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?

Maternal Mental Health and Me……….

I had wanted a baby for as long as I can remember. Growing up there were no babies in the family and so I never got the chance to even hold one, which only added to my obsession. I remember once being stood in town with my mum as she chatted to an old acquaintance who was pushing a pram. I became very fixated on the baby, longing to pick her up, to cuddle her, to smell her. Surreptitiously I offered her my finger and she gripped on, looking intently into my eyes. It was like a stolen moment that the adults didn’t know about. Later I asked lots of questions about the lady, trying to discover where she lived so that I could find a way to walk past the house, and maybe catch sight of the baby again. I felt terribly guilty about my plotting – probably all tied up with often being told off for wanting what I couldn’t have. The irony, of course, is that the mum would most likely have loved to have a ten year old come round and entertain her little one. The baby would have loved it too.

Although the feelings of longing never went away, the space became filled with the usual distractions of life.  Friends, hobbies, arguments with parents, studies, boyfriends, break-ups, career, meeting ‘the one’, mortgage, marriage……it had its ups and downs, of course; but there were no major hurdles in the trajectory I hoped I was on. Within three weeks of meeting him I asked ‘the one’ if he wanted children. “I’ve never really thought about it” he replied, “but, I guess, in theory yes”. That was all I needed. I had been teetering on the edge of falling in love and now I could throw myself over.

When the time came to try for a baby nothing happened. At first that was ok, these things can take time. But when after, 8,9,10 months I was greeted by my period, I started to panic. Blood is such an appropriate accompaniment to the horror of its meaning for me at that time. Going to the toilet was filled with dread and foreboding. If it was clear I would hold on to hope for a little longer – only for the inevitable trauma of blood shed to engulf me when it eventually arrived. For others of course, blood comes as a welcome relief. My older relatives even referred to their period as their ‘friend’. “I’ve got my friend” they would say.  It has never felt like a friend to me. At that time it was the antithesis. Real friends fell out of my life too as one by one they became pregnant – some even accidentally. I found being with them unbearable; wanting to lock myself away until I could re-join their gang. The isolation didn’t help my frame of mind, of course, but I wasn’t ready to fill my life with alternative distractions as that felt like letting go.

After a year we went to see our GP and initial investigations confirmed we should seek specialist fertility advice. The waiting list for an NHS assessment was 2 years, and every month counted in this new world of a ticking clock we had entered. Fortunately we had saved up for a kitchen as ours was falling apart, and so we could afford to go privately. We had no need of a kitchen anyway if we had no children to cook for, I rationalised. I’m not entirely sure that my husband, the chef in our relationship, felt the same way but he knew not to argue. ‘Egg shell avoidant’ had become his modus operandi. We had no idea where to start looking for a clinic – the league tables were manipulated, we had heard, such that the ‘best’ often excluded the more complex cases. (Sounds familiar). In the end we went to Prof Winston’s. Although he was no longer practicing he seemed like a decent fellow when I had heard him talk on the telly  – our rationale was as basic as that.

Very quickly into the process the Consultant identified that it was highly unlikely that we would ever conceive naturally, and that IVF was our only option. As I listened to the news, my world fell apart. It didn’t help that I had spent years studying statistics – 21% success rates, as it was at the time, were not good odds. Especially as that would have included couples who would go on to get pregnant naturally anyway. “What next?” I asked. “When you are ready you can register for your first cycle downstairs in the clinic on the right”. When we went downstairs, my husband turned left. “Where are you going?” I asked. “Home” he said. “What about registering for treatment?” I asked, dismayed. “Don’t we need to think about it?” “No” I replied, and dragged him right. It was the only option; and we needed to start sooner rather than later. He didn’t dare tread on that egg shell.

In the unlucky world of the infertile we turned out to be one of the lucky ones. Our first attempt was successful, and I became pregnant. Yes, it was a horribly stressful process. The injections, the travel to clinic miles away at unearthly hours, the waiting to see if each stage had been a success – and how much of a success. How many eggs? Too many eggs? Over stimulating which meant cancelling the whole thing? How many embryos? What quality of embryos? Had they survived? How many had survived? How many to return? Had they implanted? But when it works; all of that fades into the background. In fact it seems like a much more reasonable exchange of effort for such an extraordinary outcome than simply having sex.

