“Don’t medicalise growing up” – words of wisdom from children and young people who are brilliantly ‘blind spot’ free.

It’s been a little while since I’ve written a blog. Mainly I’ve been too busy with the day job and family life; and partly because I was running out of rants that other people weren’t already doing a far better job of raving about. And then I found myself getting all ranty about children and young people being ‘prescribed surf therapy’. Here we go again, I said to myself, ‘othering’ the children who either can’t afford, or are unable to access, or who just hadn’t had the opportunity to try surfing as an interesting and fun thing to do; and only getting a chance when they are desperate for help. Oh and squeezing through a medicalised gateway to access things that make all kids feel better if only they had been encouraged by a kindly and supportive coach. It is why I get so frustrated with the whole concept of ‘social prescribing’. Let’s make these things part of everyone’s lives and cut out the ‘middle-medic’. Or at least let’s stop thinking we are being innovative when all we are doing is recognising and facilitating the things in every day life that keep us all mentally well. Nature, community, arts, sports, activity, healthy food…..encouragement, kindness, persistence, belonging, a sense of achievement……

Then I remembered our Biblio-therapy Scheme – ‘Books to help’. As a service we were so proud of this initiative over a decade ago. Inspired by the adult Book Prescription Scheme that had been the brainchild of Dr Neil Frude, we bid for some under-spend that gave us just 3 months to develop an entire scheme for parents from start to finish. The whole team pulled together; we employed two utterly brilliant psychology assistants for just twelve weeks (that’s how desperate these fantastic folk are for the experience and a foot in the door), along with a wonderful locum psychologist prepared to roll their sleeves up for an intensive burst of activity. Determined to stick to our values and use a relational, developmental and contextual understanding of children’s distress they chose the books and the language they used carefully. They set up a systematic reviewing system including parents, psychologists, and other professionals and settled on the books that evaluated the best by all three groups across a range of topics families wanted most help with. They developed a website and a range of publicity materials and ensured there were copies of all the books in every library. The art work was by a child, of course, and even if we said so ourselves, it was utterly brilliant and evaluated very well.

In hindsight, of course, although we purposefully avoided the word ‘prescription’ we were drawing on a medical model whereby parents turn to their GP or other service provider for help; and one whereby we all feel better when we can ‘give something’, whether it’s a pill, a referral, or a ‘recommendation slip’ to take to the library. We had fallen into precisely the medicalising trap I was ranting about.  I still think it’s a great scheme, although sadly we never had the money or time to keep it updated.  Good quality, accessible and evidence based information is essential. But if we were developing it today what would we do differently? I like to think we would have the courage to step outside the power of the medical model we were trying to influence and expand from within. I like to think we would ensure that books (and apps and films) are equally available in local shops, leisure centres, community centres alongside our health, education and social care settings. I like to think giving and receiving sound advice about bringing up children is something our communities take ownership of and we contribute to; and not the other way around. It reminds me of the brilliant booklet about attachment I picked up at Timpsons when I was getting a key cut. Just out there and ‘free’ for the taking.

It is why I was so inspired by the research Hafal did when they asked young people in 2016 what they wanted from children’s mental health services. “Don’t medicalise growing-up” they said, and “help the adults who are closest to us like teachers to know how to support us”. Their ability to cut through the barriers and unnecessary layers of professionalisation that has influenced how services are accessed is so refreshing. Indeed, this ‘starting from scratch’ view is so essential if we are to truly co-produce services. We thought we were doing our bit by involving parents so heavily in the design of our scheme but we were already ‘in too deep’ to notice our blind spots. We were letting the dominant model; and our desire to play it at it’s own game, dictate our approach and trick us into thinking we were being innovative. Without distracting from the hard work and value the scheme added, and how it has helped many families, the whole idea of basing a scheme about parenting on a model of prescribing is something the wisdom of young people has made me reflect upon…………..what other blind spots will they help us uncover?

Two Heads Are Better Than One–In Celebration Of A Generation Of Job Sharing

In children’s services we tend to think in childhoods. I was nine months pregnant when my Job Share Partner Rachel Williams and I first had the conversation about jointly applying to lead the Child Psychology Service. It coincided with the retirement of our predecessor; and a desire to maintain and develop the creative and supportive culture that we both loved working in. Fast forward the clock over 17 years and my son is learning to drive – the first of many steps on his journey into the adult world. That’s a whole generation since we set out on this endeavour. It feels timely, therefore, for Rachel and I to reflect on our own journey, and what job sharing has meant to us.

Work/Life Balance

First and foremost it made the onerous leap in role from clinician to leader feel possible when we were both at such an early, and busy stage in family life. I was negotiating a return to work following the birth of my first child, and Rachel was balancing her career with three children under the age of five. Ordinarily this is not an easy time to contemplate the added responsibilities that go with the territory of managing a service. However, doing it together made all the difference, both to our confidence in our abilities, and to the day to day practicalities. It meant that we could both work part time, and share out the duties. When I was at home Rachel was in work and vice versa, enabling us to ‘switch on’ and ‘switch off’ – something that can be hard to do in such a broad and responsible position. It also opened up the opportunities for seamless holiday cover, and subsequent maternity leaves for both of us. More recently I took a career break of nearly three years and lived abroad. That was only possible as a result of our trusting partnership, and commitment to support each other at various stages in our lives.

