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.

The first five minutes of a child’s school day……..

There is nothing like a cross sector workshop dedicated to a ‘whole school approach’ to get people talking about what we could and should be doing differently if we are to achieve a step change in children’s mental health. And bravo to Wales for starting the conversation. Like any good debate it veers from one extreme to the other. On the one hand there are calls for more counselling in schools, and quick and easy access to specialist help; right the way through to radically rethinking every aspect of how we nurture and educate our children. The consensus, though, is clear – something needs to change. It’s the what and how that is the trickier bit.  It can feel a bit  like a balancing act – all suggestions have validity but too much of one thing risks it all tipping over. No one would argue that more experts with specialist training wouldn’t help, but the more we carve up mental health to someone else the more trouble we are storing up for the future. The culture of ‘referring on’ is a fundamental issue to shift, with ‘holding on’ being a far more transformational aspiration. However, too much pressure on schools to provide the whole answer and they understandably end up feeling paralysed. Especially given the current stress teachers find themselves under. We all have to be in this together if we are to achieve the change we need to see – with a whole school approach just one element of a ‘systems wide paradigm shift’. As if we didn’t already think we had enough on our plates.

I wanted to respond to offer my reflections on how we find the middle ground without compromising our vision. I believe it is possible for us to both THINK BIG and START NOW. It all centres around the core values that we focus in on;  and we can use the current frameworks to start the process of cultural change by enacting these values at any and every opportunity. Let’s take as an example the first five minutes of the school day. What message does it give our children? What message does it give every single one of our children?  My own children went to a great primary – one of the ‘best’ if you judge a school by league tables, and how much the places, even within catchment, are oversubscribed. At the time I didn’t think too much about it, but in hindsight the first five minutes of their day said a huge amount about the school, and it’s values.  The much respected headteacher would stand at the gate, late book in hand. She would smile and say hello but the message was clear – you had skidded in just in time. Others behind you would not be so lucky. The children would gather in the yard and when the bell rang they would line up by their door – girls in one row, boys in the other. No-one would be let in until everyone was standing still. A familiar routine, I’m sure, that takes place every day of every term up and down the country.

None of it was particularly controversial, and I don’t remember feeling too perturbed by it at the time. We take much of the education system for granted and don’t think to question the minute by minute minutia. However, with the benefit of hindsight, and viewing everything through the lens of children’s mental health, even within this tiny window in a thriving school I can now see cracks for children to fall through. Being on time is, of course, something to aspire to and a valuable life skill. It is easy to achieve if you are a child in a family that values this too, and has the resources (physical and emotional) to make this happen. But what does being shamed by the late book mean for the child who has had to wake their parent and dress their little sister or brother before the school day has even started? Boys and girls lining up by the door is a very straight forward and seemingly benign request. But what does it say to the child who was born into a boy’s body when they feel like a girl inside? Every single day? Standing still is never easy for children, but for some children it is a near impossible task. What does it say when you are always ‘that child’ who delays your class from moving onto the next activity?

If we choose to look at these first five minutes through the lens of a values base that underpins positive mental health then how might it look? For me, and echoed by many of my colleagues in the workshop, the values would centre around creating a culture of  safety and belonging, of connection, of empathy, of celebrating individuality, and of fun – to name but a few; and all achieved through warm and supportive relationships. With these values informing everything that happens in a school how might the first five minutes of every morning be different? Well, very simply, the headteacher would greet every child with a smile, and a “welcome to school, I’m really pleased you’re here”. They might notice who is late, but instead of it being a black mark it would become a cause for concern and a prompt to be curious about what might be happening at home – especially if there was a pattern. The children could then line up in which ever line they wanted – so long as there were two relatively even ones. Maybe even when the outdoor clock said the time, or when the teacher arrived at the door rather than a bell ringing – where else in life do we respond to a bell? Maybe instead of standing still the children could do whatever they wanted to on the spot – hop? jump? spin? So long as they were respecting the space of the other children around them why shouldn’t they get some physical exercise in at the same time? It could even be a game of Simon Says? With these values informing what happens in school the children would experience a very different start to the day, every day, and it would take no more time from the teachers involved.

If we wanted to take a step further along the continuum towards a ‘whole school approach’ to children’s mental health how might the first five minutes of the day look?  I had the privilege of experiencing a very concrete example during the three years I spent with my children in Canada. At my daughters school the children went in when the doors opened (like we do in most areas of life). Piped music was played through a sound system throughout the building. The songs were chosen by the older students on a rotation. On my visit it happened to be ‘The Final Countdown’ by Bon Jovi. The children were dancing as they took their coats off, and when I glanced in the class rooms some of the teachers were dancing too. At 9am the music changed to the Canadian National Anthem and all children stood by their desks and sang along. Toronto is one of the most multicultural cities in the world, and yet every child joined in and felt a sense of belonging – even my own fiercely loyal Welsh off spring. When that was finished, one of the teachers would talk through a mindfulness exercise that everyone took part in – it was even piped into the office. The three values communicated in the first five minutes were fun, inclusion and well-being.

And a step further along the continuum towards a ‘whole school approach’? Again I turn to Canada, and to my son’s move to high school, aged 14 – when engagement is hardest and risk of mental health difficulties soar. He went to an Arts school – but there were a number of options he could have chosen from in recognition that all young people are different and have different strengths. For example, he could equally have gone to a robotics school, or a sports school or even a school that focused on social justice. There was also the local high school, of course, for kids who were all rounders or who didn’t feel ready to narrow their options down. The first five minutes of his day involved walking down a corridor with expressive and expansive murals covering the walls and doors, including the gender neutral, male and female toilets. Dancers limbered up in the hall, singers and musicians practiced in rehearsal rooms and visual artists prepped in studios. His major was music and so he would go to his form room and set up his drums each morning, joining the rest of his class of musicians who made up the band. “For the first two lessons we focus on their major”, the head teacher explained, “because we want to get them through the door for something they love. Then it’s our job to engage them in the lessons that may hold less appeal.” All children had a general education too. None of the children in any school wore uniform…..because the fact that children aren’t uniform came across strongly as a value in the education system.

