Blog: Relational approaches to frontline work with adults & children A talk given by Andrew Balfour, Chief Executive, Tavistock Relationships to a policy roundtable, hosted by Norman Lamb MP, organised jointly by Tavistock Relationships and the Tavistock and Portman NHS Foundation Trust A report published by Childline (2016) shows the top three difficulties that children contact them to talk about. Family relationship difficulty is the only problem category that features in the top three difficulties for all age groups of children. This perhaps gives us a glimpse of the scale of the problem which services seeking to intervene in family and relationship difficulties face. What is at stake here? – intervening at the level of the couple and the family is about interrupting inter-generational cycles of transmission of mental health problems, of emotional difficulty and deprivation. The relational component is the key to breaking such inter-generational cycles, and to improving children’s life chances. We are at a very exciting point in the history of this field. Tavistock Relationships has, since its inception in 1948, had as its mission the development of relationally-orientated practice to help families and children, and this was based on clinical and qualitative evidence of the vital importance of this work. Now, for the first time, we have the empirical research evidence to support this approach. We know, for example, that children in households marked by high levels of inter-parental conflict are at elevated risk for a variety of negative psychological outcomes including anxiety, depression, aggression and reduced academic attainment. Reviewing this growing scientific evidence base earlier this year, the Early Intervention Foundation’s report ‘What works to enhance the inter-parental relationships and improve outcomes for children?’ concluded that policymakers will need to ‘play a critical role in promoting awareness of the quality of the relationship between parents as a factor that affects children directly whilst also affecting the quality of parenting of both mothers and fathers’. Now, although that might sound simply like common sense, this statement represents something of a seismic step in policy terms. Because, by explicitly identifying the quality of the inter-parental relationship as a critical element affecting children’s wellbeing, it follows that services should be expected to address the relational distress at the heart of so many of children’s difficulties. In short, they will be required to work on, and work with, the relational factors involved. But that’s not all – the evidence is that it is the couple relationship itself – and the child’s exposure to this – not just a question of how this impacts upon the parent-infant relationship that is of critical importance. And this is very significant because much of the focus and funding, historically, has gone to parenting skills based programmes, the vast majority of which do not have a couple relationship focus; indeed, improvements in parental relationship quality are very seldom reported as an outcome. It is perhaps not surprising, therefore, that a critical analysis of the last fifteen years of child and adolescent mental health policy argues that ‘the focus of the most recent major policy report in this area, Future in Mind “reproduces the idea that family life is reducible to a set of skills parents can be trained in, rather than thinking about whole families with histories and contexts, needing insight and support. Focusing on parenting skills without attending to the relational and social context of parenting is not an optimal strategy”. Tavistock Relationships has long held the view that there has been a tendency to do exactly what these researchers are suggesting is less effective – that is, to try to improve children’s well-being without properly acknowledging that it is the wider family context, particularly the quality of the relationship between parents, and not just the axis running from parent to child, that also needs to be attended to in order to get the best results. It is this kind of integrated approach which motivated Tavistock Relationships to see if we could replicate the impressive results regarding significant reductions in terms of depression and anxiety, parenting stress, violent problem-solving strategies, harsh parenting, arguments between parents about their children – and fewer acting out/aggressive and withdrawn, depressed behaviours in the children – which Professors Phil and Carolyn Cowan in the States have achieved in their couple relationship-focused, group work programmes. We’re pleased to say that we have achieved similar, and sometimes, better results than in the States, and we’re grateful to the Department for Work and Pensions for funding our Parents as Partners programme. I have already talked about parenting intervention, and I would now like to touch on a number of areas where I believe that a more relational approach would produce better outcomes for children. Firstly, children’s mental health. We have recently carried out some qualitative research to help us articulate the case as to why children’s mental health services would be much more effective if they were to include work with the parental couple relationship as part of their core offer. One quote in particular, from a clinician working in CAMHS, I think illustrates why we need a less atomised approach to children’s mental health and well-being: “I've noticed that, over a number of years, not one of the couples that I've referred out for relationship support has taken it up. But I do feel comfortable about making that referral, about putting it in black and white, because I then take responsibility, and that blame, from the child. Because I have highlighted it - it's not that this child has an inherent problem, and they will always be with this problem; I have identified how the dynamics impact on the child's presentation.” We have also collected data on 313 cases from one inner London CAMH services, finding that in the opinion of the 9 clinicians interviewed, inter-parental conflict had contributed significantly to the mental health difficulties of the child or young person in question for nearly half of all cases. Regarding adult mental health, there is historically an emphasis upon the individual patient within the NHS where it can be difficult to work with people in the context of their wider family relationships. For example, adults with depression should be able to choose from a range of NICE-recommended talking therapies. One of these is Couple Therapy for Depression, which is the intervention of choice where the patient’s couple relationship is thought to be a significant factor in precipitating or maintaining their depression. Although there are some encouraging developments within IAPT, this therapy accounted for just 12,000 out of the three and a half million sessions of therapy delivered by the IAPT programme as a whole last year, which is 1 in every 300 sessions. Now, while are there no national prevalence figures for depression for which relationship difficulties are a significant factor, we do know that over 70% of people accessing our couple therapy services have depression (and those with worse mental health problems are in the worst relationships). Are we suggesting that relationship difficulties are at the heart of the depression of just 1 in every 300 people seeking help? Or are there deeper reasons behind the paucity of provision of this couple-based intervention – for example, lack of workforce training to recognise and work with this kind of distress? Next, I would like to come on to another flagship Government policy, , the Troubled Families programme. What we have long advocated is that relationships distress is very often at the heart of the difficulties which these families face, and it was heartening to hear the newly-appointed DWP Minister, Caroline Noakes, say recently that the Government will be working to strengthen the focus of the