Courage

There is no doubt that job sharing has made us braver. The less than optimum timing meant that we were very focused about why we wanted to take on the role, and that has not wavered over the years. We were explicit both about our goal – to promote a more relational, developmental and contextual understanding of children’s distress – and the core values that underpin this endeavour. They have not always been easy to uphold, and an ever changing organisational, financial, and political landscape has posed various threats over the year. However, together we have been able to stand our ground, supporting each other to be resolute when pressures came down to bear. Often we have felt as though we were swimming against the tide, and if one of us has needed to pause and tread water, the other has paddled harder.  At the times when our ideas and service models have found more support we have encouraged each other to think bigger and bolder in our developments and innovations.

Shared Responsibilities

The tasks involved in managing a large Child Psychology Service are many and varied. Some are exciting, others are mundane and others are highly stressful. By job sharing we have been able to share out these tasks fairly, supporting each other as and when demands have peaked for either one of us. Indeed, when we first applied to job share the concept was relatively new. By way of compensation we put considerable effort into defining the roles, and offering absolute clarity about those we would lead on individually, those that were interchangeable between us, and those we would undertake jointly. Over the years, as job sharing has become more common place, and we have become more confident, we have been able to relax and there has been greater fluidity in our arrangements. So far so good, and in over 17 years no issues regarding role confusion have been raised – with us at least – and we often seek feedback. We have swapped things around from time to time, for example, firstly organising line management by geography before moving to more function based arrangements (e.g. early intervention, social services, CAMHS, Community Psychology etc). Generally our team and our key stakeholders seem clear about who to go to for what, and those situations when either of us will do. Excellent administrative support has been invaluable in ensuring this runs smoothly.

Creativity through Conversation and Difference.

This is, of course, a key concept in therapeutic relationships but it is also the case in management and service development that creative ideas are generated through dialogue. Many times we will start a conversation with a dilemma or tricky scenario and a solution will emerge during the process of talking it through. We can really check out the robustness of a plan in a way that is much harder when you are on your own. Often we may offer very different perspectives, but again discussion and compromise can lead to more rounded solutions. We help each other to notice our blind spots and our personal hobby horses. Indeed, job sharing offers built in peer supervision and support, and we are sure that it helps to prevent burn out. Occasionally we do disagree and that is fine. We model to our team that difference and challenge is okay, and indeed in a profession as broad as psychology it is to be welcomed and celebrated.

Relative Strengths and Weaknesses

Inevitably Rachel and I bring different, and often complimentary strengths to the role. Interestingly, one of our first training courses we attended as managers was about systemic practice applied to leadership. A helpful concept that emerged was about the need for leaders to sit on the periphery – keeping one eye on the internal functioning of the team, and one eye on the external influences, threats and opportunities. When you are new to leadership it is easy to get pulled in one or other direction depending on the issues that are dominating at the time. Job sharing meant that one of us could focus our attention on the team, and one on the more strategic aspects of the role. Of course, there is considerable overlap and again this has become more fluid over the years, but at the time it helped us to hold onto to both perspectives according to our relative strengths.

Fun and Friendship

Last but not least job sharing is definitely more fun! Away Days, lunches and team gatherings are easier when the responsibility you feel as Head of Service at these events is shared. Having moved into the role as clinicians from the same team we were quite taken aback when we were no longer invited to certain social gatherings because we were now ‘management’. That must feel quite isolating and lonely as a single leader. We would make our own fun and go out together anyway! As in all work contexts life intertwines and we have been through many experiences, highs and lows, both individually and as a team. Having someone to share that journey has been invaluable, and an enormous privilege for us both. We are grateful to each other and to our team and the wider organisation for the support we have received over the years.

 

Dr Liz Gregory and Dr Rachel Williams

Joint Heads – Child and Familiy Psychology and Therapies Service

Aneurin Bevan  University Health Board

Weaving well-being into the fabric of secondary education–starting where schools are now

Psychologists are pragmatists  – or at least they should be. Applying theories, models, the emerging evidence base and clinical judgement to the unique circumstances that they are presented with – whether that be an individual, a family, an organisational or societal dilemma. It is all about goodness of fit; and as Bateson said in respect of systems theory, introducing a “difference that makes the difference”. Too much and the ideas will be rejected. Too little and they are lost. I have been thinking about this in respect of the ‘whole school approach’, and how to achieve that sense of safety and belonging that is critical if we are to promote the emotional well-being of all children in our education settings. In primary schools it is much easier, and already many are a warm, happy place where children thrive. Sometimes this is as a result of the conscious efforts of the staff team, inspired by the knowledge that children can only learn when their basic need to feel safe and secure is met. For others it is the natural position adopted by the leadership team that promotes, supports and attracts this culture. Others still, of course, have a long way to go – but lets hope they catch on. The momentum is certainly growing for a more nurturing environment in our schools.

