Pause is an innovative 18 month programme offering therapeutic and practical support to women who have had two or more children permanently removed from their care, who would like to take a ‘pause’ in the cycle of repeat removal. Women who work with Pause use reversible long-acting contraception in order to facilitate the pause. Pause is not a parenting programme: it is offering women, often for the first time, the opportunity of stepping away from statutory and regulatory intervention, pregnancy and removal, to ask, who are you? What are you capable of? Who would you like to become? We would hope that after support from Pause, those women who choose to have children will be better able to care for children, and for those who may never be able to keep a child, that they have improved their relationship with any existing children, or, for those who have no contact with children:
‘I was frozen in time—staying in, not talking to anyone. Nothing had changed from when they were taken away- the kids’ stuff was in the bedrooms, there was stuff all over the floors from when the police went through everything. I didn’t clean because the place was turned upside down. I couldn’t walk from one side of the room to the other. I had rats. I had debts rising. I couldn’t talk to friends because I didn’t want anyone to know and I wasn’t allowed to come into contact with people with kids. I didn’t get out of bed. It was like that for months. And then the texts started. Every week. Just to see if I was ok and tell me I wasn’t on my own. That someone knew. Someone cared about me. They were thinking about me.’
(Lydia, woman on the Southwark Pause Programme)
Lydia had lost two children to care proceedings. It took us three months of texting, checking in and not giving up, before Lydia let us know that she was ready. 18 months later, Lydia is a Pause Southwark Graduate. She has taken accessed reduced rate gym opportunities and begun swimming. She’s gone back to college and began working on basic literacy and numeracy. She has been a member of our Leadership Group, in which women lead their own recovery using the joint wisdom of the community; share hopes and dreams; and learn how to connect again. She has made bracelets for her children, and resumed letterbox contact with them. She has found a way to talk to her daughter about the reasons she was removed. Through the Leadership Group, she’s held us to account, and told us what we could be doing better. She has swapped numbers with other women and built friendships. Asked what’s been different about Pause, Lydia says ‘The other women. I’m starting to realise life isn’t over for me. I’ve got something to offer.’
In the last 7 years, 43, 573 women in England had children removed from their care. In 2014, the London borough of Southwark had the highest rate of repeat removal in London. The human, health and financial cost of removing children are devastating. Children who have grown up in care are more likely to fall pregnant early and to experience removal of children themselves. They are more likely to enter the criminal justice system as victims and perpetrators; more likely to experience mental distress, more likely to have Special Educational Needs; less likely to be in education, training or employment. They are almost certain to experience early trauma.
After removal, mothers are most often left with no formal sources of support and are alienated and are frequently isolated from their informal networks due to the shame and stigma of removal. That is perhaps partly why over 24% of women who have had one child removed go on to have further children removed – sometimes women describe trying to fill up their physical and emotional loss through having another baby.
Usually not meeting criteria for help by services, women just stay trapped in a cycle of grief, pregnancy, and removal. Problems are frequently intergenerational – 48% of Southwark Pause women have a care history, and over 70% have experienced (known) abuse in childhood. 18/21 Pause women have reported life-changing violence, such as rape, sexual exploitation, intimate (partner) violence, and assault- often on an ongoing (chronic) basis, often beginning in the earliest years.
Women who are at risk of repeat removal, and their children, have poorer health outcomes. The experience of early trauma is associated with a range of negative health outcomes including heart disease, stroke, lung disease, obesity, suicidality, drug and alcohol problems, and mental health problems (Kaiser Permanente: Adverse Childhood Experiences (ACE) Study 1997). Without support to recover, women are at risk of passing on this legacy of deprivation and chronic trauma. These problems are too often fatal. We started counting mortality rates two years ago: for two years running, 4 in every 100 Southwark women coming through care proceedings have died before she could be supported.
89% of Pause Southwark women experience mental health problems and personality difficulties. 100% Pause Southwark women experience mental distress, frequently associated with experiences of chronic intimate violence (trauma) and guilt and grief (removal). For many Pause women, their most painful and overwhelming experiences are identified with professionals and services (reflecting at times, their earliest caregivers’ feelings towards professionals; coming into care; and having children removed). Association of professionals and services with judgement, removal from attachment figures, and the worst conceivable outcome, of loss of children, means that women frequently evidence a trauma-like response to services and professionals, compounding personality-related difficulties in appropriate help-seeking.