I share these just as examples from my own personal experience of how things could be different. Do I think Canada has found the silver bullet when it comes to children’s mental health? Of course not. There isn’t just one. But it certainly feels closer than we are even by the ‘first five minutes test’ to having a set of values that underpin positive well-being and mental health. I have also heard of several young people in my son’s Art school who say that the school saved their life. A safe space that allowed them to be themselves and celebrated their unique individuality was the thing that made all the difference to their mental health; especially important for those who had struggled to find their place in a more generic, less accepting, school environment.

There are, of course, probably many more steps along the continuum we could take. I would suggest we could even turn it around and ask how would we design schools if we were starting from scratch? We know so much more about children’s emotional well being, what they need to flourish, about child development, attachment, the adolescent brain and about the impact of adversity and trauma. If we used this evidence base as our starting point what would our schools look like, and how would they work?  If we had a blank page what education system would we create? If feels important not to lose sight of the ideal; and it would be an easy and fun question to ask children what the perfect school would be like – or even the first five minutes of the perfect school day. A ‘whole school approach’ means looking for and finding the cracks that children fall through and thinking creatively about how to fill them. There are only so many cracks you can repair before you consider whether a rebuild is a cheaper and safer alternative. Let’s think big, but don’t let thinking big prevent us from starting small. Every step can make a huge difference, especially for an individual child. And the first five minutes is an easy place to start.

 

 

 

 

 

 

 

 

That feeling when you make the team……..and why we are missing a trick by only reserving it for the ‘sporty’ kids

This is my daughter, aged 10, and this is the moment she made the team. She wasn’t going to be playing her first game until a week later; but even so the whole kit had to be tried on there and then, shin pads and all. Her sense of pride is evident; that smile speaks volumes. It was the Spring following our move from the UK to Canada; and the first time in her life she had seen herself as someone who could do sports. Up until that point she had always classed herself as one of the ‘unsporty’ kids, who never got picked. I say always. It followed numerous experiences in school of trying and falling short. It’s a feeling all too familiar to many, her own mother included. Just a quick poll on twitter has indicated that out of over 1300 people who responded, 40% would refer to themselves as ‘not sporty’ at school, rather than seeing themselves as ‘sporty’ (35%) or ‘somewhere in between’ (25%). Given our growing concerns about obesity, alongside how we know physical activity is good for emotional well-being, cognitive development and concentration; that is a huge percentage of children who potentially write themselves off. Those feelings don’t go away, often impacting on our relationship to physical activity throughout our lives.

The soccer league in Toronto was different to anything I had come across in the UK, despite years of searching. I had been determined that, unlike me, my children should have sport in their life. However,  given that it didn’t come easily to them, finding a club or setting that wasn’t highly competitive had been impossible; especially after the age of about 6. This league was huge, with about eighteen teams all randomly allocated. Each team was sponsored by a shop on the high street – hence the Yogurty’s  logo on her shirt. Every Tuesday evening the teams comprising of children from all different schools, would congregate on a large field with 9 soccer pitches marked out, playing each other throughout the season. The teams were made up of mixed abilities; including some children with learning disabilities.

It was local, relaxed and most importantly, fun. Each week my daughter got a really good work out – coming off the pitch hot and sweaty and with a sense of accomplishment that is hard to beat, regardless of the outcome of the game. Sometimes they would win, sometimes they would lose, sometimes she would score, often she would not. The random nature of the teams kept it open. Of course, she would be delighted if they beat the other side, but either way she still had a great time. Over the course of the season, everybody’s game improved. Team members took it in turn to supply half time refreshments – cut-up melon or oranges; and new friends were made by us both. The dog came too, of course.  It helped that we were usually bathed in evening sunshine.

I don’t underestimate the organisation that went into setting up and running that league, and associated leagues on different days, but it seemed to be a shared endeavour. The coaches and assistant coaches were also randomly allocated to their teams, and tended to be parents or local teachers and youth workers. It was very laid back, and encouragement and enthusiasm seemed as important as any technical knowledge of the game, although some solid coaching with a focus on team work was evident. More experienced coaches were paired with less experienced assistants, and many had been doing it for years. The referees tended to be 16 and 17 year olds, all trained and doing it as part of their volunteering for high school. No-one can graduate in Canada without accruing a set number of volunteer hours, and, as such, it is considered as important as the academic aspect of school. What a great way to give back to your community.

The fee for the league was nominal, and the kit was supplied by the high street sponsors. At the start of the season there was a table of boots laid out according to size and you could help yourself if you didn’t have any, or swap a pair each season as your child’s feet grew. The sponsors got a good deal in local advertising – especially Yogurtys, as their team frequented the frozen yogurt joint as part of their social meet ups. The team photo was displayed in pride of place in the shop, and other teams could be spotted in the butchers, the opticians, the fish mongers and just about every other business on the high street.  It really was a community affair; and something most kids seemed to be involved in. On the final Sunday of the season there were play offs, with first, second and third placings, but that really did seem incidental. My daughter played in the soccer league for all three summers we spent in the country. It was hard moving from Yogurty’s as a sponsor, but finding out who you had next and going to see your picture in the shop was all part of the fun.