In secondary education the task is much harder, and it is in this transition that many of our most vulnerable children lose their way. Comprehensive schools are big and unwieldy, and they have a specific job to do. The piece of paper that a young person leaves their gates with at the end of year 11 is the measure by which they are judged. Their modus operandi is competition – top set, student of the term, inter-form netball, most money collected for charity, prizes for the best results, the best sportsperson, the best musician, ‘A’ Team, ‘B’ Team, no team– you name it kids are pitted against each other and there are winners and losers at every turn. Some children thrive in this environment – especially those who are well supported at home and excel (or are heavily tutored) in some or all of the qualities valued in this system. Others survive, keeping their head just above water. They find ‘their place’, albeit slightly depleted by the knowledge that they will never be ‘top’. Others fail miserably, and school is experienced as somewhere where they are never good enough. If they are lucky they go on to find their niche in adult life, but for many this feeling doesn’t leave them, especially if they were never good enough at home either. Of course teenagers are already adept at doing this with and about each other anyway – with the in groups and the out groups and the ‘tiers of popularity’ as my teenage daughter describes it. Just being in a group helps, of course, even if it is the ‘lower tier’. Often our most vulnerable children have no group at all.

So what is the solution? How can we weave emotional well-being and self-belief into the fabric of the school when so many of the practices and internal and external pressures work against this? We should, of course, look at the growing knowledge that is amassing about child development, and what children need to thrive, and design an education system around this.  It is basic evidence based practice after all. However, this would pose such a huge challenge to the status quo as it would mean starting from scratch. I wont give up trying though.  Especially having experienced Canadian schools with my own children, and knowing that many of our inherent assumptions about how education needs to be are simply not true. I have written about this in previous blogs. But being a pragmatist let’s start with the strengths of the current UK system and build on that, asking the all important question: What is the difference that can make a difference? As a psychologist, emotional well-being is all about relationships, and the ‘form’ system lends itself beautifully to nurturing this. Children start high school in one form, and usually they remain in that form for the next five years, often with the same form tutor. In some schools they have mixed year group forms, and, in my opinion this is even better. The youngest in the school (who are often terrified of older children) join an established form. They can look up to their role models, and see how they negotiate the challenges that each stage brings; and become those role models of the future. And of learning can go in all directions, with younger children gaining confidence and realising they have something to offer too.

So, starting with the basic form structure, ideally in mixed age groups, how can we use this to nurture emotional well-being and create a sense of safety and belonging for all children and young people? The Head at the High School my son attended in Canada said at a welcome evening ‘We get them through the door in the morning with something they love, then it is our job to keep them interested in the subjects that may have less appeal for some’. Granted it was a publicly funded arts school and my son’s major happened to drumming, and his form happened to be a band but…..this is a great goal for a form to aim for. And with the resources of thirty kids of all ages and abilities to draw on for ideas surely it stands a chance? If the form tutor were to ask the class how to make registration as much fun as possible what would they say? Music? Dancing? Rounders? Joke telling? Board games? Thirty kids generating as many ideas as possible and each having a turn to give theirs a go would be one way of starting the morning on a high. There would of course need to be some limitations – but please, for twenty five minutes of the day, don’t let noise be one of them. Unless of course any of the young people are sensitive to noise – in which case the form need to think about how they manage this.

If we were to go a step further, and make fun AND well-being the focus of those first twenty five minutes of the day how might that look? Rather handily there are five days of the week, and five ways to well-being. What if a day a week was dedicated to each one? Monday could be connection day – especially important for children who have had a difficult weekend. How could they welcome each other and create a sense of belonging and ‘family’ to start their week? What might become their unique rituals and traditions? Tuesday could be giving day – what is the forms chosen cause? They could give their time, their skills,  or raise money or simply give to each other. Compliments go a long way to getting your day off to a good start. Wednesday could be about getting active – to tackle that mid week slump. A brisk walk? Stretching? Dancing? Simon Says? Body popping? The ideas would need to come from them of course. Thursday could be taking notice – there are lots of great mindfulness exercises as well as an opportunity to reflect on how they are in the moment – noticing their feelings and, over time, practicing expressing them in a safe and supportive way. And Friday would be learn a new skill day – now that could be really fun. Bagpipes? Slime making? Pom Poms?. I appreciate all of these ideas would flop because they are mine not theirs but hopefully you get the drift…..

So, if we had mixed aged forms, with names chosen by the young people, and a sense of fun, belonging and well-being as their central goal how might that make a difference? Well, for a start new students in year seven would join an existing family rather than having to create one on top of everything else. Indeed in primary they could receive a letter (or a video of course!) welcoming them to Hufflepuff or whatever their form happened to be called. Imagine how exciting that would be! They could be allocated an older buddy to help them settle and tell them what to expect. Indeed one theory about bullying is that it is reduced when children are given the opportunity to give care.  Younger children would have role models to look up to who they would see around the school throughout the day. These would be real people with stories other than the ‘cool kid’ or the ‘scary kid’ or ‘the geek’. The form tutors role would be to help facilitate participation so that everyone in the class contributed in their own unique way and were encouraged to find their voice no matter how quiet. They could keep an eye out for the vulnerable kids who never felt a part of things no matter what was tried. Everyone would have an equal responsibility for what happened during form time. If it wasn’t fun why not? What should they do about it? The five ways to well being would be experiential rather than taught, and embedded over five years of the young person’s life. It would also become a way of life for the teacher for as long as they held that role. Most importantly there would be no evaluation, assessment or competitive element to what happened in the form time – the one place in school where young people and teachers could just be. If this was working well then every young person would think that their form was the ‘best’. Now that would be worth getting out of bed for.

