Attendance Is All I Can Tell You

Mothers whose children are in care are often told to get therapy before they can have them back. Nobody provides it. Nobody regulates it. And nobody has written a line of guidance for the therapists doing it.

This piece grew out of a conversation with a supervisee after the same issue arose in their work. It reminded me that this is not an isolated clinical dilemma, but a wider gap in guidance, governance and provision.

The referral comes in without much ceremony. Sometimes it is an email from a social worker. Sometimes a phone call. Sometimes the woman rings my practice herself, because she has been told she must. The wording changes but the substance does not. She needs to engage in therapy to address her trauma, or her relationships, or her insight. There is usually no clinical question and no stated endpoint. What there always is, is a reason she cannot say no. Her children are in care. Everyone involved understands that her contact with them, or her chance of getting them back, depends on her doing this.

I write reports for these women. My reports say that she attended. That is all I can honestly certify, and it is worth stopping to think about how odd that is. The only thing a treating therapist can properly say about a client who was sent is the one thing that tells the local authority nothing about safety, nothing about change and nothing about her children. Attendance measures compliance. We have built a system where therapy works as proof of compliance, and then we act surprised when it does not produce the change the paperwork implies.

The situation we are recreating

Almost all the women sent to us have come out of relationships built on control. That is often why their children were removed. Not because they were violent, but because they could not keep themselves and their children safe from someone who was. They arrive having lived where someone else held the power, where access to their own life depended on doing as they were told, where what they said could be used against them, and where they never set the terms.

Then we put them in a therapy arrangement with exactly those features. Access to her children is conditional. Her compliance is watched. She has to tell private things to a stranger who reports, in some form, to the authority that holds the power. She did not choose the therapy, the therapist, the model or the timescale. If she says the wrong thing, she has good reason to think it will cost her.

I am not saying that social workers are abusers, or that child protection is the same thing as domestic abuse. Intent is not the issue. The issue is that a system built to protect children can recreate the conditions that harmed the mother in the first place, without anybody deciding it should, and nobody in the pathway is responsible for noticing. We are asking women to recover from control inside a controlling structure, on a timetable somebody else sets.

Why the therapy cannot do what is asked

This is not only uncomfortable. It is a technical problem, and anyone who trains therapists should see it straight away.

CBT runs on disclosure. It works by building a shared picture of what keeps a problem going, and that picture is only as good as what the client tells you. The work needs her to bring the things she is most ashamed of and least able to say out loud. We spend a great deal of training time on how to make that possible. Then we put a woman in a position where telling the truth is dangerous. An intrusive thought, an old relapse, a night she did not cope, a partner she has not quite let go of. Any of it might travel into a process that decides whether she sees her children.

She is not being evasive when she manages what she tells me. She is being sensible. Her mistrust does not damage the alliance. It is an accurate reading of her situation. And consent given in those conditions is not consent in any sense we would accept anywhere else in our work.

The timescale makes it worse. Care proceedings are meant to finish in twenty-six weeks. Whatever you think of that as family justice, it does not fit phased work for complex trauma. It pushes therapists towards processing trauma with women who are not stable, during the worst period of their lives, at the point they most need to hold themselves together for court and for contact. Good practice says stabilise first. The process says show change by the hearing.

The belief we are not allowed to test

There is a problem here that belongs to CBT in particular, and I have not seen anybody write it down.

These women arrive believing that the system is stacked against them. Normally that is exactly the sort of belief CBT would work with. A lot of what we do involves helping somebody look hard at a distressing conviction instead of swallowing it whole. What is the evidence for it. What is the evidence against it. What else might be true. What happens if you test it. It is one of the most useful things the therapy offers.

Except that here, when you look at the evidence honestly, the belief stands up.

Many of these women were in care themselves, so the state was already responsible for her before it became responsible for her children. The recurrence figures have not moved in ten years. The support that would make change possible is not funded in most areas, so she has been told to get a service that does not exist. She is expected to show she has changed within a timescale that would be hard for somebody with money, a stable home and a good solicitor. She has none of those things.

So the honest response is to agree with her, and agreeing with her is dangerous. A woman who says the process is unfair can be written up as lacking insight, minimising, or failing to engage. A woman who says she is the problem is described as showing insight. That is not a clinical judgement. It is a compliance test in clinical language, and we are the profession being asked to run it.