The fertility clinic held onto us for a little while – offering extra scans; and hormones to help the pregnancy to ‘stick’. Then, at twelve weeks, we were turfed out into the throng of normal pregnancies with everyone else. In some ways this should have felt like a relief; but for me it was the start of my spiralling anxiety. We weren’t a ‘normal pregnancy’. If this didn’t work we were unlikely to ever conceive again. Checking that I hadn’t started bleeding was my primary obsession in the early days. Five times during our ‘celebratory’ meal out, and only stopping there because my husband set a limit. I couldn’t wait to get home to be free from scrutiny to check as I pleased. Then came the potential risks to the baby – changing the cat litter, other peoples children who may or may not have chicken pox, soft cheese that may or may not have touched the plate I was eating from, too hot a bath, accidentally tripping on my flared trousers (my fault for being so stupid to wear them in the first place). The list was endless and as soon as I was reassured about one thing, another would be ready and waiting in line to take over in my head.

The distraction of work helped a bit, but nothing outside of work could take my mind off the inevitable, as I saw it, failure of this pregnancy. It was just a matter of time, and the dangers were everywhere. I was exhausted. My husband persuaded us to go away for a few days hoping that a change of scene would help. We went to a stunning country house hotel that fortunately, had toilets on every floor – the first thing I checked when we arrived. When we woke up on the first morning there was a note under the door saying that the decorators would be on our floor at some point, and apologising for the inconvenience. That was, quite literally, the least of my worries. After breakfast we headed out for the day. Between leaving our room and getting to the car I needed to check. “I’m sure I felt something” I told my husband as he tried to persuade me we could at least wait until we got downstairs. I dived into the toilet by the lift and emerged minutes later. “The painters are in” I said. He looked utterly devastated. “It’s ok” I reassured him, “I could still use the cubicle – they were only in the cloak room area. Everything is fine”. He burst out laughing – explaining what “the painters are in” meant to him – a crass, laddish term for periods. I didn’t so much as raise a smile.

I dont think I smiled throughout my pregnancy. The other thing I didn’t do was go anywhere near baby shops. What was the point? It meant we had prepared nothing – no nursery, no clothes, no nappies, no nothing. The midwife told us we would at least need a car seat to bring the baby home in and so we headed to Mothercare.  I blanked out everything in the shop around me as we relayed the instructions to the shop assistant – we want the safest and easiest to fit in that order please. He showed my husband how it worked and checked it in our car. I went for a walk behind the building and vomited. The one thing I did do that did seemed to help as I felt my anxiety rising was to repeat to myself “at this precise point in time, there is no evidence what so ever that this baby is anything other than fine”. I repeated it frequently; sometimes fifty times a day.  It was the only way I had of calming myself – albeit momentarily. It was a long nine months.

On the baby’s due date I went into labour. Surprisingly, I felt an incredible sense of peace – maybe because I was no longer in charge; and the safety of the pregnancy was no longer down to me. I had a wonderful midwife who, as part of a team, had supported me throughout and was happy to support a home birth as I lived so near to the hospital. It all progressed very smoothly. I didn’t mind the pain – just like the IVF it made perfect sense that none of this should come easily. Unfortunately, at ten centimetres dilated, progress stopped and we needed to transfer to the hospital. I had an emergency caesaerean – again all performed calmly and expertly by a fantastic team of professionals. When they handed us the baby I thought he was the most perfect creature to have graced this earth. I was a bit shocked hospital staff weren’t being sent in their droves to catch sight of this miracle child. The next few days passed in a blur of sleepless euphoria. I even managed to get myself discharged before the mandatory 3 days post caesarean by confusing both myself and the junior doctor in charge of my care about how long I had been there. He had probably had as little rest as I had.

