At the Edge of Care: creating downward spirals

In this blog, researchers from the At the Edge of Care project team discuss findings from a systematic review on support and interventions for parents with mental health needs and children’s social services involvement. The review - which included 41 qualitative research studies from seven countries - explored experiences of practitioners and parents. Here the research team reflect on their findings.

Working as part of a multidisciplinary research team, along with a small Lived Experience Advisory Group, we were deeply struck by the findings of this review that were published in Health & Social Care in the Community  We found that parents - which in the literature was usually shorthand for mothers - were typically parenting in the context of significant poverty and their own trauma backgrounds. These mothers often wanted support. But the kinds of support they wanted - often financial, and non-judgemental parenting support that inspired hope and confidence - were at odds with the kinds of support they received.

Living in poverty made it harder for women to keep custody of their children or leave abusive partners, and they felt shame at not being able to meet their children’s basic needs for food, warmth and housing. These pressures impacted women’s mental health, but the available treatments sometimes made it harder, not easier, to care for their children.

We noticed a downward spiral of service interventions that could end in children being removed from their families. The support women received typically focused on their symptoms and parenting deficits, and was manualised, inflexible and crisis-driven. 

Under-resourced systems limited the options open to practitioners, and some felt forced to take decisions that they knew would cause harm, but were powerless to change. Women who refused support were seen as uncooperative and resistant. This bind, coupled with the strain of scrutiny and lack of real tangible support, often worsened women’s mental distress, increasing the likelihood of further interventions and escalating their difficulties.

Intersectionality – always at an edge

Parents with mental health issues often face intersectional challenges related to other aspects of their identity such as race, ethnicity, social class, gender, disability, or sexual orientation. These intersecting factors can compound their vulnerability to involvement with child protection services. For example, parents who are also members of marginalized or minority communities may face additional discrimination and scrutiny. 

The literature we reviewed did not typically adopt an intersectional framework or explore systemic discrimination. We did though find that practitioners sometimes felt that having mental health problems and being a good parent were incompatible, and that mothers from racialised communities, those who were parenting alone or in poverty, and/or those diagnosed with a personality disorder were viewed particularly negatively. Our lived experience advisors also emphasised that families who are poor and from racialised communities face deep discrimination within services.

More holistic and empathic approach

The study highlighted the complex interplay between mental health, social support, and the child protection system. Socioeconomic factors, access to mental healthcare, and lack of social support networks can all contribute to the overrepresentation of parents with mental health issues in the child protection system. Societal discrimination surrounding mental health may also play a role in these interactions. The findings underscored the need for a more holistic and empathic approach that takes into account the broader social, economic, and structural factors influencing the lives of parents with mental health needs. 

The poverty aware paradigm

When comparing across different national contexts, some European countries, like Sweden and Germany, tend to centre families’ economic needs within their child protection approach. We do not do this in the UK, even though children living in deprived areas are 13 times more likely to be on a Child Protection Plan and 11 times more likely to be taken into local authority care. These looked after children are vulnerable to abuse, and their present and future can sometimes look and feel bleak.

The ESRC Centre for Society and Mental Health recommends that health services develop and implement a poverty aware paradigm which recognises the impact of poverty on people and communities, and enables appropriate onward referrals. This could integrate screening for poverty into health settings which may increase our ability to identify those at particular risk and allow for better referral pathways from health to other wanted services, including housing and employment. Our review provides further evidence to support this recommendation but alongside this our findings indicate that we should also tackle the root causes of poverty which requires cross-sector working with housing, local authorities, third sector, and the private sectors.

Trauma-informed care

We found that parents with mental health needs desire support, but too often do not receive adequate support from their immediate social networks or the healthcare system. Although social work practice increasingly emphasises trauma-informed care, within child protection services there is still a lack of understanding, which may reflect a broader issue of how institutions and systems do not typically consider the contextual factors and structural inequalities and oppressions that contribute to the challenges faced by parents with mental health needs. A more holistic and client-centred approach to social work practice should be taken where assessments consider the unique circumstances of each family, and tailor interventions accordingly. 

Lived experience advisory group input into this project was supported by Birth Companions, a charity dedicated to improving the lives of women and babies who experience inequality and disadvantage.