Culture change in Children’s Mental Health–some examples of transformational design in practice.

It is exciting times in children’s mental health services. It feels like we are on the brink of radical change; and a recognition that more of the same simply wont work. There have been many drivers on this journey – long waiting lists, growing demand, frustrations about ever tightening referral criteria, and an increasing focus on severity leaving an ever growing chasm in so called early intervention and prevention. I could go on. Perhaps the biggest factor, particularly locally, has been the impact of the adverse childhood experiences research, and a need to tie up how we respond to children’s mental health for our most vulnerable populations. Clinic based interventions that draw on NICE Guidelines are simply not going to work when poverty, adversity, neglect, abuse and ongoing exposure to toxic stress lie at the root of the distress families are experiencing. The ACE’s research brings into sharp relief that these are precisely the children most likely to develop not only mental health difficulties but physical health difficulties into adulthood. The irony that our most at risk populations are least able to access specialist mental health intervention is beginning to dawn. There is no evidence based therapy for families who don’t come.

As psychologists, and perhaps most importantly, as psychologists in one of the most financially deprived areas in Wales, we have known this for a long time and shouted about it as loudly as we could. Mostly that has gone unheard – we are small in numbers and it doesn’t matter how loud you shout your voice gets drowned out in a crowd of louder, more familiar voices. However, in smaller multi-agency forums where we have built relationships over time, we have a strong voice and have had the opportunity to contribute to the development of a number of models that seek to work differently. These have developed over time (our first was established 15 years ago) and it means we  have a robust set of examples across developmental stages and contexts to draw on now that a window of transformational opportunity has opened. They are small, inequitable and often rely on short term and insecure funding but their reputation, outcomes and evaluations have grown significantly in stature. They are providing solutions to some of the most entrenched problems children’s services face.

I will begin by describing the values base from which they have all developed, as this has been fundamental to their success and has never wavered.

1. that every child is unique

2. that the family and the systems around the child are crucial to our understanding

3. that the child and their family are the experts on their own experience

4. that relationships are central – relationships with children, with families, with communities, with multi-agency colleagues and within and between partner organisations

5. that children have the right to have a contextual and developmental understanding of their distress explored

6. that the language we use is very powerful and must be considered with care

7. that the least possible contact with professional services, the more empowering the experience

8. that it is often far more effective to work with the adults proximal to the child, than direct one to one therapy. Growth and change happens through relationships.

9. that as child care professionals we are our most important resource, and need to be nurtured if we are to nurture those we work with

10. that psychologists are a scarce and expensive resource, and we have a responsibility to target our specialist skills to maximal effect

The first models of alternative service provision developed out of frustration that as psychologists we had much to offer children and families who were presented in multiagency forums, but we were powerless – trapped behind long waiting lists and tight referral criteria. A basic model of a community intervention service was presented to these forums, demonstrating how we could work differently. It was based on the principle of a bespoke psychological formulation informing the direct work of community based support staff. In one area this idea was used to bid for early intervention and prevention funding and the Family Intervention Team was born. In collaboration with a voluntary sector host who provided a non-stigmatised, neutral base without the constraints of statutory services, the team has gone from strength to strength. It provides a detailed and collaboratively agreed formulation with families that informs a 12 week, goal oriented intervention. The progress is reviewed on an ongoing basis and more formally at six weeks, leading to a reformulation as required. The outcomes and feed back from children and families are fantastic. An independent economic evaluation has demonstrated it’s financial worth (for every pound invested a saving of £7). Most significantly, and of particular interest now that people are looking, referral rates for neuro-developmental assessments in the area where it operates are significantly reduced. This provides a real alternative to the status quo where families wait for a very long time to be assessed, and only one third receive a diagnosis. The rest are often left with nothing – and the problems that meant they were accepted onto the waiting list in the first place persist.

In a different local authority the same model was applied to a different group of children – those at risk of being placed out of county, and those already there – far from home and often in inadequate and extortionately expensive provision. The same principle of a formulation informed community based intervention is used but with some key differences given the severity and complexity of the difficulties these young people present with. The support workers are more highly qualified – coming from a range of backgrounds including teaching, social work and occupational therapy to name but a few. This is in recognition of the highly skilled work they undertake on a day to day basis. The team also recruits, trains and supports therapeutic foster carers – a key component of the whole systems approach towards intervention. Finally, the high risk and ever changing needs of this very vulnerable population means that formulation and reformulation can be a daily endeavour. It is highly intensive, highly demanding work requiring complete sign up from all multi-agency stakeholders. However, the pay offs, both ethical and financial, are significant. Indeed, we have reached the stage where all five of our local authorities are looking closely at this model, some further down the road than others. Keeping and supporting children closer to home is reason enough, but as one of the heads of children’s services commented “just three or four repatriated or prevented placements and the team has paid for itself”.