Back home I remember the point my world came crashing in. It was when I was sat in our sitting room with my feet up trying to rest and recuperate, and the baby was upstairs in his crib. A black cloud descended over my head like a very heavy, very physical presence. I started to shake and cry uncontrollably. “He’s going to die and it will be my fault” I screamed to my husband, who was happily preparing dinner in the next room. “he’s fine, he’s asleep upstairs” he tried to reassure me. By this time I was inconsolable. Somehow I had been given a perfect child that I didn’t deserve, and I was about to ruin his life. I was useless, I would fail him, he had been born to the wrong person, we should give him up now before it was too late. There was no talking me round and my husband knew I needed help. “Shall I phone the midwife?” he asked. ”No” I said. I told him to phone my best friend.

Within no time she was there, toddler left at home with his dad, three month old infant in her arms. I had neglected her during her pregnancies and early motherhood so painful was my infertility, but that mattered not. As soon as she walked into the room I told her I thought the baby was dead. She didnt tell me otherwise but said she would go upstairs to check. She came back down, still holding her own baby, and said he was breathing evenly, and his breath was warm on her hand. He was extremely peaceful and I had clearly done a good job of feeding him enough to help him sleep so soundly. I could come up and check him with her if I wanted, or I could rest up, which is what he needed from me most of all.

She caught me staring at her baby. “I bet he looks huge to you, and a bit odd?” How did she know? He looked like he had been pumped up like a balloon. She continued “I remember staring at my husband’s ear after our first baby was born. It looked like a giant’s that had been transplanted onto his head” she laughed. “We get so used to staring at our own baby and tuning into to their tiny perfections that it distorts everything else we see”. I felt myself starting to breath more regularly. “It’s exhaustion, its hormones, its pain killers, it’s relief – its everything you have been through”. I started to sob. “You haven’t stopped working towards this for years – sitting still and resting must feel really odd. But honestly, that is what your baby needs from you most of all so that you have energy for him when he wakes”.

She stayed for a while, and I calmed, the black cloud lifting a little. I even managed to eat some food. When she saw me start to smile she braved “lovely as it is, I think there are other shades of cardigan that would suit him better than the hospital one he is wearing”. It was time to trust that he might really be here. And even if there were no guarantees it would be forever, he did at least deserve some clothes. I will never forget how important my best friend was in getting me to that place.

The way society gives care shapes how we ask for care…….and that is where we need to focus our attention if we want to meet the needs of everyone

For my children the news we were moving to Canada for three years came entirely out of the blue. It was a tough call. Shock them, but contain them as their parents – giving them the impression we were calm and confident that this was the right decision for the family. Or include them in the long and protracted decision making process; and let them see how uncertain we actually were.  Worse still, give them the impression they might have a say when we knew that, as the grown ups, the decision had to be ours. Rightly or wrongly we chose the first option.

We moved to a frozen land – Toronto experiencing one of its hardest winters on record. It did not mix well with devastated kids. Snow did not mean jingle bells and sledging. It meant frost bite within two minutes of exposure. We knew no one. We had no car. It was not fun.

In those early days the one light in the darkness was ‘Chapters’ on Bloor Street. A fantastic book shop filled with stories to escape to; and where we could visit familiar friends – Harry Potter, Percy Jackson, Matilda, and even Pinocchio – a rediscovered favourite from years gone by – to name but a few. It was a magical place located in an Art Deco theatre that had retained many of it’s original features. The Proscenium arch, the stage, the ornate mouldings, the occasional row of red velvet seating to pour over pages of a favourite book, a children’s section in the dress circle…… The kid’s loved it and we went there most days after school. The dog was even allowed in.

After only three weeks the notice came that it would be closing in a couple of months. We were as devastated as the locals who had enjoyed it as part of their neighbourhood all their lives. We joined hundreds of them one Monday evening to campaign against the decision. A temperature of -25 kept no one away such was the love for this place.

The CEO of Indigo, the parent company, came in person to face our wrath. She was close to tears herself. She told us it was her favourite store too; but it was making a huge loss. The footfall relative to the square footage was simply not viable in an age when online purchasing of books was the option of choice for most. She asked how many of the hundreds gathered before her had bought a book here in the last six months. She didn’t shame anyone by insisting on a show of hands.