There were, of course, more competitive leagues too and competition in sport is alive and well in Canada. Indeed, I have read some pretty terrifying articles about the world of kid’s hockey and what it takes to make it to the top. The point is that there is also lots of team sports that aren’t competitive to the same extent, and that pretty much every child has the opportunity to be part of. After a year or so my daughter also took up Ultimate Frisbee in a similar set up, which she really loved. She had tried it at school first, had been encouraged by her teacher, and felt positively enough about it to go along to a club. There were lots of other options including baseball, basketball and hockey, of course. In the winter there were over 50 ice rinks to skate on, all free, and exchanges to swap your skates as you outgrew them each year. In the summer the outdoor pools were free, as was public transport. It all felt easy, accessible and something that was open to everyone.

On our return to the UK my daughter went into year 8 of high school. Very quickly she was ‘streamed’ in PE and put in bottom set. Like a switch I saw her confidence in her sporting abilities disappear over night. When I ask now how PE is going she groans. At the regular cross country race she tells me she walks at the back to keep her friends who also dislike sport company. She is still part of a team, only now it’s the ‘don’t do sport’ team. Fortunately she loves dance, and is part of an intensive class outside of school. She is a great dancer but flexibility is something that she finds tough. She perseveres because she enjoys it, and she loves meeting up with her friends of course. It is not cheap, and many families would simply not be able to afford it. Without dance I am not sure what she would do for physical activity; and it is something that really saddens me – especially as I know it can be so different.

It also makes me think about the role of sport for the more vulnerable children in our communities. Without any doubt for some it is a lifeline, but my guess is they happen to be the ‘sporty’ ones already. Going back to the poll it really does seem to be a clear dividing line here in the UK  – either you are or you aren’t sporty with only 25% seeing themselves as somewhere in the middle. It doesn’t have to be that way, and if we want to tackle major issues facing our society like obesity, isolation, screen addiction as well as providing lifelines for our most vulnerable young people then we need to take action. The pay offs for children, their futures, ourselves, our communities and even our high streets is worth it.

My starter for ten would be to start in school by not grading sport; and certainly not streaming kids into sets. Instead I would ask them do they want to do fitness for fun or for competition, and group them accordingly. They could always swap if they changed their mind, or showed real potential that needed to be nurtured. If the purpose of the lesson became enjoyment with fitness as a by product what a gift for the rest of their lives that would be.

Today’s run…….how Facebook got me outside, active, connecting with nature and making real friends

I’m as troubled about social media and the impact on mental health as anyone. Of course I am – I’m a parent of teenagers; and a psychologist who witnesses the consequences of the worst of it on a regular basis. From cyber bullying, to feeling excluded, to withdrawal from social interaction, to an obsession with image these are very real concerns impacting the daily lives of young people. No one is immune and I worry about my own reliance on my phone; and the way my anxiety can rise when the battery is about to die and I have no way of recharging it. Most of all I worry about babies and young children – desperate to make eye contact with the adults around them who are engrossed in their screens. I am concerned that the impact of this, and what it means for their developing brains and social relationships, will become the biggest public health issue to face the next generation.

The irony that I am writing this on a computer and will be posting it on twitter is not lost on me. However, there is definitely a plus side to social media; and the fact that I can share these reflections with many thousands of people across the globe is just one. Indeed. I have been blown away by my newly found twitter community and how this has enabled my blogs about children’s mental health to be read and shared by so many. The connections I have made with like minded folk around the world has been inspirational; and I have learnt so much as a result. I therefore wanted to take the opportunity to write about a very positive side of social media that really helped my own mental health at a time when I needed it most.

We had just moved to Canada, and after the busyness that comes from such an enormous relocation had settled; and my kids were in school and my husband was at work, I found myself completely alone in a strange and frozen land. The children were distraught at having to move, and my husband was stressed in his new and daunting role. It was a very unhappy time for our family and I was at risk of spiralling into a pit of loneliness, sadness and regret. I knew I had to take action. I decided I would restart my running – something that had a taken a back seat in recent months what with all the stress of giving up work, packing up a house and dragging two children kicking and screaming half way across the world. It had been something I had discovered late in life, having been a determined member of the ‘can’t run, won’t club’ since I was a child.

I knew I always felt better after a run no matter how much I dreaded going. Usually I had someone to run with to ‘force’ me to go. Here I had no one. I decided to call on Facebook to help me out. On a freezing (I mean –15, seriously freezing) Monday morning I posted my declaration. “I need your support Facebook. Please help me to get out there running again. I am going to post a picture every time I go”. I had already done my first one so I uploaded the photograph. After that I posted a picture of every run I did for a whole year. On reflection, the impact that had on my life, and the first 12 months of my time in Canada was profound. Looking back the advantages align really well with  Five Ways to Wellbeing and so I will use that as a framework to share my journey. I should say our journey. The dog always came too.

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Be Active

The most obvious positive gain from my runs was the physical activity. Don’t get me wrong, I never ran far or for long, especially at the start, but I counted things like getting dressed, going outside, having fresh air, raising my heart rate, giving the dog exercise all as benefits to this process. Especially when the alternative, doing nothing, was so very tempting. The fact that it was freezing meant it took a huge effort to persuade myself to go, and without the incentive of posting it on line, and the public commitment I had made, I am certain I wouldn’t have bothered on many occasions (if ever). Just through sheer habit my fitness increased, and from the January to the May I was ready to run, albeit very slowly, the first of several half marathon’s in Toronto. The further I ran the more I discovered about the city I came to love. It was a pivotal moment when I realised how close we lived to the shores of Lake Ontario. I was at a very low ebb at the time  but it helped me to look forward to the warmer months and having this beautiful sight on our doorstep. I also ran whatever the weather – and Toronto can be very extreme. This photo of me is during a snow storm, at a temperature of –20. I wasn’t out for long!