Hope and the Silver Bullet

Are you sitting comfortably? Then I’ll begin.

Once upon a time, long long ago and in a land far away there was a little girl called Hope. In the town where she lived everyone was worried. A monster had been troubling them for some time, but now it was looming larger in all of their lives. Some people had seen it and could describe what it looked like – although it was hard to get an exact picture because it seemed to be a little different depending who you spoke to. Some people had heard it and could describe how it sounded – although it was hard to get an exact idea because it sounded a little different to everyone you spoke to. Some people had felt it brush up against them, and others had sensed it looming large in the background, it’s breath on their neck. Hope would worry day and night about the monster – wondering when it might be her turn to come across it. She would look out for it walking home from school and she would try to spot it from her bedroom window before she went to bed. She would ask her mum and dad every day when it might come, and what might happen if it did. They could offer no reassurances because, quite frankly, they were worried too.

One morning Hope woke up very early determined to find someone who might help. She had heard about a silver bullet – a magic answer to end scary things once and for all and so she set out on a mission to find it. Her first stop was a wise woman who lived down by the river. She was nervous, but she remembered the saying her grandmother had taught her many years before. “Just a few moments of fear might change the course of history” She wished her granny was still alive, but even so the memory gave her the courage to knock. She waited and waited until eventually she heard foot steps. When the door opened the woman looked a little cross. “I’m sorry to disturb you” Hope said “but I wondered if you might have a plan to catch the monster”. “Well I am very busy” she said “ but yes, I have a plan. In fact I’m working on it right now”. She quickly told Hope what it was before closing the door so he could get back to her thoughts. Hope scribbled the ideas down in her note pad and went on her way. “It’s a good plan” she thought to herself “but I’m not sure it’s the silver bullet.”

Next, she called upon a young boy who lived near the woods. He was known to be good at making things, and sure enough his garden was filled with beautiful wooden carvings of animals and toadstools, and benches and swings. “How clever” Hope thought to herself. “I bet he has a good plan”. It took a while for Hope to find him as he was up a tree, but sure enough he was working on an idea. He didn’t have time to come and tell her, but he threw down a piece of paper with a diagram explaining it all. Hope tried to make sense of it – it looked complicated but it might work, she thought. Although she wasn’t sure it was the silver bullet. She taped it into her notebook anyway. And so Hope went on her way, calling on the Doctor, the Teacher, the Mayor, the Baker, the Farmer and just about everyone else, gathering their ideas together in one place. When her notebook was full she headed to the meadow where it was peaceful so that she could sort through everything she had written and put it in order. The ideas were as different as the people she had met along the way. As she read and re-read through the notes she could feel herself getting more and more tired, her eyes growing heavier and heavier. Eventually she fell into a deep sleep, the soundest she had slept for a long time.

Back in the town Hope’s parents noticed she was not at home. By now it was very late and they were very worried. They raised the alarm, convinced the monster had captured her, and desperately fearing the worst. Everyone in the town gathered round as fear grew for her safety. Without exception they all came out, overcoming their own worries about the monster which would usually keep them at home, safe indoors. It was a cold night and so they lit a fire, and some brought food and drinks whilst others made plans about who would search where. They worked well together late into the night, always making sure they set off in small teams; with plenty of  people back at the base resting, and there to welcome Hope in case she returned.

When Hope eventually awoke it was very dark and she felt very alone. Clutching her notepad under her arm she set off in what she hoped was the direction of the town. Somehow it made her feel a little braver. As she drew nearer she caught what she thought was the flickering light of a fire. Then she heard the reassuring hum of voices in the distance – growing louder as she moved closer. Approaching the gathering she felt a warm feeling inside; and eventually she spotted her parents and ran full pelt towards them. As the crowd realised who it was they let out a huge cheer. Hope felt overwhelmed with relief as did they all. ‘”How ever did you find us all  in the dark?” “Well first I thought I saw something, and then I thought I heard something – but mainly I just felt something – I think I felt your love” she said to the crowd. They turned and smiled at each other, a little amused but mostly touched by her childish innocence. “What’s that?” her father asked, pointing at the note book under arm. “It’s my book about how to catch the monster” she said. Everyone gathered round as she read it out loud by the light of the fire, page by page.

By the the time Hope got to the end everyone was sat on the ground listening intently. A calm had descended and all that could be heard was the crackle of the fire. Eventually the Baker spoke up. “These ideas are so good it would be great if we could all have a copy”. Everyone nodded in agreement. Suddenly the shop keeper shouted that he had a printing press rusting in his shed, someone else had ink and someone had paper, someone could help with diagrams and someone could help with binding. Before long there was a plan to turn Hope’s notes into a proper book that every family in the town could have a copy of. They would start the next day. Everyone joined in and after a lot of hard work the book was finished. Bound in leather it was called “How to Catch the Monster” by Hope and the Townsfolk and it took pride of place in everyone’s home. Just having it there made a difference to how people felt.

