Constructing the sample

This chapter reports on the interviews undertaken with mothers with mental health problems in the two study sites, A and B. While there has been significantly more readiness in recent years to acknowledge and identify differing professional perspectives in work with families with mental health needs (Falkov, 1998; Weir and Douglas, 1999; Reder et al, 2000a), the consequences of these differences for families have not as yet been fully explored. That research which explores the perspectives of parents with mental health needs has emphasised parents’ experiences of being pathologised by services (Hugman and Phillips, 1993) and of services being targeted on crises rather than delivered in a preventive or aftercare form (Green and Hyde, 1997). Our study aimed to interrogate service users’ experience of both mental health and child care services in more depth and to examine need alongside attitudes to services.

For this stage of the research, health and social services staff in the two study sites were asked to identify mothers whose children had been the subject of a child protection case conference in the previous 18 months and who had a diagnosis of mental illness. This could be a diagnosis provided by any health professional and could include diagnoses of personality disorder and repeated episodes of self-harm, but not diagnoses of substance misuse alone. Fewer interviews took place in site B, despite repeated attempts by local practitioners to recruit appropriate interviewees for the study. In this area, in particular, a number of practitioners from different agencies identified the same women as potential participants: this might be explained by the smaller size of the locality.

A total of 11 women were interviewed across both sites using a structured interview schedule devised by the research team. This schedule was developed with the help of the project advisory groups in each site. Representatives from service user groups were included on both steering groups, and their comments were particularly valuable in relation to the development of these interview schedules. An initial pilot interview was completed with one mother and the schedule was refined in the light of her feedback.

A second series of slightly less structured interviews was undertaken after a period of at least six months. A total number of eight second-stage interviews were completed. Three of the original sample proved unwilling to be interviewed or inaccessible (one having moved out of the area).

This final chapter draws together the key themes of our research and develops some recommendations for policy and practice. The study findings have relevance for transactions between practitioners and users as well as for the relationships between different groups of professionals and their organisations. Our proposal for a dyad of keyworkers in cases where mothers have mental health problems and where there are child protection issues is designed to impact on each of these interfaces. However, some of the problems identified for mothers with mental health problems are not only confined to how professional roles are defined and played out, but also concern the availability and distribution of resources. Access to resources is increasingly determined at a national level, although new initiatives still tend to have local beginnings. Therefore, the messages here are directed at policy makers at all levels as well as at the full range of practitioners in statutory and voluntary settings.

The centrality of trust

The interviews with mothers highlighted their capacity to distinguish clearly between different professionals and their primary responsibilities. Mothers were aware that child care social workers’ predominant task was the protection of children's welfare. They resented the scrutiny of their parenting by child care social workers and experienced child protection case conferences, supervised contact and other formal processes as threatening and disempowering. Such accounts are consonant with the evidence of other research studies (Cleaver and Freeman, 1995; Farmer and Owen, 1995) that have explored families’ perspectives on the child protection process. However, for mothers with mental health problems, the alienation and powerlessness experienced in relation to the child protection system are likely to exacerbate existing feelings of low self-esteem, loss of control and stigma.

The women in this study also criticised child care social workers’ lack of availability and the attitudes they displayed towards service users. Such comments may in part be a response to the statutory role of child care social workers with its implicit threat of coercion; however, they also reflect child care social workers’ limited opportunities for the exercise of interpersonal and counselling skills in the job. These restrictions can be attributed to a combination of limited resources and an emphasis on a bureaucratic, care management model of practice that prioritises assessment and the construction of care packages over therapeutic interactions with service users.

The focus groups

Since no previously validated questionnaires that addressed the issues tackled by the study were available, the research team was faced with the task of developing one that was appropriate for a wide range of professional groups, spanning both mental health and child care services. Qualitative approaches have been used extensively in the pilot phase of projects, both to inform the formulation of research questions and the selection of variables for study and to develop survey instruments (Barbour, 1999). In this study, focus group discussions with health and social care staff working in an area outside the two research sites were held to assist the development of contextually relevant questions for inclusion in the survey of professionals (Dumka et al, 1998). Focus groups have been shown to be particularly effective in accessing members’ constructions and attributions of meaning (Bloor et al, 2001), and are thus ideal for testing the acceptability and interpretations of the language used in questionnaires. Since the aim was to develop a survey instrument that was relevant for a variety of professional groups, a range of practitioners needed to be involved in this stage of the study. Given the potentially large number of workers involved in service provision for families where parents have mental health problems, it was not feasible to hold profession-specific groups. Instead, the research team opted for three interprofessional focus groups. These mirrored or approximated the real-life context of case conferences and had the added advantage that they were likely to afford insights into the issues arising for professionals in the practice environment (Kitzinger and Barbour, 1999).