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Take Notice

This is perhaps one of the most powerful differences to running that the posting of photographs made. I never listen to music, instead disappearing into my head and processing all sorts of ‘stuff’, positive and negative, when I run. Having to take notice, and actively looking for something to take a picture of helped me to spot all sorts of interesting things I would otherwise have passed by. I also had to look for something new and different every day, despite frequently running the same routes. It became the focus of the run to see what I might spot. Everything from the wildlife unique to North America, to the sublte signs of a soft and gentle culture were there to see if I looked closely enough. Things I am certain I would have otherwise missed.

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The runs also helped me to take real notice of the changing seasons. Extreme in Canada, and marked dramatically in the way people decorate their homes as well as by nature. Spring was the hardest time for me as there is no sign of it anywhere. The city went from a frozen landscape at the end of April to a balmy summer heat at the beginning of May. Seeing all the Welsh daffodils in March back at home was so hard, but when the warm weather eventually arrived, and the famous cherry blossom burst into High Park, I was overjoyed.

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Connect

Without doubt the most profound impact of my runs was the life long friends I made. At first my connections were virtual, and I don’t underestimate the power of friends at home supporting me when I needed it the most. It was those connections that kickstarted the whole journey. However, my running also connected me with friends in the real world too. From nodding and smiling at people in the local community on a regular basis to conversations in the dog park about having seen me and my very noticable labradoodle out and about, to sharing my story about posting my runs everyday, friendships started to be made. One day, at the dog meet (a regular gathering of dogs and their owners) I was chatting to a new acquaintance and she said she would come too as she was trying to get back into running herself. That was it, the start of a beautiful phase of running everyday with a new friend. We look back on it as our golden time as the weather had just turned warm and she was between jobs (she worked in the film industry) and so we were able to run every day. It was a turning point for me – I had made my first friend in Canada. And of course, the dog had his first friend too. Suddenly there were photos of me taken by someone else, and of trips to cafes for a treat after our endeavours. I had someone to share the joys of the changing seasons with, and the prospect of another winter was no longer terrifying.

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Keep learning

Maybe learning is not the right word, but my running certainly kept me discovering.  I would try new routes as often as I could, finding new neighbourhoods and parks and ravines I would never have known existed. Whenever we travelled, whether it was within Canada or to new places I would keep my running posts going. It is a brilliant way to take in new places quickly, and often at less busy times. The cover photo is a frozen Niagara Falls taken early in the morning without a soul in sight. The boat is in Iceland, a quick run fitted in on a 24 hour stop over on our way back home for a visit.

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Giving

A less obvious way that my runs contributed to well being is throuh giving, and mostly people gave to me with their online support and encouragement. I gave to myself, too. Allowing myself the time and permission to do this, and forgiving myself if a run was very short, or if I didn’t go on a particular day. Facebook friends told me they loved my posts and that it encouraged them to get out there and go for a run. Many even posted photos which I loved to see. When my friend had to go back to work I would sometimes get up at 5.30 in the morning to join her on a run so that she could keep the momentum going, and she appreciated that enormously. That’s us before the sun has risen – catching the best of the day together. Some of our most magical runs were in the silence of the city before the dawn broke – especially after a fresh blanket of snow had fallen.

After my year was up, and I was no longer posting pictures, a new friend came along. She had just moved to Canada from the UK herself and was experiencing all the angst that I had been through. I asked if she would like to take up running. She was reluctant, and anxious having never run in her life, but prepared to give it a go. We started very slowly, and went every day. Before long she was loving it. The last picture is us completing her first ever 10k race – a profound moment for her; and one I will treasure forever.

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The price of prizes and the cost of competition in our schools – and the story of the willow weave dragonflies

I have two children. They are both completely different; and they are both completely fabulous. I am allowed to say that – I heard it from the brilliant Dan Hughes during my Dyadic Developmental Psychotherapy training. He told us that we are primed to think that our own children are the best to ever walk this planet, or words to that effect. It is how attachment works. At the time he was gazing at a photograph of his extraordinary granddaughter. That my children are completely different doesn’t come into it; they are both equally wonderful. Unless you look at the mantelpieces in their bedrooms that is. One is laden with awards and trophies. One has none. You see, in our society the strengths and skills displayed by one of my children are far more readily recognised and rewarded than the strengths and skills of the other.

It starts young, and just about every aspect of school life is organised around it. From ‘top table’ to ‘sports day’ the winners are there in plain sight. In theory it should all balance out, with different children excelling in different areas of school life, but in reality it rarely works out that way. Instead, the children who are good at the things society values are often good at lots of things that society values; either because they are naturally more able across the board; or because they are encouraged and supported (and funded) at home in a range of activities; or more likely a combination of the two. And of course skills in one area facilitate skills in other areas, as well as providing children with the confidence to have a go at new things. They are also braver about demonstrating their success – who wouldn’t be when you are on a clean run of coming out on top? And then, on prize days, they get rewarded again often for the same achievements.

Neither of my children are particular fans of athletics and so sports days were often in the territory of ‘its the taking part that counts’ in our house, and something we were glad to get out of the way. But in other areas my son’s photographic memory, fascination with facts, musicianship, love of performing, and his leadership skills (did that come before or after his strengths kept being recognised?) have suited school life perfectly. My daughters skills are plentiful and inspirational – but never quite make the limelight. Her social skills, listening skills, problem solving skills, observational skills and practical skills (she can literally turn her hand to anything) blow me away. They will serve her so well in adult life; but in school they may be appreciated, but they are rarely elevated to the giddy heights of awards or trophies.

