Appreciating what works: discovering and dreaming alongside people developing resilient services for young people requiring mental health services Prof Bernie Carter*, Steve Bradley*, Robin Richardson*, Rosalind Sanders*, Dr Chris J Sutton* *Department of Nursing, **School of Health & Postgraduate Medicine, University of Central Lancashire
Correspondence address: Dr Bernie Carter Professor of Children’s Nursing Department of Nursing Clinical Practice Research Unit University of Central Lancashire Preston PR1 2HE Tel: 01772 893720 Email:
[email protected]
Introduction Within this paper we report on a study undertaken to identify resilient services for young people requiring mental health services. Whilst undertaking the study we faced issues related to determining what constitutes mental health services, and issues related to different disciplinary perspectives and discourses. These were set within an environment that was changing rapidly as new ways of working were being implemented. Having gone from a situation of relative obscurity, child and adolescent mental health (CAMH) has been the subject of a great deal of attention in the United Kingdom (UK) over the past 10 years. This has, to a greater or lesser degree, been the government’s response to the perceived epidemic of mental health problems in the child/adolescent population. Not only has the immediate impact of poor mental health been identified as being of concern (to government, society, schools, communities as well as children and their families) but the potential long term impact has also been emphasised (Heijmens Visser et al., 2000; Licence, 2004; Mental Health Foundation, 2005). Although figures vary, mental health problems in children and young people appear to be common and increasing (DoH, 1998; Meltzer et al., 2000). An estimated 10% of children are thought likely to develop a mental health problem (Meltzer et al., 2000). However, of those children, only a small proportion are reported to go on to experience a serious problem. Whilst there is much emphasis in the literature on both prevalence and incidence there is no really clear definition of what constitutes mental health problems for children and young people. Children experiencing behavioural and emotional problems are now encompassed within the broad umbrella of CAMH services; albeit their problems are often more allied to environmental and social factors (for example, poverty, parenting issues) than mental health per se. This broadening of what is legitimately encompassed within CAMH and the extension of the age range to 18 years means that services already reporting being overstretched may well be at risk from being overwhelmed. The most important element identified within reconfiguring CAMH services in the UK, is the focus on an integrated, four-tiered approach to service delivery. This was highlighted in the ‘Together We Stand’ report (NHS/HAS, 1995) and in subsequent reports. The tiers are most usually presented in the form of a triangle with the wide base of the triangle representing the breadth and diversity of generic services at tier 1 and the upper part representing specialist tier 4 services.
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Tier 1 encompasses all children, aiming to protect and promote their mental health and is supported by the endeavours of primary school teachers, youth workers, voluntary workers and primary health care professionals. Tier 2 primarily covers children at risk and those with mental health problems. Staff (for example, social workers, looked after children workers, paediatricians, primary mental health workers) working within this tier work independently of each other but within an established network. Children with emotional and behavioural difficulties most frequently fall within either Tier 1 or 2. Tier 3 encompasses children with disorders and illnesses who require more specialist support from an integrated team of professionals
working
together
(such
as
child
psychiatrists,
therapists,
educational
psychologists, behavioural specialists). Tier 4 represents highly specialist, generally residential and costly services which are provided regionally rather than locally. The aim of this integrated, tiered system is to identify and manage children within tiers 1 and 2, and thus prevent them needing referral further up the system. Along with the development of new service models, new roles (such as the primary mental health worker – PMHW) have emerged to provide flexibility to the system and respond to needs. However, despite the impetus to develop this cohesive, integrated tiered system and children and young people continue to fall through gaps in provision. This may be because they do not meet specific criteria, services are unable to recruit appropriate staff or because a specific tier has yet to be established in a particular geographical location (Day et al, 1998; Johnston and Titman, 2004). The role of the PMHW focuses primarily on consultation, liaison, direct work and training. However, the role has not been without challenge and has been introduced with varying degrees of success depending on the model and function of the PMHW service (MacDonald et al., 2004; Whitworth & Ball, 2004). Integration and multidisciplinary working between various statuary and non-statutory agencies is increasingly being implemented in practice. However, Window et al. (2004) note that “this integrative approach is often characterized by lack of clearly defined roles, overlap or fragmentation of resources, or poor co-ordination with other agencies”. Bradley et al. (2003) report on the different types of interface work across agencies with interface work growing with more developed, larger CAMHS. However, whilst the 4-tier pyramid may look good on paper it is, evidently, not easy to implement in practice: not least because it challenges traditional