 

My children had spent their entire Christmas spending money there. (They hadn’t had presents as we were flying a few days after Christmas and our luggage allowance was at it’s limit. Santa had thought he had been so clever bringing them snow boots and head phones which they could wear on the plane. Relatives were under strict instructions to only give money so they had nothing to pack, and plenty to spend across the pond).  Of course we were rare. One scared and lonely family with freshly exchanged dollars and nowhere else to go was not going to keep a business afloat. With no anonymous corporation to rail against we all went home; our donkey tail’s between our legs.

Within weeks there was a date for closure and we also knew what was going in its place. Shoppers Drug Mart – a Canadian pharmacy chain that included food, make up, seasonal goods, and magazines. At least they promised to retain the aesthetic features of the theatre. My son was devastated – it held no appeal for him whatsoever. My daughter, on the other hand, was quite excited.

It was true. She had spent many hours in the smaller Shoppers Drug Mart this would replace. She perused the confectionary, the toys, the medicines, the magazines, but it was the first aid section that really caught her attention. Plasters, ointments, bandages, and straps would fascinate her for what seemed like hours. If ever she was ‘lost’ I would always find her in this aisle. She would often slip an item into my basket – either for something that was ‘hurting’ or ‘just in case.’

I didn’t challenge it. I knew it was her way of getting care when she needed it most and in the best way she knew how. Leaving home and family and friends behind had been incredibly hard. And yet she was also happy, enjoying the new school, the new friends, and the new city to explore. It was confusing. She was hurting on the inside and an outward symbol, like a plaster, made it easier to express when mostly she was also having fun too.

She would often go into school with a band aid (a Canadian term she quickly learnt along with closet and running shoes), or a bandage or a wrist strap. Luckily her teacher was very nurturing and knew exactly what she needed. She would spot the area of ‘pain’ immediately; ask if it hurt and say “I hope it gets better soon”. She would follow up with “Come and sit by me and (insert another child’s name). We need help sorting out the (insert a practical task). She was brilliant.

As we settled as a family, and our sense of belonging grew, my daughter’s need for an outward sign of her pain diminished. My son had managed his distress in a completely different way. Perhaps because he was older; perhaps because he could put it into words more easily;  perhaps because it was more clear cut for him. “I hate it here.” And “you always told us family and friends are the most important things in life and now you have taken us away from them all”. Unlike my daughter, there was no confusion for him. He expressed his feelings with perfect clarity, and directed them entirely at the root source of the problem. Us.

I tell this story because I have been reflecting a great deal about the dominant narrative of the medical model for mental distress in our society; and more recent alternatives brought into the foreground by the Adverse Childhood Experiences research and the publication of the Power Threat Meaning Framework. Suddenly, it may seem to some, there is a different way of thinking about ‘mental illness’ or ‘disorder’. For many, this is a welcome relief. What happened to them as a child or even as an adult, is explanation enough for their distress. It is not something that is inherently wrong with ‘them’ that is the problem, as a disorder implies, but rather, how they have been treated or the experiences they have been through in life.

For others, however, this is a very challenging perspective and does not fit at all with their understanding or their experience. It feels invalidating, and makes their difficulties somehow less real. A mental disorder fits much more readily with their reality, and demonstrates far more clearly how tangible and severe their experience is. Both are right. No one is wrong. Their experiences, and need for explanation and intervention of a particular nature, are just different.

In respect of my daughter would it have helped to say her plaster was not necessary or the ‘right way’ of asking for help? Absolutely not. That would have made her feel invalidated and even ashamed. Was her pain real? Absolutely yes. Would it have helped my son to suggest he needed plasters or ointments so he could get the same sort of help for his distress? Absolutely not. Are there times when a response afforded to physical pain helps with emotional distress? Of course. Is that the answer regardless of the root cause? No. Does empahty and emotional connection help whatever is at the root? Yes.

For some very important and valid reasons the way in which my daughter sought the help she needed resulted in her receiving exactly what she required. And for some very important and valid reasons it has been easier for society to respond to physical pain; and the concept of ‘illness’ or ‘disorder’ when it comes to emotional pain. The problem with this is that it always locates the problem in the person; rather than allowing for the more complex reality that a number of factors, internal and external, interact and vary according to the individual and their unique circumstances.