After that people set about their business as usual – but they somehow missed the industry of the day before. The Farmer had an idea – now it was out and cleaned up they may as well put the printing press to good use. “Let’s start a newspaper for the town” he suggested. There was immediate agreement, and an army of volunteers to help. As Hope had started this all off in the first place they asked her what the newspaper should be called. “The Silver Bullet” she declared immediately, and everyone agreed. No other name would do. And that is how it started – “The Silver Bullet” delivering weekly news to everyone in the town, and keeping them in touch and up to date with one another. It is still printing to this day. In addition to local news, there are items for sale and adverts for events and gatherings. Hope writes a page for the children – usually with quizes and cartoons and dot to dot puzzles. Of course, there is a section in case anyone has ideas to catch the monster, but people seem a little less preoccupied with this these days. Occasionally there are stories about a sighting or something similar. They never make the headlines though because somehow the story feels smaller once it has been told.

Dear Toronto

Dear Toronto where do I start?
Thanking this city’s enormous heart
Without exception you have been kind
In these dark days; the rarest find
From the streetcar driver who took his time
To the patient folk who wait in line
Every day I have a smile
At strangers going the extra mile
The friends I’ve made along the way
I am grateful to you every day
When I glanced over and caught your eye
You paused instead of rushing by
That’s all it took to make me brave
Next time a nod and then a wave
And then a chat, and then coffee
In busy lives you made time for me
Sometimes it was just a moment or two
But a connection was there I hope you knew
We could have had more if time allowed
For that feeling this city should be proud
Openness surrounds me everyday
Trust and care is the Toronto way
When I reached out it held my hand
Nothing in return did it demand
It makes a difference to your day
(The sun helps too I have to say)
But even when it was crazy cold
It gave me courage, it made be bold
So I pushed my kids to do more too
and you embraced them the way you do
You helped them be the best they can
The only hope in a parents plan
They’ve met people here from far and wide
Sharing cultures and values with great pride
The goal is simple – to get along
And Toronto’s message is “you belong”
Why do I write this? I hear you ask
Well Britain faces an enormous task
To stand alone and turn its back
Or work together, with all its flak
My take home message is very clear
It works. There is no need to fear.
It’s not perfect, I am not naive
But together is stronger I do believe.

Snapping back to safety–oysters open up when they feel safe–and that is when the pearls of wisdom come to light

I have had this blog on the tip of my tongue for several weeks, but couldn’t quite work out what I wanted to say. As ever, a space to reflect with colleagues has helped to bring clarity; and to find the perfect analogy to bring it to life. It is about the journey of transformation we are embarking on in children’s services and how hard it can be to hold onto the ideas that will bring about a real step change in addressing their mental health and emotional well-being. The energy, enthusiasm and shared commitment to do things differently is not in question. The struggle is pinpointing the key elements that will deliver a paradigm shift; verses changes that are positive and welcome but will essentially result in perpetuating more of the same.

At the core of this struggle, I believe, is vulnerability. The vulnerability of the children we work with; and our own vulnerability in acknowledging the extent of their distress and the limitations we have as individuals to help. The system protects us from this in so many ways – from the evidence base that tells us what approach to use or how many sessions to offer; to the drawing of lines around referral and eligibility criteria; to the carving up of which agency is responsible for what aspect of their lives.  The reality, however, is much more complex – particularly for our children and families who struggle the most. Often there are many layers of difficulties that families are up against; in communities that are equally depleted in both resources and, more concerning, in hope. It would be so much simpler if a referral to one service or another, or a neat intervention would sort the problem.

It is so exciting, therefore, that there is a genuine recognition locally that we all need to be in this together if we are to turn the tanker; and that this will involve new ways of working together and new ways of collaborating with children, their families and carers to find creative solutions to seemingly intractable problems. But this is also unknown territory for us all – and as such makes us more vulnerable to snapping back to familiarity and old ways of working and thinking. Like an oyster we have begun to open up – exposing the pearls of wisdom that come with trust, shared goals and compromise. But the uncharted waters we are entering may make us want to protect ourselves and snap shut.

Forewarned is forearmed and so I will try to highlight some of the threats that risk us closing up. I am sure there are many more as I will have my own blind spots; but it is a start that I hope others will join me in:

  • the threat of old narratives that place blame on one service or organisation or agency or even the children and families themselves. Whether it’s about thresholds or expectations or funding or engagement– these are common loops we have all been on. It is of course, much harder to do if we are in the same room together, but if we hear it creeping in we are snapping back to safety

 

  • the threat of unrealistic expectations about the evidence base. It has a place, of course, and informs our practice. However, the families that we worry most about across services are often the one’s who don’t come to clinic, or attend groups in the first place. We need to have confidence to draw on the evidence base to design and evaluate new and innovative services that draw on shared core values; our extensive knowledge of child development and what children need to thrive; and practice based evidence gained over years of working in the local communities. Most importantly we need to talk to children and families about what helps them most and seek their help in designing services that meet their needs more effectively than those currently in place. We need to evaluate these, of course, but if we insist on only the highest level of evidence before we even start then we are destined to do what we have always done; snapping back to safety

 

  • the language of ‘othering’ is something we need to caution against – whether that be target groups of children or families, or specialist professionals to ‘take this on’. That is not to say that we won’t be thinking about need or drawing on expertise. However transformation for children means helping everyone to be able to ‘hold on’ not ‘refer on’. If we find ourselves thinking too much about access criteria or passing problems on then we are snapping back to safety

 

  • indeed language is critical and using terminology that is straightforward, strengths based and everyday is essential if we are to break down barriers across agencies, and more importantly for children and families. Instead of ‘assessing’ why don’t we meet? Instead of ‘screening’ why don’t we ask? Instead of ‘formulating’ let’s think together? It is scary to relinquish professional boundaries, and we must always rigorously embed our expertise, knowledge and competencies in the work that we do – but how much do we hold onto unnecessarily and at what cost? How many barriers do we unknowingly erect? If we are holding on too tightly to our professional identity then we are snapping back to safety

 

  • finally, and most importantly, is the importance of basic qualities that can and do make all the difference to children and families; and are not the domain of any one profession, agency or institution. Kindness, curiosity, hope and the intention to be helpful will have more impact than any number of sophisticated models, services or interventions. If we all prioritised these basic qualities in every aspect of our work then we would achieve great things. If we minimise their importance and allow other priorities to dominate then we are snapping back to safety.