In Wales, never is this more apparent than the Eisteddfod. An annual celebration on St Davids day that is organised entirely around competitions. Year after year my daughter entered competition after competition, and never once got so much as a placing. From singing to hand writing, to baking, to poetry reading to model making she tried. At school pick-up time, some children would run to their parents and carers covered in rosettes and others would walk slowly, their jumpers an empty void. “The main thing” I would say lamely, “is that you loved making that underwater treasure trove” or whatever the theme for that years model happened to be. And she did, she absolutely loved it. But she would have loved it more if on just one occasion she got a rosette.

One year she decided to go for it, and entered every competition possible. The half term just before we were on holiday, but even so she beavered away with the list. One day we went to visit a local wildlife centre and they had a willow weaving class that she took part in. After three hours she emerged triumphant, holding a spectacular dragonfly in her red raw hands. “Ive got an idea” she declared. “I am going to make a circular pond for him to sit on covered in ripples and enter him in the model competition”. The theme that year was ‘Environmental Pattern’. It was inspired. On the day she needed help to get all her submissions into school. She carefully carried the dragonfly herself, and friends came running up to admire it. After school I waited in my usual spot. She came out with nothing on her jumper. “See I never win anything” she said “I’m not bothering next year”. She was wearing her brother’s hat. He had entered the music contest at the last minute with a drum solo and threw his trilby into the audience in a rock star style finale; aiming at his sister. At least someone had noticed her. He came first.

At parents evening a few weeks later I plucked up the courage to say something. I felt anxious – how do you not sound like a pushy parent with sour grapes? But it wasn’t just for my daughter; it was for all children who try their hardest but don’t quite hit the mark. Her teacher was brilliant and listened intently. “I’m going to raise this at the staff meeting” she said. A few days later she telephoned me at home. “We have changed the system moving forward” she said “children will get a point for their house for every competition they enter as well as points if they win”. I told my daughter she had made a difference to how they do things at the school; and they were going to start rewarding effort as well as the winners. She was delighted. The next day the teacher from Forest Schools also came up to her in the playground. “I loved your dragonfly  – we have willow in our workshop and don’t know what to do with it – could you teach us how you made him?” She could not have felt more proud or excited; and the willow weave dragonflies on the wall in Forest Schools are another legacy she has left. There is no award or prize to show for it; but there is a huge sense of intrinsic achievement; and a story we remember often.

How do you change the competitive nature of our education system when just about every aspect of school life is based on it? Interestingly, not long after Dragonfly Gate we moved to Toronto for three years. Very quickly, my son noticed a difference. “Mum, in the UK it is all about being the best, but here it is all about doing your best”. This, from the boy who didn’t want to move; and who was used to winning prizes. He preferred that aspect of Canadian life – it felt less pressured. If you are usually winning, what happens when you don’t? It suited his sister much better too, and her self esteem blossomed. She even started taking part in sports because it was all about fun.

 

As a psychologist who has been steeped in the power of positive reinforcement I too learnt an important lesson. I volunteered as a Roots of Empathy instructor and one of the hardest things I had to give up was praising kids in the session. The rationale is to create safety in the classroom, and if children are singled out for getting ‘the right answer’ (there are no right or wrong answers in the world of emotions) or ‘the best idea’ it might leave the children who were thinking something different and too shy to put their hand up more reluctant to speak out next time. Instead, as an instructor I would repeat answers back with a smile, or say thank-you, and praise the whole class for the behaviour I appreciated from them all. It was really hard to do, but so powerful when I got into the swing of it. It certainly did create an atmosphere of acceptance and inclusion that all the children seemed to love and feel part of. The baby helped too, of course – see my blog about the wonderful Roots of Empathy programme if you want to know more.

Of course there are areas of school life where there are right answers, and where competition and winning is important. I am just suggesting that there is a balance to be had; and that the achievement can be the reward in itself and doesn’t have to be rewarded again and again for the same children. It is also important to remember the unintended consequences of this culture of winners. That for every child receiving the award there are many more feeling diminished by it; especially if they have put time, effort and hope into trying. That many of the most important qualities in life don’t lend themselves to being measured and competed for. Empathy, for example, will never come out on top – that is the point of it. Finally, my children know they are the best in my eyes regardless of what they achieve. For many many children in our schools they don’t have that buffer at home; far from it.  Furthermore, these are often the children who don’t get music lessons, or home tutoring, or even a trip to a wildlife centre and a willow weave class. Oh and if you are wondering how to pronounce Eisteddfod – for many parents it starts with an F.

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.

When the Tail is Wagging the Dog…….

I have an enormous dog. I didn’t see it coming – or maybe I chose not to. As soon as I locked eyes with him as a puppy he was coming home with us. Others in the know, or with a more objective perspective, knew exactly what lay ahead, of course. “Wow he’s got paws like saucers” they would say when I took him for a walk. “I know! So cute!” I would smile back, brightly. As he grew bigger and bigger we had no choice but to accommodate him. He outgrew his crate, his bed, the kids being able to take him for a walk……Indeed, there were some pretty major unintended consequences – like when he outgrew our car. (Ouch). But the hardest thing to get used to was his tail.