I make this point because when it comes to mental health there are radical differences between the emerging facts; historical and societal narratives; personal experience and personal meaning. All of these have a part to play in how we understand distress; how we respond to distress; and how we ask for help with distress. There is a great deal of untangling to do in sorting out what is the most helpful way forward and, of course, like all things human, it may vary radically between one person and another, and one set of circumstances and another.

There is room for all narratives, all explanations, and all experiences. The important goal is to aim for fair and equal access to the evidence in it’s broadest sense; freedom to choose; and respectful and open discourse. The challenge is bringing everyone along with the potential for learning that all perspectives provide. After all we have a very long way to go in our understanding of what it is to be human.

Eagles and swallows; and swallows that make themselves look like Eagles to survive

I am passionate about the empowerment of those closest to children and young people; systems wide solutions; and metaphors and analogies. I was delighted, therefore, when I attended a recent Care Aims training facilitated by Kate Malcomess (@KateMalcomess) to discover that she is equally passionate about these things too. The systems wide perspective that the Care Aims framework promotes is not focused on children’s mental health, but on children’s services more generally. However, there is much relevance and crossover in her ideas.

In brief, Kate identifies the implicit problems in ‘specialist’ and ‘remote’ services retaining the expertise about the children they work with. More importantly she points out the pitfalls of professionals within these services holding onto children unless they are actively intervening to reduce risk. Specifically, she highlights how high caseloads and intermittent ‘checking in’ on children can serve to increase risk rather than reduce it. Of course, this is precisely the opposite of the intention of the professionals involved, many of whom find it hard to ‘let go’ as there is often so little out there to ‘refer’ the child back to. She points out how this can lead to those closest to children, and therefore best placed to assess risk, becoming less inclined to be proactive because the ‘expert’ is involved. Everyone breathes a sigh of relief that the child is ‘under the care’ of specialist services; and little distinction is made between active intervention and monitoring, which is all that is possible when caseloads are so high.

When it comes to children’s mental health I would go a step further and say that those adults with the closest relationship to the child are best placed to provide the intervention in the first place; and that specialist work directed through this relationship is often the most effective and sustainable. However, it has to be acknowledged that in an era where front line staff in children’s services have been cut to the bone, this model is even harder to implement, particularly for our more vulnerable children and families. The irony, of course, is that more pressure is put on specialist services to ‘sort the problems’ that this depletion has contributed to. Furthermore, frontline staff are so stretched that they understandably reject pressure to provide anything other than their core business – whether that be health, education or social care. This carving up of tasks and responsibilies, alongside a lack of acknowledgement that proximity and relationships are the most powerful ingredients for change in a child’s life, arguably lie at the heart of many of the difficulties we are facing in children’s services.

A helpful analogy that Kate describes is referred to as ‘Eagles and Swallows’. She doesn’t claim to have thought of it herself, but rather attributes it to a ‘wise professor of medicine’ early in her training. She can’t recall his name but my guess is he will be delighted to be referred to in this way; and even more delighted that it has gone on to inspire service developments nationwide. Hopefully that is acknowledgment enough.

The ‘Eagles’ are the worries about a child’s presentation that will cause harm if they are not intervened with. The ‘Eagles’ cause damage if not addressed, and understandably make everybody anxious. The ‘Swallows’ are the concerns that are part of the normal spectrum of childhood and will cause no harm or ameliorate with time. When the specialists are in remote services ‘Eagles’ and ‘Swallows’ look the same from a distance. You have to be close to tell the difference. Normal life goes on hold as everyone waits to see what the experts have to say. Lots of potentially unnecessary action is taken during the waiting period, and the ones who are actually ‘Swallows’ get treated differently just in case.