Troubled Families programme on relationship support and parenting. But this brings us to the issue of how can staff working with such families be helped to take such a relational approach in their work? In thinking about this, I want to highlight something about the history of Tavistock Relationships, and indeed the Tavistock & Portman NHS Trust, which have long had much to say about this crucial area of supporting front line staff in their work. The Family Discussion Bureau, as Tavistock Relationships was called when it was formed in 1948, was staffed by social workers from the Family Welfare Association (now Family Action) and clinicians from the Tavistock Clinic who shared an ambition to study the dynamics of family life. Two pioneers of this approach, Mattinson and Sinclair (co-authors of the influential book Mate and Stalemate - an account of their work to develop relationship casework in an inner London borough) argued that families with multiple problems could be helped by social workers who provided consistent relationships to the adult couple. Only in this way, they believed, was it possible to really engage with these families and to provide meaningful help with the significant challenges they faced. Such a ‘case work’ approach has become more difficult to sustain over the past years, as an outcomes-focussed, managerial culture has become dominant in health and social care. The focus of this event today goes wider than social work of course. However, I believe that there is an important issue to think about here, which is relevant for frontline practice more generally. We, and the Tavistock & P, have a long history of training and supervising practitioners to help them work in a relationally – oriented way. I want to quote a recent article by Andrew Cooper who – describing the approach to policy in this area over the past decade – writes: ‘the impact of most policy making was weakened by a failure to engage with the emotional and relational complexity of the social processes it is attempting to steer, influence or promote’. A key element of this failure, I suggest, relates to the insufficient recognition of the crucial importance of supervision and containment of front line staff, which has left practitioners under-supported and under-equipped by their managers and organisations to engage with and address the relational and emotional distress at play within families. It is the consequences of unaddressed and uncontained distress that we have seen over and over in such tragic cases and events such as Victoria Climbié and Baby P., the Mid-Staffs scandal, and in Winterbourne View – either where parents act out their distress by harming their children, or where practitioners end up turning away from and neglecting the very people they joined their respective professions to help. The Francis review found that ‘while many staff did their best in difficult circumstances, other showed a disturbing lack of compassion towards their patients. And the action which the board took to investigate concerns “was inadequate and lacked an appropriate sense of urgency”’. How do staff who go into this work in order to help people end up showing such lack of compassion, or worse; and how do cultures get established within institutions that are set up to care for people, where staff who feel there is something wrong are silenced by fear and bullying; and where amongst senior managers and at Board level, there is also a turning away from appropriate concern and urgency? The Francis review findings read to me as an account of retreat from anxiety and engagement with the complexity and difficulty of the work at all levels, from front line staff – up to the highest levels of the organisation. How do we understand this? As Mattinson and Sinclair write – what we can contribute is our understanding of the interactive component in relationship problems – in the relationships between clients and workers and between staff in the organization. The more anxiety provoking the situation, the more difficult it will be for the staff to hold onto their basic professional skills and ethical standards of work – to retain their emotional engagement in the complex difficulties the profound anxieties and human problems they are faced with, day to day, in their work. This kind of work exposes people to high levels of anxiety- in such circumstances, it would be hard for any of us to retain clarity of thinking and engagement in anxiety provoking, complex emotional difficulties and unless supported to manage this, and helped to sustain their involvement with the troubled families they are working with, staff may take recourse to potentially destructive and damaging behaviour in order to manage their anxiety – with potentially catastrophic consequences. Such approaches to understanding anxiety and institutional defences that are part of the tradition of the Tavistock, are as relevant now as before – perhaps more so, in our process and outcomes driven culture. And the main message here is that it is only by providing proper support and containment/supervision of front life staff that they can be enabled to engage in the emotional complexity and challenging emotional experience of working closely with difficult family relationships. In summary then, I think there is a growing recognition that we won’t achieve what we all want to achieve in terms of improving children’s life chances and outcomes until and unless we pay greater attention to the quality of relationships in which these children live. A lot of work in this area is carried out within the voluntary sector, outside the mainstream, and across the country what is on offer in terms of relationally focussed help is variable. We need a universal offer, where front line staff across a broad range of health, social care and the voluntary sector are trained to recognise and to incorporate within their work an awareness of and capacity to assess and engage with couple and family troubles, linked to a range of specialist services to which they can refer those couples and families who need it, in a stepped-care model. The aim would be to build upon research based evidence to identify families where children are at most risk from inter-parental conflict and to meet them where they are, so to speak, offering preventive or light touch intervention through to more specialist services for those who need them. This would require training of front line practitioners and specialist practitioners, as well as the development of services. Developing capacity across the UK for specialist intervention also requires investment in expert practitioner training without which it would be impossible to grow the provision of evidence-based interventions available to couples and families. We must give more value to the role of staff training and supervision if we want to develop more relationally-aware and effective services. We need this at all levels and without training and development of expert practitioners, we cannot develop expert services but we also cannot provide training and support for front line staff. Promoting assessment strategies and evidence based interventions that focus on the inter-parental relationship, as well as services that support and contain the relationships which front line staff have with the families they work with, will be crucial for rectifying the negative consequences of family stress, conflict and breakdown on children and parents. We need a broad approach, which encompasses these different levels of intervention, and which aims to bring relationally focussed work from the margins to centre-stage in health and social care, as well as other statutory and voluntary sector settings (including the family justice field, where a mental health focus needs to replace an adversarial one). In this way we have a chance to interrupt the inter-generational transmission of emotional trauma and deprivation – which if it is left unattended, blights the life chances of generation after generation of children in this country.