He is the softest, gentlest most loving dog you could ever care to meet – but his tail is a lethal weapon. The irony, of course, is that the happier and more pleased to see you he is, the more dangerous his tail becomes. Like the bough of a tree broken off in a hurricane it thrashes around doing untold damage. We have to move everything and everyone out of it’s way – especially small children who he is particularly pleased to welcome. The tail needs a whole management strategy to keep danger at bay. It is, quite literally, wagging the dog and everyone else too.

Working in the public sector the concept of the tail wagging the dog is one I am very familiar with. Just like my dog, the intentions are often positive – but the unintended consequences of blanket policies and procedures can be enormous. Day in day out there are many examples – particularly for psychologists and therapists working in health which is inevitably dominated by a more medicalised model. A typical example was the infection control directives about getting rid of soft toys – often the biggest source of comfort and familiarity for our most traumatised children. These children are not physically vulnerable when they come to see us, and so the risk of infection is low – but they are emotionally vulnerable and reconnecting with a favourite toy can be a vital aspect of the therapeutic work. Another example are the community based multi-purpose clinic spaces with examination beds and sometimes even stirrups. It might be the only space available close to a young person’s home where we can offer appointments for therapeutic work – but it is wholly inappropriate, particularly when the issues might be about sexual abuse.

Indeed, often these general policies make absolute sense for physical health settings. A room that a podiatrist, a gynecologist, an ophalmologist can all use is a great use of limited space – but it is useless for a psychologist. There are many many examples like this where we just don’t fit. From the way data is collected to the response to not attending appointments (engagement and building trust is often a major part of our work and can take a significant amount of time for our more vulnerable families). Often we can challenge the ‘standard practices’ when they really don’t work for us, and we are listened to.  But it takes energy, an awful lot of it, when the work itself is already demanding enough and we have so little time. Often we have to let things go. Or we become so accommodated to our settings we may not even notice the subtleties of the messages they give out. For example having a ‘referred child’ named in correspondence. It is easier for filing, record keeping and governance purposes of course – but if ever there was a clear message that the problem is located within the child it is this.  They might have experienced domestic violence at home, severe bullying at school or a whole host of other contributing factors in their context – but they are the one identified as having ‘the problem’ and all correspondence is organised around them, and filed into history and the narrative of their life. Tackling more subtle messages like this is overwhelming – and so we don’t.

Of course health is not the only setting where the tail wags the dog. Education is another classic. At a recent parents evening I was told  by one of the teachers that my son ‘knows more than me about the topic and makes connections I had never even thought of’. He then added ‘but he needs to learn to narrow his answers down and stick to the mark scheme or he wont get the grade he deserves’. I could have cried. I do not blame the teacher – he is exceptional – and I do not blame the school – they are judged entirely by their grades, and parents are as guilty of this as anyone. But I do blame a system in which examination results trump all – even curiosity and connection making. My son is able to adapt and ‘play the game’ – and he very much sees it this way. However, for our more vulnerable children in society this endless focus on exam results is particularly damaging. It is a sure fire way of disenfranchising our most disenfranchised.

Indeed, the tail wagging the dog applies to so much of what happens to our children. A focus on exam results, pressure to conform, family discord, poverty, insecurity, neglect, abuse, poor diet, lack of play opportunities – all have such a powerful impact on our children’s mental health and yet rarely are these the target of our attention. If we started with this, and by asking what our children need in order to flourish, we would have very different systems and expectations and support models in place. Instead we continue to ask what is wrong with our children, why their mental health is such a growing problem, and how we can get more mental health specialists to ‘fix’ them in (hopefully) comfortable therapy rooms. If we started with the needs of children at the centre of our communities and institutions instead of trying to make them fit how different would things be? At least, for my dog, his tail is in charge BECAUSE he is happy and not the other way around.

Why we shouldn’t let the particular lens we view the world through blind us to what helps others see more clearly

I love my optician. She is warm and gentle as she goes about her business in the small box room I have been visiting for years. I find the whole process fascinating. She is so professional, and so thorough and yet she relies entirely on me saying ‘clearer’ or ‘less clear’ to the tiny incremental changes she makes as she switches between lenses. I trust her entirely, and yet the whole process relies entirely on her trusting me. Sometimes I find it really hard to tell if it is clearer or not, and yet together we get there. I either leave with a slight alteration to help me see more clearly; or she tells me things are just fine the way they are.

It has made me think about the old, new, ongoing and at times painfully embarrassing debates about mental health and  whose approach is ‘right’ or ‘best’. As professionals and therapists we are all trained differently– (sometimes small differences, and other times huge differences) – in how we understand the root causes and most effective interventions for mental health difficulties. If we think of this training as a lens through which we view these difficulties, it helps us remember that there are other lenses; and that these lenses may be more or less helpful to the person or family in front of us at a particular point in time. And that, after all, is the only thing that counts.

There are many lenses in mental health – for example the biological lens, the biopsychosocial lens, the psychological formulation lens, the psychodynamic lens, the systemic lens, the attachment lens, the Cognitive behavioural lens – to name but a few. All have demonstrated some worth to a greater or lesser extent along the way. To add to this we now have the ACEs lens and the Power Threat Meaning lens – welcome additions in a quest to make sense of what it is to be human. Especially as no-one can claim we have found the right ‘prescription’ for everyone.

When, as professionals, we look through our own particular lens, we do see clearly. Of course we do. We have been trained to – having sought the training out because we already were drawn to that light. And our passion and commitment to our particular lens is our strength – it keeps us striving for absolute clarity and improving that particular view on behalf of the people we work with. There is a risk, however, that it is also our downfall. It blinds us to the other lenses that may be more beneficial to that person or family at any one point in their journey towards clarity.