I will not restructure a belief that is true. No competent therapist should. But we ought to be clear about what we are refusing to do, and what it may cost the woman sitting in front of us.

Nowhere to send them

The other half of the problem is that nobody has decided where this work belongs.

In NHS Talking Therapies, the service most people are referred to for anxiety and depression, we are simply expected to absorb it. It was commissioned for mild to moderate problems, with session limits and routine outcome measures. It has no pathway for work running alongside court proceedings, no funding for it and no governance for it. There is no protocol for what we share, with whom, or on whose authority. Clinicians work it out case by case, usually well, and always alone.

In private practice there are no rules at all. Counsellor is not a protected title in this country. A woman told to get therapy may find an accredited, supervised, insured practitioner. She may find somebody with a weekend certificate and a website. Nothing in the system will notice the difference. Often she is expected to pay. The quality of care she gets, and so part of the evidence used to decide about her children, depends on which door she happens to walk through.

We write this sort of guidance when we decide that it matters. Criminal proceedings have Crown Prosecution Service guidance on therapy before a trial, written because somebody saw that the relationship between therapy and a legal process needed rules rather than individual judgement, and that therapy should not be delayed just because a case is running. Family proceedings have rules on how psychologists are instructed as experts, with the court deciding who is appointed and what they are asked. Both cover the clinician who has been formally instructed.

Neither says anything about the therapist doing the actual treatment. That person sees her every week with no instruction, no scope, no framework and often no colleague who has done it before, doing work that will still be read as bearing on whether a woman gets her children back. The one job we have left completely ungoverned is the ordinary one.

The women said all of this nearly ten years ago. The Lancaster researchers recorded their frustration at not being able to get the therapies that had been recommended during their own proceedings, and the sense of injustice that followed, because they knew perfectly well that professionals would later want evidence of improvement in their mental health when judging whether they could parent. The report asked who is accountable for making sure women can actually get the treatment recommended in court. Nobody has answered.

What should exist instead

Often, social workers and social care teams are not doing anything wrong. They are carrying out the responsibilities placed on them and acting in what they understand to be the child's best interests. The issue is not individual practice, but the absence of a distinct, properly funded specialist therapeutic service and clear national guidance for the clinicians asked to provide it. Without those, social workers, therapists and women are left trying to make an unsuitable arrangement do a job it was never designed to do.

None of this is news to the family justice system. The Lancaster study found ten years ago that around one in four birth mothers appearing in care proceedings can be expected back in court within seven years. In its review of 354 case files, over half the women had spent time in out of home care as children: forty per cent formally, as looked after children, and another fourteen per cent in informal or private arrangements. The state was corporate parent to the mother before it became corporate parent to her child. The same study described women with clear needs for reparative and therapeutic help that went unmet.

A benchmark study in 2022 found the picture unchanged. Still about one in four, measured over ten years. Closer to one in three for women who first gave birth young, and more than four in ten of the mothers coming back with a baby were estimated to have been between fourteen and nineteen at their first birth. The number of women in recurrent proceedings has gone up rather than down. Services such as Pause and the Family Drug and Alcohol Courts show what proper provision can do. They are few, unevenly spread, and some have closed for lack of money.

What is needed is not more willing therapists. It is funded specialist provision, paid for as part of the local authority's duty rather than pushed onto individual clinicians and individual women. Clear separation between the person providing treatment and the person providing assessment. National guidance for therapists working alongside proceedings. And an honest admission that therapy completed under duress is not evidence of anything.

Until then I will keep writing the only report I can defend. She attended. That is all I know, and it should bother us that it is enough.

Sources

Broadhurst, K., Mason, C., Bedston, S., Alrouh, B., Morriss, L., McQuarrie, T., Palmer, M., Shaw, M., Harwin, J. and Kershaw, S. (2017) Vulnerable Birth Mothers and Recurrent Care Proceedings: Final Summary Report. Lancaster University, funded by the Nuffield Foundation.

Nuffield Family Justice Observatory and the Family Justice Data Partnership (2022) Mothers in Recurrent Care Proceedings: New Evidence for England and Wales.

Crown Prosecution Service, guidance on therapy for victims and witnesses before a criminal trial.

Family Procedure Rules 2010, Part 25, on experts and assessors in family proceedings.

The clinical situations discussed are composites drawn from recurring themes across practice, not accounts of individual cases. Details and circumstances have been changed, and no client, referral, professional or local authority is identifiable.