boundaries,
crosses
financial
barriers,
requires
new,
flexible
ways
of
working/thinking and careful, thorough preparation of people (see for example, Sebuliba and Vostanis, 2001; Sloper, 2004). Despite these difficulties part of the vision for CAMHS set out in the NSF is that:
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“…multi-agency services, working in partnership, promote the mental health of all children and young people, provide early intervention and also meet the needs of children and young people with established or complex problems” (NSF, 2004, p4). This study was commissioned locally with the aim of helping local service providers meet the national agenda. The context of local CAMHS at the time this study was commenced was one in which an integrated, tiered (but not fully comprehensive) service did exist. PMHW were being introduced and children’s services at a macro level were undergoing reorganisation. There was evidence of cooperation and collaboration (such as multi-agency projects) between key stakeholders and across a range of agencies. In the same way that defining ‘mental health’ can be problematic so can defining what is meant by ‘mental health services’. Therefore, in approaching this study the aim was to encompass a broad definition. Thus mental health services were seen as including any service which felt it contributed to the mental health of young people. The key questions that needed to be answered in this study were – how were the services doing, what gaps existed, what evidence was there of good practice, what needed to be done? The focus of this paper is on the perspectives of service providers on the nature and focus of the mental health services for young people. ‘Resource issues’ and ‘best practice and innovation’ will be referred to but not presented in detail in this paper. Methodology The overall aim of the study was to explore what was working well within mental health services for young people (aged 15-18 years), where the gaps were and what could be done to further develop resilient and appropriate services. The study used surveys and in-depth interviews to explore the views of the key stakeholders in relation to mental health service for young people aged 15-18 years. The target population covered the main service provider groups. It aimed to include practitioners and managers from the health services, social services, youth and community services and charitable/voluntary services. The use of Appreciative Inquiry (AI)(Cooperrider and Barrett, 1990), an organisational development approach (Bushe, 1995), aimed to uncover not just challenges, issues and problems but also to highlight examples of good practice and innovation and to make recommendations for future service development. AI is an approach that genuinely appreciates the expertise and resources currently available within and across organisations. Rather than framing research questions as problems that researchers set out to resolve, it looks to the
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participants as the experts and it seeks to untap their ideas and their solutions (Carter, in press). It seeks to ‘discover the best of what is’ and ‘dream about what the best can be’. The original intention of the study was to fully integrate young people’s views into the research. However, for a number of reasons this was never fully achieved. The study with service providers used a two-phased approach: surveys and interviews. In phase 1 surveys which used a mixture of open and closed questions targeted specific services in two areas of North-West England. Snowballing on from these services was encouraged. The survey aimed to determine the extent of current mental health services for 15-18 year olds and was designed to generate baseline data including the nature, location and skill mix, referral modes, ease of access, good practice and future developments required. In phase 2 semi-structured, audio-taped interviews lasting between 30-105 minutes were undertaken with participants from health services, social services, youth and community services and charitable/voluntary services who had responded to the survey and who had indicated that they were willing to be interviewed. A flexible interview agenda was based on the analysis of the survey data. All were undertaken at times and places convenient to the interviewee. Field notes were made to support the interviews and the process of research. Notes of the steering group meetings