 

Equally there are many signs that we are in safe waters and can be vulnerable. This takes time, and trust, and building meaningful relationships – mirroring precisely what children need to flourish. I have been in more meetings in the last year than in my whole career where we started with a thorny and seemingly insurmountable issue and by the end had reached a positive, and at times, ground breaking solution. The pearls of wisdom that emerge as a result of these endeavours have been precious indeed; and a real privilege to bear witness to.

Thank you to the Gwent Attachement Team for some invaluable thinking space to formulate these ideas.

Sweet Sixteen

Tasha opened her eyes and looked around. It was beginning to feel more familiar. She had stopped having that ‘where am I’ thought that jolts you when you come too in a strange bed. The rose velvet curtains were slightly open allowing light to gently seep in, dust particles dancing in the glow. She could make out the chest of drawers, the desk piled high with her GCSE revision, the striped duvet fresh and clean and clearly bought to ‘match’ with the room – pink for a girl. She wondered if the foster carers had stipulated the sex to go with the room? Or maybe they had said gay or transgender fine too as we have pink curtains already? She snorted a laugh out loud. No. If she had been a boy they would have gone out and bought new. They were kind and thoughtful and trying very hard to do the right thing.

Tasha pulled on her dressing gown from the back of the door (pink, of course, new for her when she arrived and very fluffy – probably Primark – she kept forgetting to check the label). She went down stairs and could hear that Rob and Sue were already up and busying themselves in the kitchen. On the table were a pile of presents and cards, fresh fruit and orange juice and she could smell croissants warming in the oven. “Happy birthday to you, happy birthday to you, happy birthday dear Tasha, happy birthday to you” they sang in awkward unison. “Thanks! That’s lovely!” Tasha said, and meant it. She really did appreciate how hard they were trying. It was in stark contrast to the birthdays that had come before – images flashed before Tasha’s eyes – she pushed them hurriedly away. Not today. Not now anyway.

“Start with the cards” said Sue excitedly. She would rather not. The cards that weren’t there were like knives stabbing her heart. Nothing from her mother, obviously nothing from her father. Nothing from her gran, nothing from Jayne her previous foster carer – the list in her head went on. There it was though, Aunt Esme’s hand writing all the way from Inverness – always C/O Social Services but it didn’t matter. She never forgot. Tasha had never met her but she was the one constant thread in the family, and she always remembered birthdays. She imagined her living in a brightly painted cottage like on Ballamory, grey hair in a bun, a flowery apron on as she went about her chores, and freshly baked bread cooling on the table. The reality was probably very different – which is partly why Tasha never planned to track her down.

And there they were. The cards from her brothers and sisters. Ricky and Will who were living with Pam and Dave, Tara, Amy and Tillie who were with Rita and Richard, and the babies, Louis and Harrison who had been adopted but still allowed to send birthday cards and would meet up once a year as part of the ‘plan’. They had all been helped with their cards to some extent – but they were all there. For Tasha it was like counting her chicks. Her social worker had sent a card too. And Rob and Sue of course, and Rob’s mum – which was nice. Sue encouraged Tasha to move on to the presents – all wrapped meticulously in the same paper. A couple of books (‘teen lit’ Sue had done her homework), some smellies from Lush, some pyjamas (from Primark – Tasha checked there and then) and a small package Sue was excited about her opening. It was a navy velvet jewelry box and inside was a beautiful gold locket. “Sixteen is a very special birthday Tasha. We wanted you to have something to treasure forever”. Tasha felt tears prick the back of her eyes. Here it came again, they were so kind and generous – how do you say “thank you but how the fuck do I fit seven brothers and sisters in one locket?” Tasha gave Sue and Rob an awkward hug and left them to interpret the tears in whichever way they wanted.

Tasha was the oldest by five years and had been ‘placed’ on her own when the children had first been removed. Back then it was just her and the boys, an ‘awkward’ sibling group to place altogether. The more babies her mum had the easier the groupings became. Three girls close in age. Bang. Bang. Bang. And then twin boys removed at birth. Bingo! Adoption gold dust. Tasha had moved in with Jayne – a single carer who had fostered for many years and was ‘very experienced’. She liked it there, laid back with no pressure and other kids passing through from time to time. Ideally, she would have stayed until she was eighteen, but after 20 years as a foster carer and some sort of award from the queen, Jayne was packing it in and moving to Spain. In some ways, the social worker said, it’s worked out well. Tasha was bright and could make a real future for herself but Jayne had never really been able to help her academically – she was more of a hippy, a free spirit. Moving to Rob and Sue’s and going to Heathwood High for her last year of GCSE’s would be perfect, and really allow her to focus in on her exams. It also meant she wouldn’t be tempted to keep an eye on her brother – who was about to start at her old school. The social worker saw that as a positive. Tasha had been devastated.

