der Kolk outlined Developmental Trauma Disorder and (unsuccessfully) advocated for this diagnostic label to be included in the next iteration of the DSM. This is an example of shifts that are working towards honoring the multiplicity of meaning, context and culture. This will take time to overcome existing paradigms and arguments against such an approach, such as that without a common language and treatment protocols there may be ‘professional anarchy’ or unethical practice.

So how do we reconcile ways of naming and responding to psychological distress and trauma from a pluralist philosophy, but work ethically within the governmentality of diagnostic systems and requirements around evidence-based practice?

  • Ensure clarity of assessment/intervention question. When referrers ask for comment on clinical diagnoses, almost invariably the question at the heart of it all is about making sense of what the day-to-day implications of the individual’s emotional, psychological and behavioural wellbeing is on their experience and functioning, and how can this be supported or improved. In this vein, we often end up clarifying referral questions from ‘what are mental health concerns for this individual?’ to, for example, ‘how does this individual’s mental health impact on their day-to-day capacity to manage and cope with stress, perform daily living tasks, approach problem-solving and decision-making, and regulate emotional and behavioural responses with children, others and the world around them?’ Approaching the presence of diagnoses in this way makes it more concrete and tangible, and can be followed with ‘what does the person need to be supported?’ 
  • Be informed about the landscape of clinical diagnoses and treatment. We can take diagnoses on board in our work but, with insight to the context within which that diagnosis has been made and communicated, we can also challenge, enrich and extend on the DSM or ICD conceptualisations. With this knowledge and understanding, we can dance alongside these systems in ways that acknowledge and integrate the systemic, relational, narrative and cultural considerations relevant to making sense of diagnosis. 
  • Foster a constructive dialogue. Conduct work in this space according to principles of sharing and expanding insight and understanding of diagnostic issues, and the context of these with colleagues, other professionals and the children and families you work with. Try to limit making it an ‘us’ and ‘them’ argument. 
  • Communicate context in report writing. When making or reporting on diagnoses, it can be useful to provide some insight regarding the dilemmas identified above to help build the knowledge and capacity of other professionals in this space to make sense of diagnoses, and use them in ethically and practically sound ways that maintain the principles of the child’s individual presentation can remain the focus. For example, at Spots & Arrows we will often provide diagnoses and considerations when reviewing the diagnoses as a standalone page in a report that can be ‘pulled out’ so that diagnoses are not taken out of context and only communicated as labels. 
  • Seek feedback from the children and families you work with. Be informed about the individual or family experiences of your assessment and intervention work. In this sense, you can gather practice-based evidence that is derived from clients about what makes assessment and intervention relevant and effective for them, and where the quality of relationship is privileged. 

We’d love to hear from you – what else would be helpful in guiding your practice around the utility of diagnosis in your particular context?

Spots and Arrows