were made and these provided guidance to the team members. In phase 1 consent was implied by the return of the questionnaire although participants were given the option of returning a completed consent form with their questionnaire (as in line with Local Research Ethics Committee requirements). In phase 2 informed consent was gained from each of the participants either prior to commencing the interviews or confirmed verbally if they had already submitted a valid consent form with their questionnaire. All aspects of research governance were fully adhered to. Data analysis The qualitative data from the interviews, field notes and surveys were transcribed and subjected to thematic analysis. Each of the team members was responsible for detailed analysis of the interviews they had personally undertaken. Preliminary coding was undertaken by each member of the research team and these preliminary codes were brought to research team meetings where they were discussed and reflected upon. At each stage, every data set was read, re-read and subjected to critical scrutiny by the lead researcher. A consensus on key codes and issues was reached and the interviews were then coded against the final agreed set
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of codes/themes. The lead researcher applied the same thematic codes to the qualitative data from the surveys. The quantitative data from the survey were subjected to descriptive statistical analysis. These data are presented as raw numbers and are integrated throughout the presentation of findings. Specific job titles and very specific role details have been withheld to ensure anonymity. Findings and discussion Twenty-one service providers from different services responded to the survey, of these 11 people were interviewed (9 face-to-face and 2 by telephone). Although we would have welcomed multiple respondents from within specific services we anticipated that one person might be nominated to respond on behalf of a busy service. Responses were received from practitioners and managers and from across the four key target groups (for example, Youth Offending Team, Adoption Service, National Society for Protection of Cruelty to Children, SPCC, Social Services, Tier 3 services, Drug service, Young Person’s Clinic, Youth and Community Service, School Health Service, Psychology Service, Information and Advice Service, Leaving Care Team, Well-Being Service). All key services were represented. The participants were scattered across the geographical area covered by the study. Eight stated that they worked primarily for a mental health service (MHS) and 13 (N-MHS) stated they worked for a service that provided some mental health input although it was not primarily a mental health service. The nature and focus of the services are presented in detail in this paper and the following core issues are focused upon: key functions of and models underpinning services: diversity of mental health needs; service focus on 15-18 year olds; boundaries/transitions; referral issues; confusions and misunderstandings; and commitment to work with young people. Key functions of and models underpinning services Most services crossed a range of different boundaries, for example, by primarily providing a health function but also providing advice (see Figure 1). The services, as described, could be grouped
within three main
categories: health; social
inclusion/social support; and
information/advice. Individuals and services/agencies were committed to and often successfully worked together. Participants also noted that strength could be developed even within systems where resources were scarce when people “worked smarter, not harder” and where there were clear agreements about how to work together. As one participant stated:
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“I’d put resources into [and] work out strategies with other key organizations and …start some service level agreements to do some joint work together…so, for example, with CAMHS or with Access to do the project, or with the clinic or with other projects”. However, there were some barriers which created tensions. Some of these related to organisational bureaucracy and the difficulties of cross-agency funding and others related to lack of understanding of each other’s roles. These barriers are unsurprising in the sense that they have previously been reported on (e.g. Hannigan, 1999; Fakhoury & Wright, 2000; Sloper, 2004). Much of the impetus throughout all recent government documents relating to CAMH and the key literature (e.g Mental Health Foundation, 1999) has been the need to overcome such barriers to successful working. Indeed, there are now toolkits available for managers and practitioners and checklists for success that have been published on the web to facilitate improved practice (see Every Child Matters, accessed 2005). It would seem that despite strategies being in place, such as the Local Implementation Groups who commissioned the study, these barriers have yet to crumble. Quite why this is so is open to speculation; it may well be that there is a degree of comfort behind the barrier, especially in a professional world in which much change was being experienced. However, perhaps even more fundamental than these anticipated barriers, were the hidden philosophical ones. Individuals representing different services/agencies described their raison d’etre as arising from a specific philosophical starting point. Whilst these perspectives were not mutually exclusive, it was apparent that different services thought about and undertook their work with young people in very different ways. This created some hidden tensions between people from different agencies, with different visions for what could and should be done for and with young people. The key models/philosophical approaches included: •
