What should professionals do when we disagree on how to help a child?

Dr Dickon Bevington, Consultant in Child and Adolescent Psychiatry, shares how professionals can work together – even if they disagree on how to help a child or young person.

When professionals disagree on what the problem is and how to best help a child or young person, it is important to take some time out to understand each other’s perspectives. If we argue and fall out, the child will look on and think, “Well I feel strangely familiar here. This is like being back at home in my original family where mum and dad fought. I’m back where I was. Nothing’s changed.

Here are four things to think about when things start going wrong. After completing this first task, find below a similar exercise that you can complete with the young person in your care. All you need is a piece of paper, something to write with, and a curious mind.

Creating more understanding across the network

They are inevitable, but not necessarily a reason for shame or blame.

Professionals care (and, quite appropriately, worry) about their patients/clients/students, and in states of worry we know that making sense of other peoples’ behaviour is harder to do. This ‘dis-integration’ between professionals is normal and inevitable because professionals invest years in training in quite specific models or fields (education, therapy, youth engagement, safeguarding, etc.) that all use different languages, and highlight different aspects. It’s easy to think that we understand another professional’s job, but if that same professional assumed to understand ours to the same extent, we might feel rather differently! Starting with a reminder to oneself that there is a shared purpose around helping a child or family in need is obvious, but easily overlooked.

You will need a reasonably large piece of paper. This is a table with three rows (titled “What’s the Problem?”, “What to do?” and “Who does what?”) and multiple columns across the top, each one titled with the different people in the child’s network, starting with the child first, and probably at least one parent/carer, but including all the key professionals.

In the first row below this (“What’s the problem?”) write a few phrases that summarise what you think each person thinks ‘the problem’ is that requires their help. If you have the luxury of the professional being on hand, of course you can ask them to help, but if not, try to write these ideas of yours as if the professional had written them (so that if they “marked your work” later they might nod and say “Yes! You really got what I am saying!”) and be ready to acknowledge if you really don’t know – in that case you might decide you need to ask about this with curiosity to understand!

Different people might have very different ideas about what problems matter most. They may all be right. It may not matter that they’re different. One person might be saying the problem is ‘depression’, another that ‘he’s not being allowed back in his football team’, and another that ‘the parents have treated him so badly’. These differences are only problematic if they lead to misunderstandings or conflict in what happens next.  Are these in evidence?

Here you record descriptions of what (you think) each person in the child’s network thinks needs to be done to respond the challenge(s) they have identified and prioritised. It is about the interventions that they are prioritizing.

We may agree about the nature of the child’s the difficulties, but then we can certainly disagree about what needs to be done – the kind of intervention. It might be something as simple as taking him out for a walk rather than putting him on his PlayStation or it may be something more sophisticated like a particular kind of therapy or extra facility at school. Again, remember that differences do not necessarily need to be problems, but they can lead to confusion and conflict (taking a child out of school for therapy sessions when the school is struggling to help the child be in school, for instance, or the perception of a battle between using medicine or talking therapy, etc.).  What any professional network wants to avoid is replicating a family in which the parents and grandparents and aunts and uncles all have sincerely held views about what is good for a child but then proceed to fight about this in front of that child.

Here you record what you think different workers might be thinking about who should have Responsibility for doing what, in order to help the child.

Most professionals work in a world where there’s very limited finance, there’s not enough time in the day, we have large caseloads. It’s tempting to wish that a different team or worker will pick up an extra piece of work. If they do not, it’s most often not out of laziness – it is survival. In times of stress, we tend to get pushed into being a bit strict about rules. But in spite of this, we can create care that is less dis-integrated. The key point here is to remember point number 1. above; most complex care is dis-integrated in its natural resting state, and rather than seeing this as a failure by someone (requiring blame, or war!) it is more helpful to “reframe” our own work to include ‘the task of trying to find a way to collaborate, complement, and integrate our different offers.’  Creating integration always takes purposeful effort – it is not a kind of Garden of Eden state from which we’ve been unfairly expelled! A focus on the experience of the young person and family (what might they experience as helpful, or not, and when, in what sequence?) can help to re-orientate services to serve this shared purpose.