It was all bull shit. No one moves school half way through their GCSE’s. It was hilarious (in a not funny kind of way) how they always tried to make the story fit as though it was the plan all along. Jayne moving to Spain had been gutting – there was no way around it. She was ‘retiring’ from her job of ‘caring’ for Tasha and the other foster children who had passed through. Tasha had been ‘well looked after’ by her (well enough in a “there’s a chick pea stew on the hob help yourself if you’re hungry” kind of way) but the ties could be cut. Blood is thicker than water (even if it’s being splattered on your face from a fist fight) and even Aunt Esme who she had never met had sent her a birthday card. She tried not to take it personally with Jayne. Hippies didn’t do birthdays very well. But they did do open doors and Tasha knew deep down that if she pitched up in Spain, at any point in her life, Jayne would welcome her in and she could help herself to some veggie paella from the hob. That counted for something.

Anyway, ironically, it was working out ok. And Tasha really did want to do well at school even if her primary aim was to earn enough to take care of her brothers and sisters when the time came. The first day had been foul. For any kid starting at a new school it’s horrific. When you are a foster kid, starting half way through GCSE’s in a school where everyone knows each other and has done for years, it’s in the ‘blank off all feelings, out of body experience’ category of foul. The groupings are set, the in crowd know who they are, the geeks know who they are, the sporty kids know who they are, and the bitches smell the blood of new prey before they have even checked out what shoes you are wearing. But somehow Tasha got lucky. She ended up in the form full of waifs and strays with no clear identity other than they always lost in competitions and took great pride in it. They united in being the losers and weirdos and even made a thing of it. She was sat next to Abigail – confident, kind, and pretty in a not a scrap of make-up kind of way. They instantly bonded over a Fall Out Boy pin on Abigail’s ruck sack. One of many ranging from Harry Potter to a Gay Pride rainbow. Abigail didn’t hedge her bets – she liked what she liked and couldn’t care less what anyone thought. She also had lots of friends in the form – simply because she was nice. Tasha realised she would be just one of many and never the ‘best friend’ – but that was way better than she could have hoped for in the hell hole that is friendship groups in comp.

Best of all, Abigail’s birthday was the same week as Tasha’s. “Let’s have a joint sweet 16” she had declared. Tasha felt the panic rise – that sounded horrific. “Not in a fake tan short skirt tattooed eyebrows kind of way” Abi rushed to clarify. Phew, thought Tasha. “In a bake lots of sweet things to eat kind of way”. She loved how Abi could turn things around, and make what everyone aspires to, the ultimate selfie at a drunken party, sound boring and mainstream compared with the alternative idea. “We will do it at my house, bake all day. We can take the left overs into school.” Fun, inclusive, and most importantly safe. How did Abi manage it? “It will need to be on the Sunday – which is your actual day – is that ok?” “It’s fine” Tasha said. She was relieved she would be doing something and not having to choose a restaurant and a film to go to with Rob and Sue. She could do that on the Saturday, and meeting with her brothers and sisters at the contact centre in case her mother showed up would be on a week day anyway. Sue was a bit stung when she told her, but also relieved that the whole responsibility for her birthday didn’t fall to her. Rob was genuinely pleased for her, grasping at any straw that Tasha was settled and happy.

Abi’s house was just like her – not trying too hard to be anything, but confidently stylish as a result. She had laid out recipe books and ingredients and mixing bowls in readiness. Her mum checked they were ok and then left them to it. “I’ll be in the front room if you need me” she said. They poured through the books settling on millionaire short bread for the complicated thing, chocolate chip cookies for the easy thing, and a Victoria sandwich for the centre piece. “We don’t need a recipe for that I know it off by heart”. Abi said “I’ve made hundreds with my mum from when I was really little.” They worked together, the mess mounting as the delicious smell of sugar and butter baking permeated the house. Eventually they were finished – their achievements proudly displayed on china plates and cake stands – it looked amazing. They took photographs and Abi posted one on Instagram with a simple “Sweet 16” and tagging them both. Abi’s mum came to see. “Wow that is fantastic girls!” She declared. Tasha felt so proud but also a bit sad – it was only that good because Abi knew what she was doing; and she only knew what she was doing because her mum had taught her. There it was again, that gaping hole.

They tried a piece of everything they had made with a cup of tea before sharing it out into cake tins ready to bring to school the next day. Tasha saved some sponge for Rob and Sue. It really was delicious; and Sue declared it the best Victoria Sandwich she had ever tasted. “Abi knows the recipe off by heart and didn’t even set the timer on the oven – just kept an eye on it through the glass” Tasha told Sue, sharing some pride in her friend’s skill. “Wow that is impressive; but it just takes practice” Sue said. “I can teach you if you like. Shall we have a go next Sunday?” Tasha nodded, feeling that familiar prick of tears behind her eyes.

