In supporting people whose brain injury is often disguised by other factors, professionals must challenge unconscious bias and ensure their curiosity can see beyond a person’s immediate presentation, says Ellie Atkins, social worker and safeguarding lead at Manchester City Council.
Here, she tells the story of brain injury survivor Jessica and the many challenges she faces – but how, through the recognition of her complexities and provision of appropriate support from safeguarding and support services, she is now on the road to rebuilding her life
To understand how the Care Act 2014 and social work leadership in safeguarding can support a bespoke approach to rebuilding a person’s life, we must provide opportunities to hear their stories.
Why would someone sleep rough and drink alcohol all day, refusing to come indoors? To understand this, their story is critical to making sense of the why.
Jessica is 28 years old. She sleeps rough on the streets of Manchester and drinks alcohol all day, every day. She neglects everything other than what she describes as her ‘survival need to cope’ – alcohol.
But she wants her story to be heard, for people to know she is so much more than she may appear.
Our team have known and worked with Jessica for eight years. We know she experienced childhood neglect and sexual abuse from a family member. She lost her baby in a car accident, in which she herself experienced a significant head injury. Jessica later witnessed the murder of a partner.
She tells me she is too scared to stop drinking, that she needs to feel numb. And this is why she drinks.
In my world, on the frontline of social work, I meet women like Jessica every day, who are deeply scarred by their experience of trauma. Trauma like being neglected as a child, childhood sexual abuse by people in a position of trust, brought up in care with no love or primary attachments. Many go on to tell me that it doesn’t actually get much better.
Statistics show that 85 per cent of people who are homeless, sleeping rough and excusing substances will have experienced childhood trauma. Up to 95 per cent will experience more trauma from violence, abuse or sexual assaults while being homeless. Around 50 per cent have acquired brain injuries.
I often wonder what the world must look like through their eyes. What must that feel like every day. These are some of the most traumatised people in our society, many of whom have complex PTSD from their lived experiences.
I see people like Jessica with brain injuries from the beatings that they have taken. I see people with alcohol-related brain damage from drowning their pain and trying to survive through alcohol like Jessica.
We’ve heard the importance of people’s stories in our assessments within the Care Act. And evidence from research suggests that with a safeguarding leadership team around your approach, you can start to peel back the layers and get to the core of why Jessica sleeps rough and drinks alcohol.
Safeguarding is about empowering Jessica, listening to her and removing barriers. We do this by working in partnership to protect Jessica in the most proportionate way. Evidence from research shows that this works when we have a safeguarding lead and a team around Jessica.
Executive function is critical to this, as a set of cognitive processes that are essential in controlling all human behaviours. They are the brain’s functions that provide us with the ability to be who we want to be. Does Jessica really want to sleep rough on the streets of Manchester drinking alcohol every day? Is this a lifestyle choice? Or is it more to do with her executive functioning being compromised?
As a professional, I am so glad the knowledge of executive dysfunction came into my world, because it has changed my practice as a social worker.
It was extremely difficult to understand and communicate with Jessica. Yes, she was intoxicated, but she would never hold on to a topic long enough for it to register. The inflammation in her brain seems to be working so fast, that she could not recall, retain, weigh up or make any decisions. Jessica had no insight into how she presented. She was a proud young woman, yet was unaware of the faeces on her hands and that her jeans had fallen down.
Jessica was fixated on certain things that she would struggle to adjust to any attempts to change topic. Was this because she was addicted to alcohol? Or was her a brain’s ability to think flexibly struggling in some way? She would say she wanted to come indoors, that this was really, really important to her. But she never did, not even with support. Why was this? Why would she say one thing, but consistently do another?
She could be highly organised in some areas, but this was limited to topics that she was fixated on. She would act impulsively. She did not seem to think out the consequences of her actions, which meant that she could take huge risks, and her behaviour was unpredictable. It could cause fear and apprehension among others.
Is this what you do when you’re intoxicated? Or was her impulse control over executive function affected? She presented in hyper vigilant dysregulated emotional states that fluctuated between panic and anger. This did not seem to be because of her drinking.
This seemed to be because she was scared of applying the principles of making safeguarding personal. In the eight years that we have worked with Jessica, we have been able to establish the context in which her struggles appeared. These were later diagnosed as PTSD, ADHD, traumatic brain injury, and correlated brain damage from the years of drinking.
In hindsight, it was obvious. But up until this point, Jessica have been assumed by so many people to be a moral failure and a drunk.
It had been assumed by every professional that she’d had contact with that her behaviour was because of her drinking. Jessica has hidden disabilities from the executive dysfunction, and this is why it’s critical to understand this. Safety comes from the brain’s executive function – which means that Jessica’s non-negotiable, fundamental human need is to feel safe, is compromised.
For Jessica, things are changing. She is in recovery from alcohol addiction and is thriving in a provision for women with acquired brain injury. But to get to this point and for Jessica to access the support she needed, we needed to get past those assumptions and delve into the background of what had happened to her.
We must challenge any unconscious bias and have professional curiosity, so we can help more people like Jessica. We must realise they are not a failure, but they have hidden disabilities and differences that prevent them from being who they want to be.
With the right support, there is hope. People can thrive, recover, and become who they really want to be.
- Ellie Atkins was speaking at the UKABIF Summit 2023
