by David Jones
“My mum and dad had been arguing for months and the atmosphere at home was horrible. I became very withdrawn and unhappy, and then my dad starting hitting my mum. I thought it was my fault and I felt so guilty. Self-harming eased these feelings somehow, but only for a few minutes.”
Worried by the change in Carla’s behaviour, the school nurse discussed the issue with the 15-year-old and her parents, and it was agreed that she should see her GP, who in turn referred her to the child and adolescent mental health service (Camhs).
A year later and Carla is feeling better about herself. “Things seem clearer now,” she explains. “I still want to self-harm at times when I feel sad, but I’ve managed to stop myself.”
For me personally as a residential children’s home worker, one of the most damaging things I see is the effect of self-harm. In my area, Derby, statistics show that the number of youngsters admitted to hospital for self-harming is 50% higher than the national average in recent years. The city also had the largest number of 10- to 24-year-olds hospitalised for self-harming in the East Midlands.
Carla’s experience of Camhs was positive, but this is not shared by many other young people – as well as professionals. For example, a lack of uniformity of practice across the UK means that some Camhs teams will deal with young people up to the age of 18, while others only work with those up to 16.
Indeed, as recently as August 2014, Liberal Democrat health minister Norman Lamb claimed that Camhs was not “fit for purpose” and was “stuck in the dark ages”.
One child says that, having missed one appointment with Camhs, they then refused to see him. “They told me I know the rules but I didn’t mean to mess them around. I just got the wrong day.”
Another says: “The man I spoke to was really unfriendly and used big words that I couldn’t understand.”
Social worker experiences are as disappointing, according to a child, family and school social worker based in the Midlands: “I couldn’t challenge their decision not to provide a better service because they are so self-governing. What ethics are at work when refusing to help a child with mental health issues? Also, Camhs weren’t always available for multi-agency working with the young person, which wasn’t helpful for a very confused child.”
The effect on youngsters can’t be underestimated. “The service is dire,” says a former Camhs counsellor. “Thresholds are too high, and if a [young person] has no recognised psychiatric disorder, Camhs aren’t interested. Good, multi-agency collaboration is a must.”
In recognition of Camhs failings, an NHS-funded pilot scheme announced at the end of last year is reviewing Camhs thresholds to test improvements to children’s mental health services. Involving eight local areas – Devon, Derbyshire, Newcastle, Norfolk, Southampton, South Sefton, Tameside and Glossop and Wolverhampton – which have shared £500,000 of funding, the projects are addressing a range of concerns such as the use of out-of-area placements for unwell young people.
In Derbyshire, a service based on a ‘team around the school’ approach will test a single point of access, with a set of referral and threshold criteria drafted for targeted and specialist services. In Norfolk, a pilot will focus on the learning disabilities pathway and test out how CAMHS and local authority outreach teams can jointly manage cases.
In Wolverhampton, the commissioning of inpatient beds and use of out-of-area placements will be analysed in a bid to prevent large numbers of children being sent miles from home for care. The project will also commission ‘urgent care’ services to boost community-based support for young people in crisis.
The Education Committee also launched an inquiry last month into the mental health and wellbeing of looked-after children, which aims to build on the report by the Health Committee on children and adolescents’ mental health services, published last November. It found that Camhs service providers had reported a “dramatic increase in demand for their services”, and NHS England reported an increase in bed occupancy rates and reported admissions to the highest need, Tier 4 units, from 2012-2013.
Witnessing the effect on a child who has self-harmed is one of the most distressing aspects of working in a children’s home.
Once when I went to check on 16-year-old Maddie, who was feeling low, and knocked on her bedroom door, I could hear her crying inconsolably. She asked me to come into her room and I was immediately struck by a maze of thin red lines criss-crossing the insides of both of her forearms. She hadn’t actually broken the skin, and while only superficial, the marks were still shocking to see. This girl didn’t have a history of self-harming and for the next hour she poured her heart out to me. She blamed herself for being in care and missed her younger sister who wanted her to come home.
She explained to me that hurting herself in this way had felt the natural thing to do, that it somehow made her feel in charge of her situation. She admitted that she’d wanted to self-harm on previous occasions and had done so now because “I’ve never felt this bad about myself before”.
I contacted Maddie’s social worker and with the agreement of Maddie and her parents, I took her to see her GP who referred her to Camhs. Maddie admitted that initially she found it too upsetting to really open up to someone who she didn’t know, but that in time she began to feel more at ease and learned to value being listened to and understood.
“It’s hard to explain, but I began to feel more in control of who I was and my feelings were less jumbled up,” she says. “I also felt less anxious and sad.” Maddie hasn’t self-harmed since.
The reasons young people self-harm are myriad, and can range from being bullied, problems at home and relationship breakdown, to low self-esteem, feeling depressed and even suicidal. Camhs will first assess a young person and then arrange a series of appointments with a counsellor. However, it doesn’t always necessarily follow that a young person will engage.
On one occasion when I accompanied 14-year-old Nick to an assessment by two Camhs workers, he became verbally abusive to them and physically threatening. The meeting was stopped and on the way back to the children’s home I asked Nick why he’d become so angry. “They gave me the creeps with all their questions, asking me things that were none of their business.”
A Camhs counsellor for 12 years, Dave explains that such an extreme reaction is relatively rare, but he does understand it. “Some [young people], even though it has been explained to them what we are about, will agree to an assessment but then find the experience too intrusive. They are very troubled youngsters after all, and opening up can prove a massive challenge.
“My job is to talk to the young person and try and look for the reasons why they feel the need to self-harm. Hopefully this will give them the strength and confidence to gradually assume some control over their emotions and situation. It’s about enabling a [young person] to recognise that they have the tools to achieve this.”
Camhs can and do work, of course. One child I recall told me that the counsellor really changed her way of feeling about herself and she gained so much in terms of self-esteem and self-confidence. But improvements in reducing thresholds would make a massive difference to children’s emotional wellbeing. A child shouldn’t be at risk of serious self-harm being before being accepted for counselling, and a missed appointment certainly shouldn’t signal the end of a child’s treatment.
The names of all the people interviewed have been changed.