The point of placing these different ideas about what the problem is (the explanation), what needs doing (the intervention) and who should be doing what (the responsibility in across the system) is not to create a completely coherent and perfect plan (although this would be good!) it is first to create more understanding across the network, and second to identify where the most unhelpful (to the client) dis-integrations exist.  It is often helpful just to become clearer about what level differences exist at (Explanation, Intervention, or Responsibility?), but sometimes a specific difference (or ‘dis-integration’) can be identified that invites specific action. Here, the problem for professionals in a network (rather than a single managed system, with a single boss, and a straightforward hierarchy of power) is that they must rely mostly on relationships to help adapt and change arrangements.  The science of influence suggests strongly that the doors to influence start with understanding; if I experience you as understanding me and my dilemmas, then my mind is naturally more inclined to open to, to become interested in, and to trust what you might have to suggest.  This works between workers and their clients/patients/pupils, but between workers and their professional peers just as much.

How Young People Can Help Professionals and Carers to Be More Helpful

Map out the Caring Network with the child

There are two ways to map a caring network with a young person.

First, you can do it on a white board or a large sheet of flipchart paper.  Draw a stick person in the middle to represent the young person.  Ask them to add other people that have a significant role in their life, but to think about how they position these people – draw lines between each figure and “them” in the centre; if the person really understands and gets them (is closely trusted) draw them close in, if not, draw them further out.  In addition to the young person’s own relationship to each worker, you can ask them to imagine what the relationships between these different professionals might look like (“Would the doctor be closer to your social worker, or further apart?  What about your teacher – how much do you think they see eye to eye with your therapist?”)  As the positioning of each professional is discussed and arranged, be careful to keep reminding the young person that “these are just our guesses about how these people make sense of each other!” but from these guesses it may be that approaching and asking one or other worker about their connections across the network makes sense as a plan. We call this form of mapping a “Pro-gram” as it is primarily about mapping professional relationships, but of course it may be helpful to add key informal supports (family members, friends) as their relationship with these professionals may make a significant difference.

The second way to map with a young person is to use the “Dis-integration grid” described above, but with the young person.  Of course the key person that they can “fill in” with some accuracy is themselves. It may be very helpful to identify where a young person is unclear or uncertain about how a specific worker sees their role, and this may trigger an invitation to help the young person get into a dialogue about the help that this worker is offering.  

Help the young person to imagine what’s in the minds of the people in their Caring Network

Both of the exercises above are ways to help a young person to imagine themselves into the minds of these individuals rather than just thinking of them as ‘just grown-ups’ or just ‘helpers’ (or less flattering descriptions!) If the professionals in their network can become people, they also become minds that might have been well understood or might not. Thinking like this helps a young person to experience themselves as having some “agency” (the power and ability to act and change a system) in relation to their help – rather than leaving them as passive recipients. “What do you think your social worker thinks is the difficulty that she’s trying to help you with? How might you and I think about alerting her to the worries that you have said you see as the biggest ones for you right now? What do you think your teacher thinks that he should be doing or that needs to be done to help some of these difficulties? Do you think your doctor thinks she should be the person helping you to get access to the Sports Centre? Who do you think she hopes will sort this out?”

 Identify questions and make a plan to discover answers.

There may be big question marks that both you and the young person draw. Neither of us know for sure what the youth worker sees as their role, and what they’re trying to do. Do we want to go and ask? We create the conditions for a young person to get a bit curious. What are you going to ask your youth worker? Why don’t you go? We could go together? We have a conversation with your social worker about what he thinks needs to be done by the medical people that are involved in your care?

Try and encourage that young person to just gradually become a little bit more active: by our engaging them in these kinds of activities, we are showing that help isn’t something that just happens to them: they can help these helpers to become more helpful.

Interested readers will find more information on this topic and downloadable resources in the comprehensive ‘Addressing Dis-integration’ published in the online AMBIT manual here.

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