Reflective Case Analysis on Adult with Learning Disability

Reflective Case Analysis

My placement was in the statutory sector, the Mental Capacity Act and Deprivation of Liberty Safeguards (MCA/DoLS) Team for a Local Authority. Referrals to the MCA/DoLS team came from hospitals, care homes, supported living settings and occasionally other independent organisations. The role of the team is to assess the mental capacity of the individual and whether they can make an informed decision as to the most appropriate care for themselves. When the individual lacks capacity to make decisions regarding their care a ‘best interest’ decision would be made on their behalf. The Mental Capacity Act (2005) and the code of practice provided the statutory guideline on how specific decisions would be made. I worked with service users who had learning disabilities and the elderly.  More specifically, my role involved completing the following; a social care and wellbeing assessment, which evaluated their needs under the Care Act 2014, a mental capacity assessment, creating personalised support plans for these individuals, liaising with professionals and other agencies and working with the service users families.

Introduction

In this essay I will reflect on my experiences gained during my placement with reference to a specific case study. I am aware that an effective social worker must constantly ask the question ‘why’ to help develop their practice (Thompson, 2009). This required me to explore the models of reflection that have informed my practice as a student social worker to answer the “why” question.

I found Schon’s theory of reflection (Schon, 2002) the most useful model to reflect on my practice (PCF8). Schon enforced 2 types of reflective practice. Firstly, reflection-on-action, which relates to experience gained or action already undertaken. It requires an individual to reflect on what could have been done differently, also looking at the strengths from that session (Schon, 2002). Secondly, Schon refers to reflection-in-action, i.e., reflecting on your actions as you are doing them, being mindful of issues such as best practice throughout the process. For this essay, my focus was mostly reflection-on-action. However, this type of reflection should also be used to inform future practice and encourage appropriate reflection-in-action should a similar situation arise in the future.

The service user

F1 is a 25-year old female with a learning disability and acquired brain injury sustained during an attempt to alleviate severe epilepsy when she was younger. At the age of 16, F1 lived in a specialist residential provision for people with a learning disability and autism. At 21 years of age, she moved to a different placement but was later evicted after she assaulted staff. F1 then lived at home with her mother and two younger siblings. Currently, she stays in a supported living residence. F1 likes to keep busy and enjoys going to Bingo.

F1 was placed on Section Two of the Mental Health Act (2007) meaning that she needed an assessment for a mental health disorder. F1 was admitted to a mental health service due to paranoid ideation, mood instability and increased aggressive and destructive behaviour. F1 was discharged by tribunal. When in crisis, F1 can be verbally abusive, violent towards members of staff and make racist comments.

F1 also behaves in ways which suggest that she is vulnerable so that others might take advantage of her. For example, she has occasionally stood in the middle of the road outside her mothers’ house, laid down and taken off her clothes. When upset or angry, F1 prefers people to leave her alone to calm down which reduces the risk of harm towards others. F1 also threatens to harm herself by standing or laying down naked in the road though always moves away from approaching cars.

My involvement with F1

I became involved with F1 as it was recognised that she needed additional support to reduce these potentially harmful behaviours. F1 behaviours were identified to be due to boredom, lack of stimulation and therefore it was felt increasing in her care package/ daytime activities would help. F1’s previous social worker allocated the task of helping her to find meaningful activities to fill in her time to me.

According to Parker and Bradley (2010), an assessment is a process in which social workers work in partnership with service users to recognise areas of development and change. In carrying out my initial assessment with F1, I considered the Milner & O’Byrne (2009) model of how to approach an assessment. The model identifies five stages of an assessment, namely; preparing for the task; gathering data, applying professional knowledge; making judgements and deciding what is to be done. I had no prior experience of assessing a student and felt anxious about this process. I prepared myself for the task by reading material that relates to social work assessments and working with people who have a learning disability (PCF1).

I am aware of the capabilities statement for working with adults who have learning disabilities states how to assess the needs of such adults(PCF5). Social workers must enable and promote the same access to “adults with lived experiences learning disabilities as for any other citizens, embedding their values and ethics into rights-based practice that makes a difference to people’s lives” (BASW, 2019) (PCF2).

I was reminded by Trevithick (2012) who points out the importance of preparations before an assessment. l, therefore, gathered information from F1’s case notes and sought clarification from colleagues who had worked with F1 previously(PCF1). I was mindful not be judgemental(PCF1) about F1 and her behaviour, for example, racist remarks to her support workers when she’s angry or when they do not agree with something she wants to do. She made comments a black woman could find offence. While I avoided labelling, I was conscious that she needed to be taught and realise that her comments could be inappropriate. This knowledge improved my cultural awareness and what could be perceived as offensive to people of different races and culture(PCF2).