Kate argues that it would be much better to have some expert advice on hand in the fields – to help people to learn how to look up and spot the differences themselves. It would be so much more freeing to not feel anxious unless it is absolutely necessary. The time waiting for the expert to declare if it is an ‘Eagle’ or ‘Swallow’ could be put to better use; and everyone would be more at ease. I would argue that this is the same for children’s mental health where there is lots of concern over very understandable and developmentally appropriate expressions of distress that can, and should, be managed closer to home. More experts in the field helping others to spot the ‘Eagles’ and ‘Swallows’ would help enormously; and everyone would grow in confidence that actually the ‘Eagles’ are very rare indeed.

However, there is an additional complication in mental health in that many children, particularly those from adverse environments and who have experienced trauma, make themselves look that ‘Eagles’ in order to survive, so much so even the specialists find it hard to tell them apart. For example, a child who experiences neglect, domestic violence or abuse can present in exactly the same way as a child with neuro-developmental difficulties who was born that way and would struggle regardless of their environment.

Furthermore, when these adverse experiences are significant and prolonged they impact on the way a child’s brain functions – making them even more convincingly ‘Eagle’ like in their presentation. It is little wonder therefore, that children’s mental health is so complex, and even controversial. How can you say its a ‘Swallow’ when it looks exactly like an ‘Eagle’ even close up?  Especially when there is so much judgement surrounding the ‘Swallows’ that look like ‘Eagles’, the implication being something could have been done to prevent this.

Fortunately, we are not dealing with ‘Eagles’ or ‘Swallows’ or even ‘Eagle like Swallows’; we are dealing with children. Even more fortunately, fundamentally what they all need more than anything else are warm, caring and supportive relationships with adults who tune into their unique and individual needs; accept them for who they are; and focus on their strengths. This is the key to working out what lies at the root of their concerning and risky behaviours, and, more importantly, it is the most powerful vehicle for change. If we focus on getting these things right, the ones who need specialist help will be more obvious for everyone to spot. Even so, we still need to adapt the landscape so they feel they have as much right to be there as anyone else.

 

 

What I learnt behind this gate………

Two and a half years in Toronto and the clock was ticking….we had to make the very most of every opportunity available to us. We had done whatever we could to explore as much as possible. We didn’t buy any ‘stuff’,  and instead spent every penny on events and travel. “You have seen more of our country than we have, and we’ve lived here all our lives” was a common conversation amongst our new Canadian friends. It was true, we had not come up for air, and would have visited nine out of the 10 Provinces in the world’s second largest country by the time our adventure was up; as well as a couple of trips to the States. March break, the last school holiday before we flew home to the UK via the East Coast, was a final chance to do something different while we were this side of the Pond.

Traditionally, Torontonians head to the sun in March break as the city is still in the grip of serious Winter weather. Cuba, Mexico, Jamaica, Costa Rica were all on the list of popular destinations, and very appealing when a wind chill factor of –25 dictates your itinerary if you stay at home. However, money was tight and as I was searching Panama kept coming up as a cheaper alternative. The Zika virus had reached neighbouring Colombia and so the price of flights had plummeted, with no specifically identified risk. I searched around for accommodation and found what sounded like paradise. A cabana in the rainforest, on a private surf beach, with freshly caught fish and home grown vegetables prepared for you each evening. It was on the Pacific Coast, a six hour drive from the airport – another reason it was so cheap, but that only added to the adventure. The kids were 12 and 14 now – we were up for this.

After an exciting first night in Panama City, named the Miami of Central America, we headed South. En-route we stopped  off to take in the Panama Canal, an awesome feat of engineering, timing it just right to watch an enormous container ship patiently work her way through. We waved at the sailors who stood on deck waving back, happy to see new and friendly faces. I thought of my own father as a young man in the merchant navy, who would have been in exactly their shoes many years before, and I waved harder. After waving them off, we went on our way, sat nav behaving itself despite the increasingly remote landscape. “What are the arrival instructions?” my husband asked, having left all the planning to me, a ‘stay at home mom’ for the duration of our stay in Toronto. I had failed to become the domestic goddess of my fantasies, but travel arrangements I had nailed. He flashed me a look as I read out the e-mail “Wait at a rusty gate for a black car to arrive. Bring only cash. American Dollars”.

