Too close to the edge


    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    and was very low and withdrawn.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

    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”

    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

    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

    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

    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

    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


    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

    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

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