CASE STUDY

The name of the service user has been changed

SITUATION: Liam Barry is 17 years old and has a history of challenging and aggressive behaviour that has seen him excluded from school for prolonged periods. His inability to control his anger has often got him into trouble - not least with his own family. His local child and adolescent mental health team is not prepared to work with him because of his aggression.

PROBLEM: Liam moved out of his parents' home about nine months ago because they couldn't cope with him. He had started to use drugs and was getting into scrapes with police. He moved in with an uncle - an ex-boxer - who felt he could cope and deal with Liam's aggressive spells. Recently Liam turned up at the accident and emergency unit at his local hospital following a bout of self-harm - he had been cutting the top half of his arms and legs with a Stanley knife. He said he had begun self-harming about six months or so ago. He expressed feelings of depression and suicide to the nursing staff. He was far from aggressive or abusive and was very low and withdrawn. He also said that he had a bust-up with his uncle who had caught him sniffing glue with some other youths down an alley behind the house and was now without accommodation.

Panel Responses

David Glover-Wright

Conventional mental health services fail young people like Liam. They are unable to work with them given the lack of "access points" and their inability to recognise the signs he presents with which fall outside strict clinical confines. Mental health services are medicalised to the point where social care models appear subjective and irrelevant.

Mental health services should be creative and flexible in their approach, especially where young people are concerned. Often, the local child and adolescent mental health services (Camhs) team is overstretched and under-resourced. Liam's problem doesn't even pass their initial screening process given his "challenging" behaviour.

There are many young people like Liam turning up at accident and emergency wards with self-harming type behaviour. A&E provides a medicalised route into a medicalised service. The duty psychiatric nurse or doctor will use tried and trusted assessment tools to screen for evidence of mental disorder. Hopefully, the assessment will pick up on Liam's unstable mental health, and connections will be made with his prevailing social circumstances. Liam might be referred to the local crisis intervention service.

Follow-up support will depend on the particular model of practice followed by the crisis team and whether there is access to suitable accommodation options. A joined-up multi-agency response is vital in this sort of situation. Robust links between children's and adult services help to bridge the gap. Establishing a new team such as an early intervention service for young people is not always the answer. Proactive services should transcend traditional operational boundaries.

Liam is hurting and needs tangible help and support. Ideally, a local sheltered housing project for young people might offer him some accommodation and, together with a keyworker, help him settle and develop independent living skills giving him a real chance of making positive changes in his life.

Hopefully, a specialist voluntary or charitable project is on hand to engage with Liam and provide him with the continuity of care and mentoring which statutory services often struggle to provide.

Kate Vaughan

Liam is a vulnerable young man in need of structure and regular contact during his week. He has immediate needs which require input from the mental health services and I would seek to work in tandem with them. I would suggest a referral to a local training agency to explore some employment opportunities. Liam is clearly lacking in self-confidence and forward direction in his life. He has turned his hurt and anger inwards and is in need of support to provide him with a way through.

He could visit our multi-agency drop-in service where he would be able to access advice, information and support from colleagues from other services. They could help him address different aspects: for example, his accommodation need, employment and training, counselling, and substance misuse. Services must pull together to co-ordinate effectively a response to young people like Liam. 

I doubt whether Liam would use the above services if he was merely signposted by an agency like the local A&E department. He needs assertive outreach to reach where he is in his life. There would need to be effective links in place with the A&E department offering a viable alternative to conventional mental health services with direct links to support services in the community.

Liam needs information and advice concerning his substance misuse and the risks he is exposed to. His solvent abuse is a high-risk activity which mirrors his out-of-control circumstances; there are no end points to this habit. Other substance users perceive glue sniffers as unsophisticated and beyond their boundaries.

Liam will be acutely aware of his marginalised status and his self-harming is an outward sign of his problems.

It feels as if Liam is balanced at a point where he can be reached and pulled back from the brink. Without assistance, his social circumstances are highly fragile and he is vulnerable to drift in to a pattern of further aggressive behaviour. There seem to be no positive role models for him to draw upon: his parents have abandoned him and this will further serve to reinforce his low self-esteem. A mediating service looking at resolving ongoing conflicts with parents could be asked to work with Liam. Success will depend on his level of motivation and engagement with support services.

USER VIEW

I find myself wondering why Liam is so angry and aggressive and whether any real attempts have been made to find out. It would be easy to write him off as a "bad lad" but his recent self-harming and suicidal feelings suggest there could be some emotional issues behind at least some of his anti-social behaviour, and everyone would surely benefit from exploring the nature and impetus for these, writes Kay Sheldon.

I don't think the mental health services should ever give up on anyone. While staff should not have to put up with violence and aggression, and it may have been right at the time to disengage with Liam, I do think the services should now approach him again. Clear boundaries and guidelines should be set, while at the same time making it clear that the team is there for him and is willing to help him despite his past behaviour.

It is essential that the approach to Liam focuses on more than just illness or behaviour. It may be worth working in partnership with a voluntary agency that specialises in working with young people who are struggling to cope for whatever reason. Indeed, it may be more appropriate or acceptable to Liam for such an agency to be his main source of input and support. Contact with mental health services is not always beneficial and can even be counter-productive - especially in the long-term.

Effort should be invested into building up a secure and supportive relationship with Liam, possibly finding a role model. Time should be spent with him finding out what he's interested in, what his hopes for the future are, as well as what he thinks about his difficulties and what might help. In the first instance, he obviously needs help finding somewhere suitable to live. It would also be worth trying to involve his family although it may not be the right time for this.

A range of options come to mind that Liam might find helpful: counselling or some other form of psychological therapy; providing detailed information about a range of drugs and other substances and their effects - through either printed information or attendance at a drugs awareness training course; anger management; art or music therapy; and sport or exercise - depending, of course, on where Liam's interests lay and what is likely to engage him most effectively.

Liam needs to feel in control of what's happening to him and encouraged to take responsibility for his feelings and behaviour. He needs help and support to build up his self-esteem.

Kay Sheldon is a mental health service user.