Since the principal reason for holding focus groups was to inform the design of the questionnaire, it was more important for recruitment purposes than is usually the case in focus group research to convene groups that were representative of the wider population to be studied (Bloor et al, 2001). Therefore, the groups involved a range of staff with different professional roles and remits, working in both the statutory and voluntary sector, and with varying levels of seniority and experience. Those recruited included representatives of the following professional groups: child care social workers; health visitors; adult psychiatrists; mental health social workers; community psychiatric nurses (CPNs); children's guardians; practitioners from voluntary organisations serving mental health services users, and from similar organisations for children; and middle managers from both community health and social services.

This chapter examines the ways in which the mental health needs of mothers are conceptualised within health and social care. Mothering is simultaneously identified as a prime site of origin for women's mental health problems and a key determinant of children's mental health. It is widely acknowledged that mothering is a stressful, demanding activity that offers many opportunities for failure and consequent loss of self-esteem. However, it is also defined as a cluster of psychological and practical skills which deliver nurturing and care to other family members. ‘Competent mothering’, difficult as it is to pin down, is construed in both popular and professional debates as the foundation of children’s mental health. While the successful exercise of parenting skills and the intimate relationships that mothers experience with their children can be a source of satisfaction and pride, in the context of mothers with mental health needs, research has tended to focus on adverse outcomes. Positive outcomes for parents with mental health problems and their children are rarely noted.

The dual representation of motherhood is supported by a wide range of popular media images of mothers (Coward, 1997). These include the ‘harassed mum’, the ‘dual-career mum’, the ‘stay-at-home mum’, the ‘feckless teenage mum’, the ‘glamorous Victoria Beckham mum’ and (an image popularised by Cherie Booth, the wife of the Prime Minister) the ‘juggling mum’. The juxtaposition of images and the diversity evident in these representations of motherhood reflect mothers’ subjective experience of ambivalence. Featherstone (1997) identifies this ambivalence as a key characteristic of modern mothering and suggests that, in the face of the conflict between the adult's need for autonomy and the child's need for dependence, some feminist theorists have ducked the question of how children's developmental needs are best met. Mental health and child care services have also been slow to identify the significance of this conflict for their clients, and it can be argued that services have made little progress in offering mothers solutions to the dilemmas that arise when their own mental health needs conflict with their children's needs for secure parenting.

The chapter explores the different theoretical models that have been developed to explain women's mental health needs. In particular, research that draws attention to social roles and life events, especially experience of abuse, will be discussed.

Identifying difficulties in interprofessional coordination

This chapter reports on practitioners’ experiences of interprofessional communication and coordination and examines their views on which services were best equipped to take a lead in work with families where mental health needs and child care concerns coincided. Our survey asked respondents to identify the frequency of difficulties in coordinating work on such cases with a wide range of professional groups. As Table 10.1 shows, 35% of practitioners reported always or frequently having problems in coordinating their work with GPs, while 27% reported the same frequency of problems with adult psychiatrists. These rates were substantially higher than the levels of difficulties identified for other professional groups. For example, only 17% reported consistent or frequent difficulties in working with child care social workers, and 12% had a similar level of problems with community psychiatric nurses (CPNs).

The professionals with whom respondents were least likely to experience difficulties were health visitors: 58% reported that they hardly ever or never had problems in coordinating work. Lupton et al (2001) report similar levels of satisfaction from other professionals commenting on their work with health visitors. The other groups of practitioners with whom respondents appeared to have fewer problems were child and family centre workers (49% reported hardly ever or never having difficulties) and child care social workers (42% reported hardly ever or never having difficulties).

Child care social workers, child and family centre workers and children's guardians (formerly known as Guardians ad Litem, this group of professionals will all have trained and practised as child care social workers) were the professional groups most likely to report frequent or constant difficulties with GPs. Over half of the respondents in these three professional groups described a high level of difficulties. In contrast, GPs did not identify similar difficulties in relation to these groups. Few health visitors and CPNs reported high levels of problems with GPs. The professionals who themselves worked in primary care settings, such as health visitors and GPs, were most likely to report very seldom having difficulties in coordinating work with GPs. About half of CPNs sometimes had difficulties with GPs. Professionals working in adult psychiatry were also likely to report that they sometimes had difficulties.

The child care social workers’ evaluations of work with GPs are consonant with the findings of both Hallett's (1995) research and Lupton et al's (2001) study.