Multi-disciplinary teams, in theory, guard against this. However, in reality there is often an overpowering lens, whether it is a hospital setting, a ‘consultant led’ team, a dominant narrative or simply a lack of options as is most commonly the case.  Moreover, ‘multi-disciplinary’ usually exists within one organisation (health), negating the social, cultural, contextual and political lenses that play such a significant role in the development and maintenance of, and interventions for mental health. Multi-agency lenses are essential if we are really going to see through the complexities more clearly. Even more importantly, those who have experience of using our services provide a crucial lens, or perhaps even the overview that all lenses are given a fair consideration – checking that some of the box isn’t hidden from view? Indeed a range of views is essential, as we can all become evangelical about ‘the thing’ that worked for us.

Not forgetting the historical and cultural lens that our society is drawn to view mental health through. Why, for example, despite a consistently strong evidence base, is there a consistent avoidance of the socio-economic factors that play a huge part in mental health? Far more politically convenient to locate the problem in the individual. Furthermore, we have the added complication of the evidence base. The opticians equivalent of saying ‘Most people your age benefit from this lens. No, really they do. Try it – it should work for you too’. Sometimes it does of course; and that saves everyone time and energy. But often times it doesn’t – and even if it does work is there any guarantee that another lens might not have worked better? That approach is so very different to the gentle trying and retrying and responding to feedback that my optician goes through every time I visit.

It is a hard one, of course (I will resist the temptation to talk about hard and soft lenses). In mental health services people are often at their most vulnerable and seek certainty. Especially when they have waited a very long time to be seen. The prospect that even the ‘expert’ doesn’t know which lens is ‘right’ might feel disappointing, overwhelming or even anxiety provoking in itself. There is the added complication that many therapeutic approaches are more effective if they are delivered with confidence and an assertion they will work. In my experience, however, sharing that ‘uncertainty’ confidently, with a determination to stay alongside and try alternatives (or alternative colleagues) is containing in itself. A constant checking and rechecking that the approach we are using is helping them to gain clarity. I don’t expect for one moment my optician will find the ‘right’ lens straight away – even though she probably has a pretty good idea when I walk in the door based on my previous prescription. I value her careful checking and rechecking and determined look of not knowing she has on her face throughout.

In these tough times it is a big ask to have a full box of lenses available to create a bespoke prescription for mental health; checking and rechecking the goodness of fit for each individual. It is far more convenient to have a small selection of lenses that usually work, or even one lens that works well enough for most. The cost, however, of not having all the lenses to hand is it risks us carrying on blindly working in the dark. That is something my optician would never settle for.

We are teetering on the edge of a radical overhaul of Children’s Mental Health Services – are all our ducks in a row to be able to take advantage of the opportunities for change?

Children’s Mental Health is suddenly on everyone’s agenda. For all the wrong reasons of course; but sometimes things have to get really bad for people to take notice. It’s a bit like children’s behaviour generally. It is often ignored until it escalates and starts to affect the lives of others. Those children who trundle along under the radar rarely get attention – but that doesn’t mean all is well. It can no longer be said that Children’s Mental Health Services are trundling along under the radar- they are rarely out of the spotlight. Looking at this positively, it does provide us with a real opportunity for systemic change in a system that has been broken for years. More of the same won’t work – but politicians and policy makers don’t know that. (How could they?) Those of us in Mental Health Services need to tell them why it wont; and more importantly; we need to show them what will.

A recent evening stroll, and happening upon these ducks all in a row, inspired me to write this blog. Are we ready to take advantage of the opportunities that may be around the corner? Are all our ducks in a row when it comes to inspiration and ideas for reconfiguring children’s mental health services to make a real impact? Or are our heads down; busily firefighting the constant demand. Will we grasp the opportunity to do things differently? Or, out of desperation, will we grasp any resources that come our way to keep doing more of what we have always done in the hope that just a bit more of us will relieve the pressure? I have attempted to identify the ducks I think need to be in a row to be really innovative about how we invest, or reinvest the scarce resources available in children’s mental health services; and in children’s services more generally. I think all are equally important and so they are not in any particular duck order.

Duck 1 – things need to change

Is there a recognition that things aren’t working as they currently are? Or is there  a culture of agencies blaming one another for the problems? Is it all CAMHS ‘fault’ for their unhelpfully strict referral criteria? Is it Social Care’s ‘fault’ for asking health to fix problems that they are responsible for? Is it education’s ‘fault’ for insisting on an assessment or even a diagnosis in order to justify additional support for children in school? So long as these old narratives are floating around there is unlikely to be a climate that can cultivate real and lasting change. The failure in the system is no one agencies or professions fault. The problems are too big for more of the same to be the answer.

Duck 2 – change involves everyone

Is there a recognition that everyone has a part to play in every individual child’s mental health and wellbeing? Or is the modus operandi one of ‘referring on’ to specialist services for ‘diagnosis’ or ‘therapy’ or ‘medication’ or a combination of all three to ‘fix’ the problem? Is the ‘innovation’ to have these specialists in schools – perpetuating a model of more therapy (albeit closer to home and less stigmatised) as the ‘big’ solution. Is there a central, multi-agency space where children of concern are discussed and the pros and cons of different approaches and pathways talked through? Or is the acceptance and rejection of specialist services done in writing against a tight set of criteria? Are these referral criteria organised around the medicalised language of disorder that separates out the social context of children’s lives? Or is there an understanding that children’s mental health difficulties are complex and arise as a result of a range of interacting factors; and that a range of services may be more or less helpful for that individual child at a particular point in time? Unless there is a recognition of this complexity we will continue to seek simplified solutions, and more of the same will prevail.