Social educational/social empowerment
•
Therapeutic caring
•
Health promotion/protection
•
Social support
•
Intervention (statutory and non-
•
Child protection
statutory)
•
Consultative
Social justice
•
Referral
•
Working together successfully requires each individual or service to make some adjustments to their primary function. Hannigan (1999 p25) proposes that “increased opportunities for interprofessional ‘seepage’ and a sharing of complementary perspectives, and for joint education and training” may help services align. Some of these philosophical approaches had greater resonance with each other (e.g. therapeutic caring and health promotion/protection). However, others were more problematic to align and created some dissonance for service providers/agencies, for example, social justice (which often operated on an ‘opt-in’ approach) 6
and intervention (which was sometimes a statutory requirement for the young person to engage). These different philosophical approaches appeared to act in the same way as ‘competing paradigms’ (Kuhn, 1970) and may partially explain why so much commitment is needed to make things work even when more obvious barriers have been confronted and tackled. However, one explanation may be that there is not a well established history of genuine dialogue across and between different disciplines and, as such, successful dialogue and subsequent sharing and collaboration are muted. The notion of philosophical barriers does not appear to be widely or specifically reported in the literature which primarily focuses on structural, operational and strategic barriers (see Hannigan, 1999; Rees et al., 2004). It is possible that each discipline perceives it has ‘monological authority’ and therefore is less able to enter into dialogue with other disciplines (see Frank, 2004 for a discussion of monological authority in the context of professional-patient dyad).What is interesting to note is that whilst joint working was valued by the participants and it is the mantra of current service developments (see the Every Child Matters website for inspiration and practical help), there is very little evidence, certainly within CAMHS, that it does make any difference in terms of effectiveness (see Cameron & Lart, 2003). An exception to this is, perhaps, Pettit’s (2003) report that suggests that amongst other factors, joint working led to an increase in children's happiness and well-being. However, some of the best practice identified fell into the category ‘philosophical and relational best practice’ and reflected the awareness of the strengths and vulnerabilities of young people needing mental health and mental illness services. Whilst no single model could be determined to be the best model; best practice seemed to occur in services which drew upon principles from social empowerment/justice, therapeutic caring and social support models. This included services with a primary health focus as well as those with a more explicit social aspect. Respect and liking for young people was evident from all participants’ statements as was partnership, collaboration and confidentiality. Other philosophical aspects that were indicative of best practice were having services which were predicated on negotiating agreements with clients, consulting with clients, being client-centred, and being focused on the young person and their family. These best practice indicators reflect those identified as practice ‘benchmarks’ within many policy and guidance documents (see for example, Street, 2004) Best practice occurred in services where there was an active multi-agency agenda and where there was a “diversity of disciplinary approaches and theoretical perspectives” that resulted in individuals “firing ideas off each other”. Other participants noted that supervision, clinical