Knowledge of the Care Act (2014) guided my assessment, as this states that the local authority has a duty to promote an individual wellbeing and assess their needs. With support from F1’s previous social worker, I was able to promote equality of opportunity for F1. This empowered me to advocate with, and on behalf of F1, to receive the extra hours she required from the support workers to help her with her day to day routine such as cleaning and cooking(PCF3). I was reminded of Trevithick (2007) who highlights that advocacy attempts to make the voices and interests of the service-users heard. Thus by advocating on her behalf F1’s voice was heard and listened to ensure her needs were met.

The Mental Capacity Act (2005) also guided my assessment and intervention with F1. Williams and Evans (2013) state that professionals often wrongly assume that people with learning disabilities lack capacity to make decisions due to their cognitive impairment (PCF4). This guided me to ensure that I did not make assumptions about F1’s needs, wishes and feelings.

A mental capacity assessment (MCA) was completed prior to my work with F1 which determined that F1 has the capacity to make decisions about her care and finances. Using the five principles of the MCA, I am aware that just because F1 makes unwise decisions does not mean she lacks capacity (PCF4). Principle 3 of the MCA states “a person who makes a decision that others think is unwise should not automatically be labelled as lacking the capacity to make a decision” (SCIE, 2009).

F1 would make unwise decisions with respect to her finances. For instance, during one visit with F1, she told me that she is struggling financially and as a result, she planned to pawn some of her belonging to help pay for other activities she wanted to undertake.

The Human Rights Act (1998) emphasises the importance of upholding people’s rights, especially when they have the capacity to make financial decisions (PCF4). It was also important that I did not impose upon her my views, i.e., that I felt she is being irresponsible with her money; my role was to support her and advise her and not try an influence her in how she chose to spend her money. I found this very challenging as naturally, I am a person who always wants to help someone by listening and giving advice’ and I was hoping she would listen to my suggestions. Jenkinson and Chamberlain (2019) state even though people make unwise decisions, the role of a social worker is to support them to acknowledge that their decision is unwise and look for alternatives.

I learned to accept and acknowledge her unwise decision though however, I supported her to make informed decisions while ensuring that she was protected and remained safe. I was reminded of my social work values which were not to be judgmental and to accept that not all the advice or support that I might offer, will be acceptable to a service user (PCF2). It is working in an anti-oppressive practice and respect her decisions as ultimately it is about her wishes and feelings. The capabilities statement for working with adults with learning disabilities encourages social workers to respect and follow individuals expressed wishes, feelings and choices also previously expressed wishes where they do not have capacity to make a decision (BASW 2019) (PCF3).

I endeavoured to meet F1’s needs by working in partnership with other professionals (PCF8). The Human Rights Act (1998) and The Equality Act (2010) reminded me that all work should be done in an anti-oppressive and anti-discrimination manner (Brammer, 2007). Due to different agencies sharing information, I felt that F1 would benefit enormously if she was able to have a routine and a clear view of what’s going on with her life.  For instance, as a result of sharing the information I was able to help F1 not to miss her appointments and I would do this by reminding her the day before a scheduled appointment with another agency.

I was able to use strength-based social work as the main method of my work with F1. Strength-based social work is described as a collaborative process between the social worker and the service user, working together to draw out the strengths and asserts that a person has to achieve an outcome (SCIE, 2019). This method is also used in collaboration with community-led support, which is a new initiative of considering what is available in the community that the person resides in before looking at paid for services(PCF7). 

When working with F1 there have been some challenges. She found the transition from living with 24/7 support from care staff to independence quite challenging.  I can sympathise with her because while she wants the freedom offered by living in her own place, but when situations such as managing her finances occur rise or when she is in crisis, she panics and says she does not want to live there anymore saying things such as ‘I am not keeping myself safe’. This is the language she must have heard professionals use and she started to use this as a trigger for response. I am aware that sometimes the jargon social workers use can become part of the service user’s vocabulary(PCF1).

When speaking to the manager of the supported living placement, she informed me that this is quite a common response from service users who have transitioned from 24/7 support to living independently or supported living.

It is very difficult for someone to go from having constant support to little/barely any support (Hudson, 2003). Though ‘F1’ does get support, for her it is quite disempowering and concerning that she never got the chance to go through the life stages that I did, for example, going to school and college. I understand how difficult it was for her as she never had the opportunity to build any life skills because she had been institutionalised. She had to adapt to living on her own and build other daily skills slowly. With this, I recognised the Erikson (1950) stages of human development which state there are eight stages of man and he described each stage as a struggle between emotional opposites. Erikson focused on the importance of identity information. For example, in the adolescent stage, their identity is drawn from their family, interests, activities, their peers and aspirations for the future. I am aware that F1 was never given the chance to build her identity through the life stages.