Just before arriving we had lost the satellite and telephone signal, and so we drove up and down the rough road for a while. Panama has no shortage of rusty gates. Eventually we saw a beaten up black Land Rover heading up a dust track. Beatrix, who I had been in regular e-mail exchanges with, bounced out of the driver seat beaming at us.”Welcome to Panama” she yelled, and we all breathed a sigh of relief. Twenty minutes and five more rusty, padlocked gates later, and we arrived at our destination. “Why is security so tight?” I asked when we got out of the car. Beatriz looked puzzled. “Oh the gates aren’t for security” she smiled “it is just how the farmers have divided up the land”. “Phew” I thought. Two men were filleting and hosing an enormous fish on a marble slate at the entrance to a lush green garden, bursting with vibrant flowers the colour of jewels. It could not have been more simple or more beautiful. We were shown to our Cabana –  a large, cool, white airy space with dark wood furniture and a balcony over looking rain forest – a hammock swinging gently in the soft breeze.  “The fishermen are just cleaning their catch for our evening meal” she said. See you for dinner in about an hour?” Wow.

After unpacking and exploring the garden a little we headed down to the main building – a wooden house with a large veranda set with two tables. Darkness was beginning to fall but you could hear the waves crashing onto the beach just below. The second Cabana was not taken that week and so we were to be the only guests. Dinner was simple, and simply delicious – the fish as fresh as it could possibly be. We met Pedro, the owner and he told us the story of how he had moved to the area from the Basque region as a young man, drawn by the best surf beaches in the world. He would spend his days surfing and his nights in a hammock strung between two trees. He picked up building work here and there and eventually saved enough to buy the plot of land. Over a number of years he had built the house and then the Cabanas. He had married and had a son, now 8 who was back in Europe with his grandmother for Easter.  On our way back to the Cabana we met Matilda, the spider monkey (we were advised to keep our distance as she seemed friendlier that she actually was) and Luna, the black cat with a white crescent moon, who was friendlier than she actually seemed, and spent the night on my daughter’s bed.

In the morning we woke to the sounds of the rain forest and headed down for a breakfast of fresh bread, eggs and fruit and plenty of coffee. Pedro had gone fishing for the day but Mai, his wife, took care of us and Beatrix said she would give the children a surf lesson later in the afternoon. The view from the veranda was stunning – a huge expanse of beach all to ourselves. We decided to head down there straight after breakfast, and spend the morning exploring. We borrowed a couple of body boards from under the house and walked down the steps straight onto the sand. The children decided they wanted to go into the water, and my husband followed after them. I found a place to lay our towels and settled to take it all in. I couldn’t use my usual excuse, that I was minding the bags, for not going in the water as there was not a soul in sight. Perhaps I would just have a paddle. I walked to the waters edge feeling just about as happy as I had ever felt.

Like a dimmer switch I remember delight fading first into annoyance, then into frustration, then into worry and then into total panic. They were too far out – did they even know how far out they were? I started to shout and wave but I couldn’t hear what they were saying – and they were disappearing further out to sea. I ran into the shallows, now screaming at the top of my voice “come back you are too far out”. My son, who didn’t have a body board, was a little closer than his sister and father, who seemed to have been swept further away. I ran as close as I could towards him without going out of my depth. Seeing how close I was seemed to help him make progress against the waves and he swam towards me. He disappeared under the surf a couple of times but then he managed to stand and we ran to the shore together. I looked back and I couldn’t see my husband and daughter – they had disappeared altogeher beyond the swell of the waves.

“Stay here” I shouted to him “I’m going to run for help”. “Are they going to die?” he asked. “We are going to do everything in our power to make sure that doesn’t happen, but please don’t go back in the water. They need you on the shore”. I ran as fast as I could back up the beach and to the house. My mind was racing “who can help? We are in the middle of nowhere. How can they possibly survive they are so far out to sea? What was I thinking booking a holiday so far away from civilisation? This is my fault. The black cloud that had shrouded me for a couple of days when I first gave birth was back. It had been right all along. “I was not fit to be a mother and I did not deserve this beautiful child”. Wow, I thought I had kicked that into touch a long time ago.