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development forums and teaching time resulted in staff who were better prepared to develop and sustain best practice. These mechanisms have been noted in other literature that has identified ways of facilitating joint working (Cameron & Lart, 2003; Sloper, 2004). Again, a shift from a monologic to a dialogic approach may account for why best practice occurred across a diverse range of practices; perhaps the ability to talk, listen, share and internalise other people’s perspectives is key to practising in ways that are ‘better’ for young people and for practitioners. Diversity of mental health needs There was a great diversity in the mental health needs/problems that service providers identified young people presented with. Categorising these needs inevitably results in fairly crude divisions which are open to debate. However five main categories emerged relating to: emotional, mental health, developmental, behavioural and social issues. All tiers of need and provision were discussed. All participants noted how vital it was that Tier 1 and Tier 2 services were adequately resourced as they noted that early intervention with the child, family/carers, stakeholders and community could reduce progression to Tier 3 and 4 services. However, early intervention was an area that was perceived as being under-resourced. Participants were sometimes frustrated because they were either “already overstretched” or the focus was still primarily on interventions for mental ill health rather promotion of mental well-being, as highlighted in the following quote: “in an ideal world I’d like more focus to be on mental health rather than mental illness. I think because of that lack of focus we can let a lot of young people go further down the road than they need to. I think we could intervene much earlier when we start to see they’re vulnerable rather than letting them start to experience mental health problems...” These views on the need to further develop Tier 1 and 2 services are very much in-line with the current drive of “get ‘em early and stop ‘em going wrong” which can be seen not only in CAMHS but also in other services such as Sure Start and Positive Parenting (see also Morrow et al., 2005). Some services were reported as being flexible, with drop-in sessions, and were extremely young person oriented. Others had more formal or rigid appointment systems but staff were still oriented to the needs of young people. Services ranged from being those with a purely voluntary association to those which were statutory and which were able to exert considerable authority and power over the young people. However, all aimed to attain “purposeful relationships with the young people”. The best services were those which were perceived as drawing on “an evidence base for practice” and which offered a range of different provision for young people by appropriately trained/qualified people who were committed to “making things
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better for young people”. However, whether or not these particular “evidence bases” were based on a coherent and broadly accepted philosophical position is hard to judge; in some instances participants found it hard to articulate exactly what their position was – although they intuitively knew they had one. Often the evidence base was presented in broad terms such as empowerment or social justice. Whether there was a shared understanding of what such terms meant across a team or between services would be interesting to pursue. However, it is likely that such shared and consistent understandings are only likely to be achieved (or abandoned) if time is taken for dialogue so that shared understandings and jointly owned meanings can be developed. Service focus on 15-18 year olds Sixteen participants (n= 6 MHS, 10 N-MHS) felt that services were focused on people younger than 15-18 year olds, with seven participants (n= 2 MHS, 5 N-MHS) stating that services were focused appropriately and four (N-MHS) stating that services were focused on people older than 15-18 years. This reflected and included issues such as environment, staff training and staff attitudes. Resource limitations often meant that there were restricted facilities: “So I think we need some decent facilities for young people. It’s this kind of work, that really needs to be properly resourced, I think in terms of the, not just in terms of the staff, also in terms of the fabric of the facilities…. We [need] the same kind of facilities that you have in school or wherever” Most participants (n= 4 MHS, 14 N-MHS) felt that services ‘partially’ or ‘only a bit’ met the needs of young people. No-one felt that young people’s needs were fully met or not met at all. Only four participant (3 – MHS; 1- N-MHS) stated that young people’s needs were mostly met. Young people mostly comprised a small percentage of total caseloads. Most participants felt that there were significant gaps in service provision for 15-18 year olds and that this age group often fell through service provision even though their needs were acute. That our survey revealed gaps in local service provision was not surprising as this reflects a wider national picture of fragmented CAMH services, especially for this specific age group (see for example, Badger & Nolan, 2000; Barnet Community Health Council, 2001; Morley & Wilson, 2001; Pettitt, 2003; Sainsbury Centre for Mental Health, 2003). Despite the perception that there were “big gaps” and “poor service provision” for young people, the level of need was reported as being “high”. One participant noted: ”the organisations that I work with tend to have quite a few young people who are experiencing mental health problems and they’re in distress. And it is very difficult to refer them, especially the 16 to 18 year olds, and that tends to be the focus of a lot of worker’s time”.