Hannah had blood clots on her lungs, and was scheduled for treatment at Kings College Hospital. On presenting there, she behaved aggressively and was asked to leave. What the medical team did not realise was that Hannah had been brought to Kings when she was seven after having been thrown from a bus by her mum and had spent weeks in treatment subsequently. Later, Hannah had had two babies removed from the same hospital. For Hannah, to walk back into Kings was to walk into a space of untrammelled trauma. To submit to lying helpless and unconscious while being operated upon, was for Hannah to reawaken memories of the helplessness of early sexual and physical abuse. To do so in a clinical environment among professionals, the same people she associated with having judged her as a failed parent and removed her babies, felt deeply frightening. Hannah required the 1-1, minute-by-minute support of her Pause worker to begin to return to treatment; to wait together, side by side, in the hours leading up to her operation, and to be holding her hand as she woke up from her operation, reassuring her, and translating apparently aggressive responses to the medical team.
Pause is an innovative 18 month programme offering therapeutic and practical support to women who have had two or more children permanently removed from their care, who would like to take a ‘pause’ in the cycle of repeat removal. Women who work with Pause use reversible long-acting contraception in order to facilitate the pause. Pause is not a parenting programme: it is offering women, often for the first time, the opportunity of stepping away from statutory and regulatory intervention, pregnancy and removal, to ask, who are you? What are you capable of? Who would you like to become? We would hope that after support from Pause, those women who choose to have children will be better able to care for children, and for those who may never be able to keep a child, that they have improved their relationship with any existing children, or, for those who have no contact with children: ‘When s/he comes looking for me I’ll have something to be proud of – something to show them.’ Pause is an ‘assertive outreach’ model, with a vision that women of the Pause community require people and services to ‘do things differently’, meeting women where they are at, and supporting women to encounter new experiences for the first time. Practitioners may work with women for many hours in the community at a time in what are frequently highly complex circumstances.
Pause Southwark was one of the 8 Pause pilots being trialled nationally, working with women who had had two or more women permanently removed from their care. In response to the challenge of intervening with complex and chronic trauma, in correlation with profound difficulties in appropriate help-seeking and an aversion to health services, frequently in correlation with profound social and financial exclusion (75% women were homeless or in unstable accommodation when we met them, for example) and other difficulties (32% women have diagnosed learning difficulties and disabilities, 63% women have drug and alcohol problems) Pause Southwark has developed a specific approach. Alongside our assertive outreach model, in which we may in times of particular crisis spend a few hours or a few days with women, for example, as they navigate fleeing domestic violence, we have worked with a dual focus – embedding strategic learning to allow systems to flex more responsively around our women, and taking a psychological approach to support and sustain practical changes.
At Pause Southwark, we have chosen to bring in some of the latest knowledge of trauma, connection and the brain to inform our work, with an emphasis on ‘bringing psychological expertise out of the clinic into everyday lives and communities’ (for example, blending work of Siegal, Gallese, Ogden, and others). People who have experienced chronic adverse experiences are very good ‘beginners’ and may ‘start again’ over and over again, only to fall off progress as motivation lapses. Every time they ‘fail’, they consolidate an identity that ‘I am a failure and will not succeed’, a message that has often been imbued since earliest caregiving and then, as time goes on, is consolidated by social labels (offender, victim, perpetrator, chaotic, abuser) and the relationships in which they are held. We understand the key difficulty of ‘repeated beginnings’ as a feature of brain, body and social function when exposed over a long period of time to severe and unpredictable risk – long term planning, connection, nuance appreciation, negotiation and reflection become subjugated to black and white thinking, fight, freeze or flight responses, and ‘quick win’ seeking – exactly the processing which leads to chronic problems with drugs and alcohol, violence, or the dissociative ‘freeze’, articulated above by Lydia, sometimes seen in child neglect. These are the underlying difficulties that underpin high levels of homelessness, debt, violence, and child removal. Early and chronic experiences of severe risk shape the brain- but at Pause Southwark, we also know that the brain is social, and learns across the lifespan.