Current research on people with a learning disability and the transition process from leaving in a care home to supported living placement helped me to understand F1’s behaviour better(PCF9). I researched on care leavers transitioning to independent living stating how young people leaving care are more vulnerable to poor life choice and social excursion. They are less likely to be involved in education or employment. (PCF5). Although research focuses on young people, adults with learning disabilities also face similar barriers (Choices Advocacy, 2019). 

Care history can have a significant impact on how an individual develops such as the ability to build and maintain significant relationships and influences their attitudes and self-esteem (Morris, 2001). My understanding of this research helped me to have insight into F1’s situation as a care leaver and that enhanced the planning and intervention process.

I felt that there were a lot of expectations for ‘F1’. For instance, support staff spoke about how she did not engage with activities or make new friends. They do not appear to appreciate that this is all new to her. She never had the same opportunities they had from a young age to help build these social skills, she is only learning now.

I feel that her previous carers failed to prepare her for independence. This is something I have tried getting the support staff to understand as recently she would want to participate in activities such as bowling but didn’t have anyone to go with her. The staff member suggested that ‘she needs to make friends’. I felt sad for her because she wants to make these friends but also does not understand that with friendship there would be boundaries. I was able to support her by signposting to a woman’s group where she is supported to learn to develop her social skills as sometimes staff are not always available to go to certain places with her. I was able to help her differentiate between friendship and the help she receives from support staff.

I feel that this is due to attachment issues; attachment theory (Bowlby,1958) recognises that most adults have a basic need to feel loved and wanted by another adult. For an adult in care service, the experience of the care service can compound and increase an adult’s attachment anxiety.  I feel this applies to F1 as when her key support worker was on leave it heightens her sense that she is not loved and wanted. F1’s would behave in a manner to set response from workers. This response was to reassure her that people around her still cared.

During my supervision sessions with my practice educator, we discussed the models of assessments I should consider in my work with F1. Supervision enabled me to take on aboard the positive advice and understanding professional criticism as a learning tool (PCF1).

I first considered using the model approach to assessment which sees the social worker as the expert following a format of questions, listening and then processing the answer. I then realised that it was inappropriate to use this model with F1 as it does not analyse and gather information to understand her needs.

I employed the exchange model which views the person involved as the expert on their problem with an emphasis on the exchange of information (Smale et al, 1993). I felt this was the appropriate model in my work with F1 as it placed F1 as the expert on her problem. I was able to follow what she is saying rather than trying to interpret what she thinks so that we were able to exchange ideas, find information to look for alternatives for her case and focus on her strengths (Milner and O’Byrne, 2002) (PCF 7).

l employed the systems theory which identifies that assessments are a crucial part of social work; it’s creating a working partnership with the service- user using a holistic approach by placing the service user at the heart of the assessment (Greene, 1991). I felt that this theory was appropriate as it enabled me to view F1’s behaviour relative to the relationship that exists between her and those around her. Therefore reflecting on this approach, l felt if l holistically understood F1 by adopting the systems theory l would be in a better position to help her with her problems. 

The systems theory enabled me to analyse the current level of support services in F1’s life. It enabled me to see which other networks were available for F1 to access (PCF 5). Using this theory it enabled me to signpost F1 to relevant agencies which saw F1 getting support with her probation and social skills.

I was also aware of the importance of establishing a good working relationship with F1 to enable her to gain independence. Taking this into consideration l would contact F1 before a meeting to agree on the venue, day and time. I ensured that I did not impose anything when F1 was not available certain days and time. I considered my values and l respected this instead rescheduled and arranged on the days she was available. Thompson (2008) highlights the importance of eliminating feelings of oppression that can be brought out by one’s position as a practitioner as one works with service-users.

In conclusion, placement allowed me to learn to promote people’s rights with knowledge of the Human Rights Act (1998). I was able to apply the Mental Capacity Act (2005) in practice. I have been able to demonstrate the knowledge and skills and statement for social workers in adult services; particularly statement eight as supervision has been a crucial part of my training and development. Supervision has been an effective tool for reflecting and analysing my practice(Trevithick, 2012).

Even though they have been dilemma’s with F1; I feel that my work was effective as I was able to help F1 develop her social skills by supporting her to join a women’s group. I was able to support and encourage F1 to participate in activities by helping her get a ‘buddy’ also getting F1 extra hours with the staff in her care plan. At F1’s review meeting it was acknowledged that since F1’s started engaging in activities there has been a noticeable change in her behaviour.

REFERENCE LIST

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