I also remember thinking “So this is what it’s like, the final moments before the news headline that shocks the nation until they move onto the next page ‘Father and daughter drown on beach holiday in Panama’”. All the while I could hear screaming until I realised it was me. “Please help – they’ve been swept out to sea – please help me.” The house was empty and I was screaming in vain.

In the distance I saw Beatrix – running from our Cabana where she had been cleaning. We ran down to the beach together – taking a short cut I didn’t know about. Mai and the cook were already on the beach having heard my screams and ran down the other way. As the shore came into view I could see my son pulling his sister over some rocks. She was bleeding but standing. My husband was close behind. He collapsed onto the sand utterly exhausted. I ran over to them and burst into tears. It seemed implausible that they had managed to swim back. When my husband caught his breath he told me what had happened. They had gone from a fun splash in the water to suddenly feeling like they were out at sea – the shore looked so far away and I was just a dot on the beach. He had tried to swim, pushing my daughter and her board, but he was making no progress and tiring fast. Each wave would sweep over them, and they would lose the boards, which thankfully were attached to their legs. He knew for certain that they would not make it, and he was willing me to run for help. He also knew that there was probably no help to be found.

He then told me that our daughter, who was just 12, had remained incredibly calm and had tried her hardest to swim back to shore, but could see it was not working. At one point she said “dad let’s swap boards so you are pulling me instead of pushing me – like a tug”. He had said no, insisting that she kept her own board as it was their only hope in the now ferocious and deep water. The risk of not being able to see her must have been terrifying “but dad it will always be attached to me anyway”. He tried, and sure enough he could feel them making progress. Each wave meant starting again, but even so he could feel they were getting closer. Eventually, as a wave washed over them again, his toe hit sand and he was able to give a final push to the shore. Our twelve year old’s cool head and problem solving skills had saved the day. She had saved their lives.

Carrying on with our holiday after that felt very bizarre. We lunged from the trivial, like what to eat for lunch, to the profound, how lucky we were to be alive.  In some ways, the heightened anxiety made the holiday even more vibrant than it already was, and our appreciation for each and every precious moment was acute. A trip to a Coiba Island, and seeing a sloth were magical experiences we will never forget. In other ways we just wanted to get home and get on with life as though the trip had never happened. I felt so guilty for dragging my children so far away for no other reason than a holiday. I felt furious with myself and my quest for adventure and exciting experiences.

I also felt shocked by a core belief, laid bare in my darkest hour. I did not deserve to be a mother and should never have been entrusted with them in the first place. I would frequently disappear into a parallel universe where all three of them had drowned and I was all alone – having got exactly what it seemed I thought I deserved. I guess it was a way of punishing myself when there was no punishment after all. There had been no price to pay for that overwhelming rush of sheer terror – which was hard to make sense of.

We were anxious about the sea, of course, and only ventured back in with Beatrix. She explained about the safest areas and times to swim – things we should have checked before rushing down straight from breakfast. The children had surf lessons and managed to stand – but it felt more like a job they had to do than the fun it was meant to be. They have since had good times in the water but we are very much more cautious, and delighted to be on busy beaches with life guards, and boats near by. We save our empty beaches for winter walks with the dog.

On the plane on the way home, both my husband and I were incredibly emotional – the sheer relief having caught up with us. He passed me headphones telling me to listen to the lyrics of the next song along with a note which read “I keep imagining you lying in bed alone, listening to this while we are out at sea”. It was Kate Bush – The Man with the Child in his Eyes. I can’t listen to it without tears streaming down my face. Back at home, the flashbacks were frequent to begin with, and would catch me off guard. They have settled, and sometimes I even force myself into them so that I can feel the fear rising in my body. I am lucky that I am now in control of them, but I am not quite ready to let them go. They help remind me how incredibly fortunate I am.

The whole experience was a sharp reminder that risk and parenthood go hand in hand. You cannot have one without the other. Luckily both my children were able to save themselves – possibly even because of the many smaller riskes and challenges they have experienced along the way. Who knows what the right balance is – and how preparing your children for the unexpected sometimes means  putting them in danger’s way – and potentially risking everything.

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