One of the first means through which we engage women in developing preventative approach to health and mental health, and begin to input therapeutic and psychological recovery alongside practical help, is by creating a nurturing community that supports the ‘redefinition’ of identities, reframing stories of ‘isolation’, ‘chaos’ and ‘failure’ to a normalising narrative of compassion, integration, commitment, determination, pleasure, thoughtfulness, kindness, and integrity. We run a fortnightly group as well as working intensively 1-1, and our fortnightly newsletter, sharing news, views and achievements is a key aspect to this. The experience of community has become central to recovery: brains are social, and it is our ability to reduce women’s isolation and exclusion that will be the decider of their ability creates change that is self sustaining.
We pay careful attention to language. We recognise that each of our women has come through more in a few years than many in a lifetime. We foster friendships between women where appropriate, and carefully support women as they begin to navigate these. Initially, many Pause Southwark women are not ready for therapy: for them to be in a clinical setting arouses such anxiety that they are not in general able to engage and sustain engagement. Therefore, when we bring our group together, we pay careful attention to creating conditions for growth: we focus on warmth, laughter, joy, teasing and playfulness, while working very hard to attune and embed psychological knowledge and education, and intervention, almost ‘under the radar’. We are informal and intimate. We celebrate. We use therapy tools but creatively mix these with games, artwork and chatter. When women feel the ‘professional/client’ relationship emerging, they withdraw. Our challenge is to stay human, kind, and intimate, while ensuring our focus is unflinching: we maintain boundaries by retaining an unwavering focus on women’s outcomes and recovery, and through regular clinical supervision.
At the end of March, our first cohort graduated in an intimate and moving ceremony with their significant others – mums, partners and friends – at which women were presented with certificates of outstanding achievement: often the first time they had ever graduated successfully from anything. As one women explained, ‘it’s the first time I’ve ever finished something.’
Wider Active Support
We are situated within the council within Children’s Services, so we are fully integrated within the local authority. Our Director of Children’s Services has explicitly framed that the local authority is keen to be guided by our women’s experiences to help create better responses to women at risk of repeat removal, and Our Principle Social Worker for Children has been meeting with women to hear their stories and understand what might be done differently. Our practice lead will be delivering training to new social workers during their inductions to help them understand the role of trauma in repeat removal and means of effectively engaging this group.
We understand that without informing systems change and educating systems around women, they will continue to fall out of support and change will not be embedded. Therefore, we have a strategic board comprised of Public Health, a District Judge, and the Directors of Children’s and Adults Services. We are currently using our privileged voice and position within the local authority to support and champion the development of a local women’s centre, which be advantageous to women who may be at risk of removal and exclusion, but would not yet meet our criteria for help. We offer multiagency training locally, which supports networking between frontline professionals, as well as embedding knowledge and understanding for our client group. We recently presented at the London Network of Midwives and Nurses annual conference to help them understand the health challenges women face, and how to support them.
Some of our inter-organisational links are as follows:
Because our women frequently have very entrenched drug and alcohol problems, and experience a lot of crisis, it is easy for systems to become reactive around them. Noticing this, we have set up a Pause-Substance Misuse-Interface Panel, at which the leaders of all substance misuse services, statutory and voluntary, and mental health services, come together to case formulate women’s presentations, and coordinate treatment across all services accordingly.
We have built strong links with South London and Maudsley, as our women were frequently coming into brief contact with mental health services before disengaging or being discharged. Their DBT lead in Southwark is delivering training to our practitioners around case formulation and engaging ambivalence, and will support us to deliver groups and psychoeducation on a 1-1 basis around emotional regulation, relationship management, and distress tolerance. All Pause women will be DBT case formulated with the support of our SLAM colleagues and DBT practitioners situated within the Assessment and Liaison teams will help to smooth women’s pathways through mental health treatment services by ensuring that A&L and Community Mental Health liaison practitioners are informed by this formulation.
We have developed close links with Solace domestic abuse service, as all of our women are survivors of intimate violence but none of them had managed to successfully access help from domestic abuse agencies, partly because DA services tend to aim interventions at a much ‘higher functioning’ group, rather than aiming at people with chronic and complex violence and maltreatment difficulties. Solace are developing bespoke DA workshops for our women, reducing women’s anxiety about engaging with them in future.