We have also developed a number of models that have culture change as their focus. Our Attachment and Developmental Trauma team has training and consultation as it’s primary mode of operation. Established in 2016 it has developed a two day training programme, with follow-up skills development sessions over six months, and has systemically worked through 26 child care teams across social services, education and health. It has been so well received that recent integrated care funding has been prioritised by our partnership board for the team’s expansion. This is particularly significant in a traditional dynamic that pressurises health to do more and more direct work and ‘fix’ children with therapy (an invitation, of course, that health more often than not rejects leading to significant tensions between agencies). This has been achieved because the team have practiced what they preach and have put relationships at the centre of their development. They liaised closely with each agency about their plans, developing the package of training collaboratively to fit the needs of the respective organisations. Most importantly they started with a top down approach training heads of service and service managers first so that they would be clear about what their teams would be learning. Attachment informed practice means slowing down, sticking with, and getting in touch with the very unique needs of the individual child. It challenges traditional service structures. Without total sign up from all concerned it would fail. Instead, its work has been celebrated and expanded – representing genuine culture change.

More recently, initiated by an ‘experimental’ session offered to a housing association on a short term basis, we have begun to develop a community psychology model of service delivery. Here the focus is on having psychological and systemic expertise readily available to support staff working in our most disadvantaged communities with the aim of informing their work, and building greater resilience at a very local level. This has led to subsequent investment from a couple of local authorities to provide more of this type of resource, albeit short term as is the nature of their funding streams. Again, direct work is not the focus, although occasionally the psychologists will join support staff on a home visit if all other options have been exhausted. The model has been so successful it has formed the basis of a multi-agency bid for transformation funding. The main premise is placing expertise at the heart of communities, and empowering those who work closest with children and families on a daily basis to feel confident in what they are doing. Rather than ‘referring on’ the model offers an option to ‘join with’ and recognises the therapeutic value of ‘sticking with’ and ‘being alongside’ our most vulnerable families. From this approach a number of creative solutions can grow, informed by very local need and with the voice of families at the centre. It feels a very exciting development.

We also have a number of psychologists and psychotherapists embedded in existing services. Flying start is one example where the focus is on getting those earliest relationships off to the best start, including antenatally. The adoption service is another example where psychology is embedded in the team, so that it can impact on all aspects of service, and we have similar examples in Social Care teams for children in the looked after population. For all of these posts, consultation, supervision and training is as important as direct therapy. Indeed, any direct work with children and families is carefully negotiated to ensure all the appropriate supports are in place to make this as effective as possible, and in recognition that it has significant limitations when contextual influences are potentially damaging and ongoing. The difference, of course, is that instead of ‘rejecting’ the request remotely, the psychologist or therapist continues to be available to offer ongoing support and consultation. All the while, they continue to try to influence at a contextual and organisational level too.

Of course, we also have a number of psychologists and therapists working into more traditional, clinic based CAMHS settings, our tier 3 day unit and our Primary Care Mental Health Support Services. They are providing a full range of psychological and therapeutic interventions, consultation, and training, and their work is highly valued both by colleagues and by families who meet the criteria for these services. Most importantly, we all come together on a regular basis. Indeed, we see the provision of a professional home, and support from like minded colleagues as crucial to the success of all of these areas of service provision. Psychology is about offering a different perspective and challenging the status quo which can be a lonely and isolating endeavour. We find the support we gain from each other keeps our ideas strong and refreshed, and enables us to hold steady when we are a lone voice in whatever context we find ourselves in. Interestingly, even within psychology we have often felt a lone voice. In 2012 we presented these ideas at a conference organised by our professional body. We called it ‘Swimming against the tide’. Nobody came, choosing a parallel workshop on a more traditional topic instead.

I have written this summary of what is happening in our area in response to many requests for more information since I started my blog about children’s mental health. My aim is to avoid our respective psychologists being contacted directly as they are too busy delivering services to be able to respond. They are at different stages of evaluating, researching and documenting the impact of their work but it is a hard balance to achieve when often you are the lone psychologist, and often part time. Also, there is no short cut and these services can’t simply be transplanted elsewhere. They have developed over time, through relationships and with trust and collaboration at their centre. Indeed, the notion that a small bit of psychology goes a long way characterises many of these achievements. When myself and my fantastic job share partner, Dr Rachel Williams, came into post 16 years ago we used the above Anita Roddick quote as the basis of our joint presentation at interview……..we have stood steady with the same set of values ever since and they are really beginning to bear fruit.

6 thoughts on “Culture change in Children’s Mental Health–some examples of transformational design in practice.

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  1. Yet another informative and inspiring blog post – THANK you! I will share across all my platforms, as people really like to see what alternative provision might look like. Thanks for putting some flesh on the bones of what updated, collaborative, mulit-disciplinary, child-centred services can look like. Fab! :0) Cheers, J.

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  2. Elizabeth … your values base / principles should be at the very heart of all national and local, thinking and planning and the models you describe appear to be successful examples of the ‘dog wagging it’s tail’ 😉😂! if only decision makers, at all levels, would adopt the same values / principles to inform their thinking, planning and spending they’d realise that “more of the same simply wont work” and it would also hasten us over that “brink of radical change” which is so needed. May your mosquito continue to bite hard, though I suspect it’s quite a swarm by now ! Thank you for the difference you are making.

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