Hope follows trust

Children and young people with mental health needs who exhibit
challenging behaviour often become children lost to or failed by
the system. In Southampton the Behaviour Resource Service (BRS) was
set up to meet the needs of these young people, such as 14-year-old
Sadie Caine.

Sadie was identified as one of 50 children in the area with highly
complex needs, a high proportion of whom, unsurprisingly, were
looked-after children. She was referred to the service’s on-site
residential unit, managed by Jamie Schofield.

The four-bedded residential unit, staffed by mental health nurses
and social workers, provides one-to-one staffing 24 hours a day for
young people aged between 13 and 18 who are placed on a six-week
assessment.

Sadie’s unpredictable behaviour was compounded by her problems with
drugs and alcohol. She had problems sleeping and become anxious and
aggressive at bedtimes. Around bedtimes, her aggression resulted in
worrying periods of restraint. Although the unit’s mental health
nurses have access to medication, none had been administered in the
project’s three-year life. However, Schofield concedes, sedation
was considered for the first time. “It was a dilemma – some thought
it would be better to use injections than the possible harm from
restraining her. Others said that, as she was anxious enough, how
more anxious might she feel if she thought we were going to be
dosing her up?” Sedation was ruled out.

Sadie then disclosed for the first time a traumatic sexual assault
that she had suffered. For the team it was rewarding that Sadie
trusted them with this painful disclosure and it helped explain her
aggression in terms of post-traumatic stress.

However, despite this progress, Sadie was proving too difficult to
manage effectively in the residential unit. “We basically couldn’t
keep her safe but we still wanted to do the work – so we moved her
to a secure unit,” says Schofield. “It was difficult. She had built
up some good relationships and having disclosed to us we didn’t
want her to feel we were dumping her out somewhere. So the message
was: ‘You’re moving because of the safety aspect – but we don’t
want to give up on you’. And we continued our work with her.”

The team began exploring placement options “because we thought she
needed something much longer term owing to her post-traumatic
stress,” says Schofield. “Our big worry was the courts at this
time. But we managed to persuade them that a custodial sentence
would not be in her interest.” To this end, a psychiatric hospital
with secure and open sections was identified.

Schofield believes that the crux of the intervention with Sadie was
the personal engagement. “She’d never had anybody to engage with.
This is something we work very hard at. For Sadie, this was very
much about finding individuals whom she trusted. We built a lot
around the fact that she was a fantastic drawer and a really good
footballer, and concentrated on what she was good at.” But, in
essence, given her post-traumatic stress, it was “lots and lots of
listening, really”.

Sadie was given a weekly journal to complete. Each morning she and
staff would plan her day. “This would include some educational bits
because she was out of school. And we’d get her to fill in her
journal at the end of the day but well before her bedtime,
concentrating on what she had achieved. This helped because, if 9pm
was the time she would normally blow, at about 8pm we’d be filling
the journal in with all the positives about her day,” says
Schofield. Sadie remained in the hospital for about a year –
successfully graduating to the open unit. She returned to
Southampton last year, since when her behaviour was much better
managed and she remained crime-free.

However, Sadie has since committed another assault, having become
involved with an old acquaintance. Although seen as a one-off, it
was a serious enough offence to see her placed back into the
psychiatric unit.

Despite this setback, the team are rightly proud of their work with
Sadie. Without the support of the BRS it’s safe to surmise that
Sadie would have been imprisoned. Now, she has hope.

Case notes

Practitioner: Jamie Schofield, residential team manager,
Behaviour Resource Service (BRS). 

Field: Assessment of children and young people with complex
mental health needs and behavioural difficulties. 

Location: Southampton 

Client: Sadie Caine is a 14-year-old girl whose family has been
known to social services for some time. 

Case history: Sadie was involving herself in crime almost daily.
An   aggressive young person, she was often arrested for assaulting
police officers. Placed in a secure unit, she was referred to the
BRS community team for assessment. Sadie would regularly harm
herself and had twice taken an overdose. However, because of her
behaviour, the BRS community team referred her to the residential
unit, believing this to be a more appropriate setting. But at this
time Sadie’s criminality had meant that a court appearance was
imminent and a custodial sentence was very likely. 

Dilemma: Sadie’s behaviour is pushing her towards a custodial
sentence but time is needed to build up a relationship and trust –
time that might not be available. 

Risk factor: A custodial sentence could permanently damage any
attempt to rehabilitate Sadie, but her aggressive and destructive
behaviour puts her and others at serious risk of harm. 

Ooutcome: Sadie’s residential placement in a psychiatric
hospital was successful and she returned home to live a crime-free
life for a year, but has now been placed back into psychiatric
care.

Arguments for risk 

• Drawing on their experience and skills, the team managed to
  engage with Sadie and once this proved possible there was a good
  opportunity, if she could be kept out of prison, that positive
  therapeutic work could be successfully carried out – albeit at
  first under secure conditions. 
• That Sadie disclosed the sexual assault not only confirmed her
  engagement by the team and Sadie’s trust in them, but also made her
  aggression more understandable: she was suffering from
  post-traumatic stress. 
• The team knew that, if trigger points could be countered with
  positive work, Sadie’s aggression – which had landed her with the
  strong possibility of a custodial sentence – might be better
  managed. Her aggression increased at bedtimes as her attack had
  taken place late at night. 
• While recognising Sadie’s potential to return to the community
  and mainstream services, it was clear that this would take time –
  and a safe, longer-term placement was required.   

BOXTEXT: Arguments against risk 

• Even though engagement had taken place, Sadie was still
  exhibiting aggression to staff with whom she had formed
  attachments. This would suggest that it would always be a risk
  placing her anywhere other than a secure placement, as she clearly
  could not control her behaviour.  
• Sadie’s targeting of police officers, in particular, for
  assault, showed a lack of respect for authority and even suggested
  a desire to be arrested and imprisoned. Her self-harming and
  overdosing point to her inability to cope alone. Perhaps she
  subconsciously knew she was unsafe in the community and desired a
  secure place where she could be “made” to be safe. 
• Despite having been crime-free for a year upon her return to
  Southampton she has fallen in with one of her old acquaintances and
  has committed another serious assault. There may be valid claims
  that she acted against her own better judgement and that it was a
  one-off, but that must be little comfort to the victim.

Independent comment 

 Adolescents who have complex needs, especially those with
post-traumatic stress disorder arising out of earlier abuse, pose
the single most anxiety-provoking challenge to services, writes Dr
Susan Bailey. 

Such young people are highly likely to fall into any gaps in
service provision, presenting to services as disruptive, with
self-harming tendencies and dangerous behaviour. 

Initiatives such as the Behaviour Resource Service provide a
bridge with safety rails to take the young person from chaos to
safe autonomous thinking and choices in adult life. To work, these
initiatives require structural agreement by senior officers in
health, social care, education and justice that accepts life cannot
be risk-free. And it is vital that the officers will not allow
themselves to be driven by a blame and shame culture. 

Rejecting easy options, such as medication to control, takes
great honesty, courage and a supportive team. Listening therapy is
the most difficult to do, but is most likely to be needed and
wanted by the young person. 

Whatever further criminal behaviour occurred or may occur, for a
critical part of this young woman’s life, her needs were understood
and met. The hope is this acted as a true turning point for her,
increasing her internal resilience, whatever the future holds. The
real test of innovative services will be if this turning point
helps young people in the safe parenting of their own
children. 

Dr Susan Bailey is a child and adolescent forensic
psychiatrist.