We have developed very close links with the voluntary sector local mental Wellbeing Hub, and co-deliver gym sessions with them on Fridays. They have developed a specific Self Management Group for our women, helping women to manage and understand their own mental recovery.
We have forged links with another voluntary sector organisation You First, with the result that they have begun delivering Next Steps support to our women when they transition out of our programme, so that they don’t go from ‘everything to nothing’. We have co-designed this support programme with them ensuring it remains consistent with the intervention we have delivered to date, and builds on an excellent understanding of our women. This programme is specifically supporting women to gain ‘confidence and competence’ in independence skills, is of a lower intensity than our 18-month programme, and is a year long.
We have forged strategic links with Housing and Environment and Leisure services within the borough to streamline women’s access to safe housing and wellbeing services such as the gym and libraries. Now, we are succeeding in building housing solutions around women as opposed to funnelling women through a housing system that does not meet their needs (for example, recognising that placing a woman whose drug recovery is fragile in a hostel surrounded by other users, is not appropriate.)
We are training local GPs in their annual conference in taking a trauma informed perspective to understanding women at risk of repeat removal, as they are often women’s first point of contact, and engagement often breaks down at this point.
Co-Production
We have formed a leadership group with our women who are able to tell us what we should be doing better. Following women’s feedback, for example, women have taught us how to explicitly welcome people of different identities and heritages to ensure that everyone joining our community feels welcomed and respected, and that there is a zero tolerance approach to discrimination. We have challenged examples of heteronormativity within our community. Our women put together the core principles of our community, choosing such values as compassion, respect, thoughtfulness, kindness.
We have begun offering support to male members of the community through a voluntary role. We seek feedback on a 1-1 basis as well as through the leadership group. Most importantly, we treat ‘negative’ incidents as vital items of ‘feedback’ because some of our most challenging and excluded women do not have all the skills for explicit feedback, and may express feedback through other means. Having reflected on ‘implicit’ behavioural feedback (such as disengagement or challenging behaviour) during clinical supervision, we then sit down together with the women concerned to support them to translate behavioural feedback into verbal (adaptive) feedback, thus empowering women to learn crucial skills that will support them to manage better in the community.
We also recognise that some of the most important feedback about our programme efficacy and accessibility may come from the people who have not been able to access our service. Therefore we annually review the demographics of those who meet Pause criteria and evaluate against those who have actually successfully joined the service, and amend and improve our programme in response. We proactively meet with groups who may find it harder to access our programme, so that we can make reasonable adjustments and remove barriers – for example, last year we met with the Southwark Travellers to talk about repeat removal and think about how we could work better with this group, and this year, noticing that some eligible women are of Latin American heritage and we have not yet managed successfully to engage this group, we are bringing the Latin American women’s rights group to inform, educate, and shape us.
Looking Back/Challenges Faced
Initially we had a very strong focus on the 1-1 relationship with the practitioner. While this was a key strength of our programme – with the extraordinary response that practitioners succeeded in maintaining 21/21 ‘hard to reach’ women within the programme over 18 months – we learned over time that too great an emphasis on that 1-1 relationship risked creating a dependence on our programme: in fact we need to maintain a focus on pathways into other services and communities from the start of the work, and work harder to embed skills in engagement with support networks (e.g. how to feedback and complain appropriately, how to help-seek appropriately) from the very start. This is what has led to our increasingly psychologically informed approach and to our increasing emphasis on creating community rather than predominantly the potential ‘dependency’ of the 1-1. We reflected increasingly of the centrality of the peer-peer support relationship to women, and found this exponentially more powerful than the dyadic and perhaps implicitly ‘parent-child’ relationship of the practitioner –client.
Sustainability
Our strategic board, comprised of judiciary, Directors of Children’s and Adults Services, and Public Health, is absolutely key to maintaining a visible and influential profile within the local authority. We have developed processes to ensure annual review and accountability such as the annual report. We have honed our business case analysis by creating a cost audit of every woman coming onto the Pause programme, so that it is easy to evidence our cost effectiveness – ultimately a key decision maker as to programme sustainability.