Children with mental health difficulties are falling through the cracks–we need many safety nets of varying shapes and sizes if we are to catch them all

There is nothing controversial in the reflection that children’s mental health services are at crisis point. The controversy comes when we try to agree the ‘solution’; with a huge variety of ideas vying for attention in a very crowded ‘market place’. Every service and profession will justifiably argue that they need more resources; and of course more resources would help. A bit. However, I would argue that the scale of the problem is so enormous that investing in pre-existing models will not provide ‘the answer’. Indeed, more concerning, this approach may even perpetuate the problem; especially if we invest in ‘specialist services’ that carve off mental health difficulties from every day life. We need a ‘whole school’, ‘systems wide’ approach, with a range of safety nets if we are to be sure that children don’t fall through the cracks.

I will use the ‘net’ analogy to illustrate the point. Currently Specialist Child and Adolescent Mental Health Services (SCAMHS) could be described, for the most part, as a basket ball net, and one that is located far outside of the schools and communities where children live their lives. Teachers and other child care professionals have to put a huge effort in if they stand any chance of ‘scoring’ help for a particular young person. Often it’s a miss – either because the person doesn’t meet the tight referral criteria, or because they don’t fit neatly with the help that is on offer at a specific moment in time. Miss your chance and it’s gone. Indeed, the basket ball net maps very neatly with the way in which SCAMHS works. Children and young people pass through, and rarely does the service stay involved for an extended period. There is huge pressure from within specialist services to ‘let go’, essential if capacity and demand models (for example the Choice and Partnership Approach), and target waiting times are to be achieved. This is not a criticism. It is inappropriate for ‘specialists’ to remain in a child’s life for prolonged periods of time, especially when there is not active intervention focused on change, and it is not helpful for specialists to drift into more supportive roles. Far better that this support is facilitated through the every day relationships in a child’s life. However, it is no doubt a huge source of frustration for all concerned when the ‘specialists’ withdraw, especially when there are not other support systems in place to ‘catch’ the young people at the other end. Mental health ebbs and flows in all of ours lives, and is rarely, if ever, ‘cured’ once and for all.

In recognition of this frustration, there have been calls for more specialists to work within schools and other community settings. It certainly would address the perceived distance and inaccessibility of the current system, and I appreciate that it is very appealing for overstretched teachers and child care professionals. However, my concern, especially if this is seen as THE solution, is the risk that it replicates one of the biggest disadvantages of the ‘specialist’ services model.  By this I mean perpetuating the commonly held notion that mental health can somehow be seperated off, and is the business of only those with ‘special’ training. If it were a net I would argue that this is a fishing net approach –  a specialist on site scooping up the children and young people who present in a certain way that rings alarm bells. Again, ‘referral criteria’ would be required, and some would fit, whilst others, often our most vulnerable who act out their distress behaviourally, or who don’t show up to school, would not. It would also, inevitably, be dominated by a ‘within child’ model of therapeutic support (e.g. counselling, CBT), failing to recognise the hugely important contextual factors that impact on a child’s mental health, including poverty, adversity and ongoing exposure to trauma. I have written about this risk in a number of my blog posts. Far better that those specialists share their fishing knowledge, and hand out smaller nets to core staff, supporting them from the sidelines – empowering and up-skilling them all the while.

However, the net I would like to see if we are truly to turn children’s mental health concerns around, is the safety net. A ‘catch all’ whole system approach, where we apply what we know helps children to flourish to all our children in all our child care institutions. A set of values that nurture and celebrate our young people should be at the heart of all child care practice. This would focus on relationships, and facilitate safety, connection, warmth, celebration of the unique individual, inclusion, and a recognition that not all children are starting from the same baseline – whether that is developmentally, temperamentally, emotionally or socially. Again, I have written extensively about this and how it might work in practice. The beauty of it is that simple changes can make all the difference; often requiring no additional time but rather a redirection of focus. Most importantly, the outcome of children flourishing means the academic targets so prized in our culture would follow. Indeed, it could be argued that even our brightest, most secure and privileged children survive rather than thrive in the current system. With this approach they would continue to shine, and those who get lost in the pressure to achieve,or in the chaos of their disruptive home lives would also find their place. Children cannot learn if they don’t feel valued and safe.

So, in summary, we need to think more creatively about the nets to catch our children to prevent them falling through the cracks. Specialist CAMHS has it’s place, as does more accessible and targeted support. However, if we are to really tackle the enormous problems with mental health we are facing as a society, both for our children and the adults of the future, then we need a safety net for all. A whole systems approach that embeds emotional well-being and mental health in every aspect of our children’s, and those who work with them’s lives. Where schools become a place of safety and security for our most vulnerable young people; where inclusion for all becomes a focus, and a celebration of the uniqueness of the individual becomes the norm. It is not that ambitious, and as I have written about recently, just changing the first five minutes of the school day can make a huge difference. The price of not doing this is, on the other hand, is enormous, and we know from the Adverse Childhood Experiences research that the impact of not taking serious action is alarming not only for mental health but for physical health too. To put it bluntly, it is like asking a trapeze artist to perform with only a basket ball net to catch them if they fall. Instead, we need to empower everyone in a child’s life to recognise that if we all hold on to the safety net no one need fall through. Indeed, these everyday relationships with those most proximal to the young person have the most therapeutic power. With this in place as our baseline, the children and young people who need to be fished out for specialist help would become obvious – always keeping in mind that they are coming back and will need to be held by us all.

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