Duck 3 – change involves an element or risk and experimentation

Is there a recognition that whilst evidence based practice has a vitally important role, it also has it’s limitations? Or is an openness to flexible and creative solutions blocked by an insistence on approaches that meet the unrealistic criteria for randomly controlled trials? Is the direction of travel towards delivering more and more single modality and manualised interventions? Or is there an acknowledgement that skills in complex formulation and systemic approaches are equally relevant and important? Do these voices have an equal say in service development? Is there a recognition that many of our most vulnerable and in need children and families are not able to take up clinic based interventions either because of poverty of resources (physical and psychological), or ongoing trauma and adversity which means they are unable to engage in the work even if they could get to the venues on a regular basis? These acknowledgements quickly lead to the conclusion that we need much more creative solutions to meet the needs of our most at risk children and families. The Adverse Childhood Experiences Research brings this into sharp relief; and outlines the importance of a trauma informed workforce who have ready access to specialist advice and consultation to support them in their challenging front line work. That is not to say new solutions should not draw on research and practice based evidence; and, of course, be fully scrutinised and evaluated. We just don’t know what all the solutions look like yet; and an openness to ‘informed experimentation’ in the absence of answers is crucial.

Duck 4 – measureable outcomes don’t tell the whole story

Is there a recognition that measuring the success of services on ‘waiting times’ fails to represent the quality or even the utility of the activity being delivered? That is not to say, of course, that there isn’t great work happening; but waiting times alone is not a demonstration of this. In fact, they could have the opposite effect as the pressure becomes one of discharging families as soon as possible to free up clinicians to focus on ‘through put’. There are many other things that we equally need to measure – objective outcomes, of course, and the satisfaction of children, families and referrers with the service they have received. This happens to a lesser or greater to degree but these are not the headline measures and the ones that make the ‘news’.

Indeed, I would go a step further. How many families come for a one off assessment and are sent on their way? Sure, this can serve a useful therapeutic function and reassurances that there are no ‘significant mental health’ concerns; and that families are doing all they can to support the child or young person. But is that really the very best use of a scarce expert resource? Especially when a week, a month, or six months down the road things may have changed for that child or young person anyway? Is the system open to thinking more creatively about the use of this resource? How about the expertise being available to the professionals who work with children day in and day out and can tune into their changing worlds?

A classic example can be found in neurodevelopmental services. Families wait for several months or often much longer for an assessment. For one third they will receive a diagnosis; which often results in relief but no direct intervention. However, up to two thirds receive nothing – and yet the problems that got them accepted onto the waiting list in the first place persist. Surely this model is ripe for creatively rethinking; especially as so many resources are tied up in maintaining and even enhancing it? How about developing formulation based family intervention services that are relevant for all children who present with puzzling behaviour;  and retaining the specialist assessments for those children who still present with difficulties following this? We have great examples of services working in this way, and the comprehensive pre-assessment understanding they generate really facilitates the more formal assessment process.

Duck 5 – all practice in children’s services needs to be informed by our knowledge and understanding of child development and the promotion of emotional well-being

Is there a recognition amongst policy makers that the systems in which children exist often contribute to and exacerbate their mental health difficulties? Education is the classic example, where an increasing focus on results fails to acknowledge that this takes its toll on children’s emotional well-being. In therapy a child might be getting the message that they have unique strengths; and not to judge themselves by their grades. For the rest of the week they will be getting the message that this is their most important year; that their success depends on how much effort they put in and how hard they work; and advised that their social outlets and hobbies should take a back seat for the exam period. I say this as a mother of a 16 year old sitting GCSEs.

There are many many examples across all children’s services where we are giving contradictory messages to those we know to be the most therapeutic response for children because it suits the organisation to work in that way. Signing children off when they do not attend appointments in health, for example, fails to acknowledge the impact of trauma and the complexity of the lives of our most vulnerable families. Changing social workers because the child is moving from ‘assessment’ to ‘long term’, or is now ‘sixteen plus’ fails to recognise the importance of relationships and trust with those who have known them longest, and who know them best. The list is endless; and an openness to challenging the status quo is essential if we are to become truly child and family centred environments.

Duck 6 – partner agencies need to develop trusting relationships and demonstrate compromise

Does everyone in children’s services get around the table, or better still, the coffee urn on a regular basis? By everyone; is that those in the most senior positions with access to budgets and power to influence service delivery and those with front line and clinical experience, recognising the importance of both perspectives? Does that include Mental Health? Public Health? Physical Health? Social Care? Education? Police? Early years? Leisure? Housing? Voluntary sector? Parents? Carers? Children? Young People? Who else? It can feel daunting, but regular meetings, month in month out, year in year out is the only way to make this happen. Those with energy and passion for change will keep coming, regardless of frustrations and wondering if time could be better spent. There is nothing liked an integrated pot of money to prioritise bids against for sharpening focus, and working through barriers. Are there examples of jointly commissioned services that demonstrate the effectiveness of working in this way?

So these are my ducks. And in our area I feel very excited that they are all more or less in a row, or at least beginning to line up. We are already delivering services at a range of levels from infant mental health to repatriating our most troubled children – all working in a formulation informed; multi-agency way. They are often inequitable; and often funded on a short term basis; but they are a start in a way of working that involves everyone coming together and agreeing what the next priority should be.

One of the first lessons I learnt as a psychologist was that consistency in children’s lives matters. Back then my focus was parents, grandparents, teachers and social workers– now it’s everyone who comes into contact with children and who makes decisions about how services should be delivered. The ducks are bigger and harder to get in a row – but think what could be achieved when they are?

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