Evaluation (Peer or Academic)
We have had an external evaluation, which is linked to our national programme. Commissioned by the Department for Education; Opcit Research worked closely with the University of Central Lancashire to research changes Pause brings for women their families and the services they use. Southwark Pause women and staff were interviewed throughout the 18 month programme. The findings are due to be published in the summer of 2017. An analysis from a recent OPCIT report show that the outcomes of Pause intervention demonstrate an improvement in key social issues affecting the women Pause works with. http://www.pause.org.uk/pause-in-action/learning-and-evaluation.
Outcomes
• No children have been conceived by Pause women during the lifetime of the project.
• There will be long-term cost avoidance throughout health and social care services as women access health care and maintain healthier life choices. Over the course of an 18 month project it can be estimated that by having an average of 20 women involved and actively engaging with the programme, up to 10 children may be prevented from being taken into care. Over 5 years, with no intervention provided, the estimated number of children would be approximately 35.
• The estimated cost of permanent removal and placement of one child stands at £42,956 (based on a minimum calculation of legal fees and adoption placement costs). In comparison, the annual cost per woman of Pause stands at £14,397.
• Pause Women have become better equipped (with a range of practical skills, reasoning skills, personal resilience strategies) to make life choices that reduce the likelihood of repeat, short interval pregnancies that result in children being born into enduring and unchanging chaotic circumstances.
• We have worked on this relational approach both at individual and community level interventions:
• 19 women have evidenced increases in planning and anticipating problems.
• 19 women have evidenced increased ability to complain and feed back appropriately within formal and informal (e.g. family, friends) systems.
• 19 women having identified a person within their network, be it professional or personal, they can talk to and ask for help. One woman said “when I need help I ask for it – this makes me feel stronger….Talking helps me to get it all out and expressing my feelings helps by sharing the load with someone else. When I ask for help there are people out there who are willing & able to help.”
• 19 women have incorporated adaptive pleasurable activities and experiences into their daily lives (e.g. walking, sewing, swimming). 18 women have attended group activity sessions (art work, jewellery making, nail art, cards and collages).
• 19 women have been supported to address physical health issues through accessing GP, hospitals etc. 19 women have been supported to improve physical health by participation in exercise – running, walking, cycling, riding, or going to the gym.
• 15 women have accessed counselling and psychotherapy.
• 19 women have increased mental wellbeing and describe greater positive identity – ‘I’m beginning to like myself’.
• 4 women have identified and addressed life threatening conditions (diabetes, lung blood clots, suspected cancer) as a result of their engagement with Pause and subsequent engagement with medical services.
• 2 women posing a risk to self as a result of mental distress have been supported to access mental health services. 8 women have been supported to manage suicidal crises through assertive support, risk assessment and interagency liaison through crisis periods. 19 women are now routinely accessing preventative health, including sexual health services.
• 19 women have been supported to improve quality of contact with children through a range of means including support and counselling around loss and grief; resuming letterbox contact; liaison and face to face meetings with social workers; facilitation and uptake of split LAC reviews. One woman said ‘I learned who I am… to be a mum without my kids’.
• 5 women have been supported in accommodation. We supported 3 women who were previously homeless –including a woman who spent a period of 3.5 years in homelessness, during which time she was obliged to exchange sex for places to stay; 1 eviction was prevented and options for downsizing arranged; 1 woman had no tenancy and was still residing in 4-bedroom family home where everything reminded her of living with her children -housing made a direct offer and successfully managed her move.
Sharing
Pause Southwark is committed to shaping outcomes and trajectories for everyone at risk of repeat removal and their children – not just the people we are currently supporting. We are regular contributors to conferences, both within the national Pause framework; the local authority; London; and elsewhere. For example, in 2016 we delivered a Repeat Removal Seminar to solicitors in South London and another to mental and physical health professionals in Southwark, explaining the factors supporting repeat removal, and giving practical tools for embedding trauma-informed practice in everyday frontline work. In June, we will be speaking at a domestic abuse conference in Sheffield, talking about working in highly complex contexts where the presence of multiple difficulties may complicate an intervention, and lessons we have learned in light of this.