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Age, rather than individual based need, seemed in some instances to take precedence in the way that decisions were made about referral on to more specialist services as can be seen in the following example: “…if they’re 15, 16, 17 because they kind of fall between the two age ranges for services. …I had a young girl who was coming up 16, CAMHS were reluctant to take her on because they said realistically she wouldn’t be seen as a priority in the next few months and Adult Services were a bit reluctant to take her on, she was not quite 16. …… She’d identified herself and I’d given her as far as I could give her but I still felt she would benefit from a bit more intensive input from somebody who was doing that work on a more regular basis.” However, most services reported some flexibility in terms of engaging with young people and children who fell outside their usual age-provision criteria. Whilst most services needed flexibility in accommodating clients older than their usual client group, other services had to flex in both directions by accepting clients younger and older than their usual target age range. These decisions were based on the argument that the individual was either older/ younger than their chronological age and in need of services available in Children’s Services but either unobtainable/inaccessible in Adult Services. Other gaps were specific to particular groups of young people such 16-17 year old girls who self-harm. Young men also were highlighted as particularly at risk: “I don’t think there’s anything [mental health] for young boys [16-18 yrs old], I had one of my cases recently and he managed to slip through…he didn’t fit into the LAC [looked after children] or accommodated child system…..I said to [various services] ‘this child needs a lot of support and he’s quite vulnerable’ but there was nothing I could do, the system was letting him down.” Even when there was service provision, timing sometimes meant that young people were not “ready to engage”, as one participant described: “I don’t know how many young people I’ve worked with where they’ve been through the entire system, they’ve had this and they’ve had that, they’ve been offered it all – that’s fine. But they were offered it at a time when couldn’t engage in it and move it and learn from it……..” Boundaries/Transitions Some gaps reflected the fact that services had not been set up to meet the needs of young people. However, other gaps reflected problems where children did not fit current service models. For example, a service for looked after children (LAC) identified concerns about young people “on the edge” of service provision. “There’s a whole group of people who are on the edge of coming into or leaving the LAC system, either to go into adoption placements or to leave the care system altogether. That’s created quite strong demands for some psychological input and that’s been really difficult to do really“.
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The notion of people being on the edge was evident from many participants’ descriptions of young people who would benefit from their service but this was often “at odds” with the design of the service. “I’ve been asked to work with the 6th Form [17-18 year olds] as well, but I just haven’t got the capacity to do that at moment. My remit isn’t to work with 6th formers, I do some work with them if they come to the drop-in…. but…” Some participants felt that services needed to reflect on the current boundaries as this affected inter-agency working: “So I think sometimes CAMHS teams can be reluctant in some ways and they think long and hard and draw boundaries around work they might take on. So sometimes there’s been a bit of tension between CAMHS teams and myself and probably people in social services as to how CAMHS services can meet children’s needs The transition to adult services was noted to be problematic either because no services were available or because it was used as an excuse to not provide services as they would be starting with adult services “soon.” “There was a young person with ADHD, a classic case, a CAHMS issue, where, they turned 18 but adult services didn’t recognise them. All of a sudden we have a family saying, ‘what do I do now’?. They’d had wonderful support ‘til then, but CAMHS was no longer relevant, and adult services locally doesn’t recognise it. So there are big gaps” Referral issues Referral processes both into and out of services were not always clear. Referrals from outside of MH services were mostly seen as difficult. Different structures were noted ranging from: • strict referral protocols with specific, “enforced” criteria, • personal contact and discussion, • referral forums, and • serendipity. Referrals to mental health services came from different agencies and people including psychiatrists, psychologists, child development teams, GPs, paediatricians, children’s nurses, school nurses, CAMHS workers, social workers, teachers, criminal justice system, foster carers, parents/carers, and self referral. The time between referral and accessing the service varied, ranging from less than one month to more than three months. Mostly dissatisfaction with waiting times was reported as was the difficulty young people would have in accessing their service: “…. …more effective referral as well, for the cases that do need more intensive intervention because at the moment referrals – they’re very long,…there’s a long waiting list….”
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Key reasons for referrals to MH services from N-MH services were generally focused on a need for “more specialist support than they could offer”, or “more intensive intervention”.
In
addition, young people were referred-on where there were “risks or crises to the young person’s health or well-being” such as risk of self harm or where people suspected that the young person was “depressed” or “needed a diagnosis”. Other key reasons noted were where mental health issues were acting as “a barrier to education or employment”. Length of waiting times was sometimes a deterrent but referring-on was often seen as the only “safe option”. Whether this was safe for the young person and/or for the professional was never very clearly stated. One participant noted that although they had a “good and close relationship with CAMHS” that the young people they worked with did not like being referred to CAMHS due to the stigma associated with ‘mental health’ or being ‘mental’: “A lot of young people do not like access service due to it being called Mental Health. I do refer, but many [young people] do not attend appointments” More discreet, outreach services that undertook the sort of “mental health work” undertaken by CAMHS but which were labelled/marketed differently, were seen as potentially reducing the numbers of “do not attends”. Confusions and misunderstandings Whilst most individuals were clearly very willing to work with different agencies and services and ‘professional turfism’ was notably absent, there remained a level of confusion about the nature of provision by some services and about particular roles. For example “my role is often misconceived in that first of all they think I’m a youth worker and then they think I’m a counsellor”. In fact the worker was neither. Although some confusion existed there was a genuine willingness to learn about each others’ roles, for example: “I’d like a better insight into what a mental health worker does when they take a young person on as a referral on their caseload - the kind of things they’d be doing on a weekly, two weekly or monthly, how regularly they see them and whether we could support the young person by doing some of that in school when they’re already there. It’s a bit of a mystery to me as to what they do, sometimes when they go there is it that there’s a structure, this is the way they run the session that they’re obviously time limited is it kind of counselling session, I’m not really sure, we’ve got that great deal of overlap to know what happens when they go there” Individuals and services were mostly not complacent about any such knowledge deficits, with one participant, who was developing a new service, noting that: “One of the things we will be doing is running joint training, … before the doors even open and that will be about getting agencies to understand what’s different about us and them, what are our priorities”
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The need for dialogue is also hinted at in many reports and publications as well as the potential tensions in ensuring that dialogue does occur. Referring specifically to generating understanding between health and schools the Mental Health Foundation (2005) state: “Getting CAMHS and schools to work together inevitably raises issues of differing expectations, which need to be managed, and different organisational and professional cultures, which need to be understood. Good communications and information sharing, as always, are vital. (Mental Health Foundation, 2005 p17) The participants in the study expressed a consensus on the need for capability and capacity building within the existing services. Participants felt that this would bring many rewards including reducing the need to ‘refer on’, providing young people with more skilled support whilst waiting to be seen by people with specific expertise, and increasing the confidence of service providers when working with young people. For example, one participant neatly summed up many of the key issues when stating: “…. I think people do worry about not having the capacity to deal with mental health problems as they come along and [they] refer very quickly. So that young person can get labelled quite early within the system which isn’t necessarily always the right route. It might be more a case of empowering staff working directly with the young people to [make them] feel more comfortable dealing with them [young people]” Another N-MH service saw opportunities to work with CAMHS but expressed confusion about how to refer and whether or not MH services would provide support and care in the same way as their service: “So, I see there’s a lot of opportunity to work with CAMHS or to liaise with them and to refer and network with them, there’s no doubt. But, I wouldn’t know how to go about it. Commitment to work with young people Whilst participants were realistic about the pressures and challenges associated with delivering services and providing support to young people they were all extremely enthusiastic and committed to their work. Most described their role in terms of “being there” for young people and they all emphasised positive aspects about the young people they worked with. “I enjoy the whole of it, I really do. I like the face-to-face interaction. I even quite like the battles and the stuff they [young people] throw at me…… It’s a very, very good job. It’s the person-to-person interaction I enjoy the most. Talk about rewards, it’s one of the most rewarding jobs that you can actually be in and that’s one of the reasons I chose to actually come into this. It’s the high level of face-to-face work - you see a lot of positive stuff” They described their role as being “diverse” and crossing many different aspects of a young person’s life, for example, health, education and social. Their roles were often described as being “different” from and more “personally fulfilling” than previous roles. They all expressed