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Patient experiences
Pause Southwark makes a particular and disciplined effort to work in a human and non-pathologising way, and to break down traditional service barriers to engagement, using highly qualified and experienced staff from across disciplines. We are deliberately informal. We hug – where appropriate. We stay warm. We show the pleasure we take in relating. We use self disclosure as a key tool to support women to understand and normalise their situations, in a way that is often considered challenging by other agencies, particularly social care. For example, when Jasmine had an abnormal smear test and was too scared to attend for a follow-up, our practitioner shared her own experience of being called back for an abnormal smear – her own fears, what was helpful for her, and her subsequent reflections. We reflect on disclosure as a team during weekly supervision sessions. We focus on instilling and practising negotiation of consent and the right to review- for everything, from physical contact such as hugs, to information sharing, to levels of Pause-woman contact via phone and other media –as Pause women have frequently been coerced and controlled and are inexperienced at negotiating consent for themselves (for example, 3/21 Pause women have reported being coerced into immigration marriages).
Women tell us, ‘I feel like I’m being talked to like a person for the first time’. We have retained 21 women previously not engaged by services, who have considerable and complex needs, over 18 months. Practitioners on the team concur, ‘It’s how I’ve always wanted to work’, and, as one of our women explained, ‘It’s a partnership, not a dictatorship’.
Our commitment to fostering normality, peer support and community though is perhaps what we are most proud of – based on a recognition that no matter how hard we work, and no matter how much we love our jobs and value the privilege of walking alongside women as they carve out better lives for themselves and improve outcomes for their children, a professional service can and should only ever be a small part of the answer. Asked what has been different for women about Pause Southwark, women tell us again and again – ‘the other women.’
Patient outcomes/ improving access
We recognise that a key difficulty for many agencies supporting women who face multiple exclusion has been that systems are aimed at addressing discrete, severe problems, through identification and treatment of pathological features.
As noted, women of the Pause community frequently do not meet criteria for ongoing help from statutory services. Although most women meet criteria for a personality disorder, often emotionally unstable personality disorder, most women do not meet criteria for ongoing help because their risks are predominantly relational (e.g. to children in their care, or from partners – 100% of our women have experienced violence in intimate relationships) rather than intrapersonal (although nearly all our women have tried to end their lives or used self harm to cope with difficulties at times, these are not usually chronic, severe or ongoing enough to qualify for ongoing help). As a result, they end up presenting an extremely high cost to reactive services – such as children’s services and an extremely high human cost – their own, their networks and most fundamentally, their children.
Pause Southwark operates on 3 levels to break the cycle of repeat removal and ensure patient outcomes, recognising that no matter how effective the 1-1 relationship is with women, if we do not succeed in creating communities that understand and respond better, children and families will continue to bear the brunt. Thus we work on the microcosmic – working to understand and support women on a practical and psychological basis, advocating and supporting women to ensure their voices are heard on a day to day basis; the interagency, where we create local networks with other agencies so they can understand and better flex to meet the needs of women through training and education, networking, and operational links; and the systemic/strategic, where, for example, we use our strategic board and have conscripted the Chief Executive of the Council and Director of Public Health in advocating for our community, and used our links with the National organisation to spread influence and ensure that the needs of the community of people at risk of repeat removal are better understood. We are lucky to operate within a local authority in which there is a high level of motivation to do things differently and improve the offer to local communities at risk of exclusion.
Some of the extent of the offer from the multiagency community as a result of our advocacy is described above (consultation, advice, co-delivery of groups, and training from the mental health trust; domestic abuse workshops designed around the needs of our women from Solace; the Pause/Substance Misuse Panel, at which all local SMU agencies work with us to formulate and design a bespoke and trauma-informed approach to meet women’s needs), and we are proud and grateful that we have succeeded in persuading community agencies around Pause women to deliver such high and creative levels of access to women, who have taken up the offer with alacrity.
We believe that the 3 tier approach to multiple exclusion and trauma (personal/practical/psychological; interagency; systemic/strategic) is paramount in ensuring change not just now but for the future, sustained change, and that this is evidenced by the projected cost-avoid of £687, 245.86 over an 18 month period. Although the data is not conclusive yet, we believe the efficacy and utility of a programme offering psychologically and strategically informed practical support to women at risk of repeat removal may be further suggested by a significant drop in the rate of care proceedings in Southwark since our programme’s inception – moving from the highest rate of repeat removal in London (33%) in 2014-15, to below the national average (22%) in 2016-17.