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their commitment to the young people and felt that they often made a difference, although this difference/change was “sometimes a long time coming and well down the road”. Whilst the pace of the jobs was often busy or even “hectic with some chaos thrown in for good measure”, this in itself was often seen as being stimulating and rewarding. However, the need for supervision and/or support for staff under pressure was seen as vital to facilitate continued effective working. Participants felt rewarded by the opportunities to “expand knowledge of issues” Opportunities to develop close, collaborative working relations with other agencies and disciplines also brought rewards. Some experienced service providers found that their ‘new’ roles allowed them to develop a greater insight into other professionals’ ways of working, for example: “I’ve enjoyed kind of working and understanding more what social workers actually do and that’s despite having worked with social workers for years and years and thinking I knew about their role”. Conclusions It is clear even from this relatively small scale, local study that CAMH services are still struggling to build a secure matrix of services that encompass all children across all Tiers. Whilst there was evidence of some excellent working, all of the participants appreciated that there was considerable work to be undertaken to meet the vision of the NSF (2004). Partnership working across the agencies was evident but by no means fully established. Some services were working to promote young people’s mental health and there were examples of early and innovative intervention. However, the young people with the “most established and complex problems” (NSF, 2004) were described as having the fewest options. Those aged 15-18 years old were most vulnerable to dropping through the service net as, despite the reorientation of services to look after young people up to the age of 18 years, CAMHS were still finding difficulty in providing appropriate support. Indeed the 4-tier system could, in the short-term at least compound the problem for those young people with the most complex problems, since so much attention is being paid to the preventative services in tier 1 and 2. Whilst it is vital that early intervention services are developed it seems that the focus is on early in the sense of early chronologically rather than early in the mental ill-health trajectory. This means that some young people are not able to access light touch, early intervention support services.
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It was clear from the study that whilst nearly every participant felt that young people were not served particularly well, many of the professionals did not feel very well prepared to work with young people aged 15-18 years. This was specifically evident in those services that traditionally have focused on younger children. Enhancing the capability, confidence and capacity of service providers across all tiers and agencies might be a way of reducing referrals which could potentially/should be handled “lower down the tiers”. Skilling-up could be achieved through specific training, collaboration, mentorship/support from specialists to more genericallyoriented providers. Joint training could also facilitate better joint working and could facilitate reciprocal dialogue and dialogic practice. Enhancing and developing the facilities available and the accommodation for young people’s services would ensure that the physical provision matches the quality of support and intervention that service providers do provide when working with young people. This in line with the need to reduce referral waiting times and provide equitable access to CAMHS for young people aged 15-18 years. These issues are important across all CAMHS but crucial for young people referred-on to more intensive services. Using an appreciative inquiry approach meant that the study did not dwell on what was not working or what was not available but allowed focus on, and discovery of, the things that were working well and were being achieved (Carter, in press). Whilst all the services reported being extremely stretched and busy, participants shared their experiences and identified (‘dreamt’ in AI terminology) ways in which they felt services could be developed in the future. It proved an interesting, and fruitful way of exploring CAMHS services and it has shed light on how philosophical differences between agencies need to be acknowledged and considered.
Acknowledgements Thanks to all of the participants who gave freely of their time to support the study.
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Figure 1: Key functions of services Health
• Assess, plan, implement care for YP with MHP • Provide specialist assessment and treatment intervention • Promotion of sexual health • Reduce health inequalities, stimulate awareness of health needs, implement programme of health care • Consult, support, advise carers and professionally develop practitioners
Social
• Provide a therapeutic service for children and young people
inclusion/social
• Provide social education support
support
• Support vulnerable young people in their transition to independent living • Promote adoption with support plans, facilitate contact between adoptive and birth families • Promote well-being and keep children and YP safe • Reduce offending rates, prevent re-offending • Facilitate programmes that empower, provide opportunities and promote diversity and participation • Raise self-esteem and communication skills of young men.
Information and
• Provide information, advice and support
Advice
• Provide information and advice on employment and training, refer to other agencies • Help YP into employment and training
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