Child and Adolescent Mental Health Services (CAMHS) in the United Kingdom have undergone significant changes during the last ten years or so. Since the publication of Every Child Matters (a 2003 government white paper often described as one of the most important policy initiatives and development programmes related to children and childrenâs services in recent times, and leading to the adoption of the Children Act 20041 and The National Service Framework2 for Children, Young People and Maternity Services in 2004), emphasis has been placed on CAMHS aiming to decrease social exclusion, take account of user perspectives and encourage all services working with children to work together. These expectations have led to CAMHS professionals increasingly working outside the clinic or the hospital, in schools, general practices, nurseries and childrenâs centres, than was the case in the past. Fitting in with this commitment to attend to the needs of all children, young people and their families comprehensively, there has been a growing realisation that the health of children and young people, to a large extent, depends on the ease of access to services and the possibility of delivering interventions early. This has further underscored the need for CAMHS professionals to work in ways which bring them closer to the populations and the communities who may need their services.
Coming closer to communities necessitates not just a closeness in terms of location and physical proximity, but closeness in terms of the ways of understanding well-being and the interventions that may support it. However, these changes and aims, admirable though they are, have had far-reaching implications not only for service delivery but also for the organisation of services, for funding, models of treatment and theoretical developments. For example, going outside clinics and hospitals have enabled professionals to meet sections of the population who may not consider themselves to be âclientsâ or âpatientsâ. Mental health professional work may also be less defined if this involves brief contact and advice during a visit to a childrenâs centre or school. How should this work be categorised and costs calculated? Who should pay? Indeed as a recent report notes, the commissioning of CAMHS and early intervention services is often precarious, and suffers from reduced, insecure and short-term funding (House of Commons Health Committee, 2014). The same report offers the following summary of the state of CAMHS in the UK in 2014: âThere are serious and deeply ingrained problems with the commissioning and provision of childrenâs and adolescentsâ mental health services. These run through the whole system from prevention and early intervention through to inpatient services for the most vulnerable young peopleâ (House of Commons, 2014, p. 3).
The daily experience of clinicians of this state of affairs, as well as local organisational changes in our service (an inner-city, urban CAMH service) led to the beginning of the writing of this book in 2012. Professionals in the service were working hard to cope with the growing need to deliver services in the community, that is to say working outside the clinic without other mental health colleagues in close proximity, and with the reduction in funding at a time when success in increasing access had resulted in an increase in numbers of referrals. These two somewhat contradictory processes prompted a change in the organisation of our work, the way we approached our clients and the way we thought about and applied our theoretical models. While all staff in the service have been faced with the changes outlined above, not everyone wanted to write about their experiences. However a sizeable and representative group of professionals felt that they had something new to contribute to the development of contemporary CAMHS work, and two of us, Taiwo Afuape and Britt Krause, took on the task of planning and editing a book based on these experiences.
Taiwo and Britt are both systemic psychotherapists in the CAMHS team. However they work in different subdivisions of the team, and they are different in other ways too. As a Black African woman of working-class and Nigerian heritage, Taiwo was interested in racism and mental health, and after reading Aliens and Alienists: Ethnic Minorities and Psychiatry by Ronald Littlewood and Maurice Lipsedge (1989) in 1992 contacted Dr Lipsedge to arrange to interview him about his book. During this interview Dr Lipsedge commented on Taiwoâs passion for well-being and challenging questions about racism and psychiatry and suggested that she would make a good clinical psychologist. Taiwo worked on the ward Dr Lipsedge was the consultant psychiatrist on, as an auxiliary nurse in the year before earning a bachelor degree in psychology and during university terms throughout her degree course. In changing her course of action and deciding to pursue clinical psychology rather than social and community activism, Taiwo was adamant that she wanted to train to be a critical (rather than mainstream) psychologist and trained at the University of East London because of the emphasis on critical and political approaches to mental health and psychology there. Two years after qualifying as a clinical psychologist in 2002, Taiwo trained as a systemic therapist, again choosing to train in a training school that emphasised critical and social constructionist approaches to systemic intervention.
Britt, on the other hand, trained originally as a social anthropologist and carried out ethnographic fieldwork with a Hindu population living in North Western Nepal (Krause, 2002) as well as with the Punjabi Sikh population in Bedford, UK (Krause, 1989; Krause et al, 1990). She trained as a systemic psychotherapist twenty-five years ago and has worked in the National Health Service (NHS) ever since amongst other things setting up specialist cross-cultural psychotherapy services. She is a White middle-aged woman with grown children. She grew up in Denmark but has lived all her professional life in the UK. Her experiences as a social anthropologist, speaking different languages and participating in different and to her foreign ways of being and doing has sensitised her to how different and to her often unimaginable, experiences, expectations and hopes can be for persons and groups of persons in different locations. Britt is aware that these circumstances can sometimes lead to clients and client populations from marginalised minority backgrounds experiencing mental health services as discriminating, excluding and even useless.
The Child and Adolescent Mental Health Service
The CAMH service in which the contributors to this book work is a community service. This means that as far as possible mental health services are offered in settings outside of the hospital or clinic, in a domiciliary setting, in the homes of clients, in schools, nurseries or in the surgeries of general practitioners. This alternative to in-patient care was part of the UK governmentâs strategy to increase accessibility to Child and Adolescent Mental Health Services generally and was first set out in the 2000 white paper Reforming the Mental Health Act. The term âoutreachâ was used in this paper to highlight issues about access, and the paper also emphasised the aims of the reforms to be compatible with the Humans Rights Act, to decrease social exclusion and to place user perspectives at the heart of mental health service delivery. As noted above, the subsequent developments in Child and Adolescent Mental Health Services further emphasised these principles and with the subsequent formation of Childrenâs Trusts3, emphasised local partnerships which brought together organisations responsible for services for children, young people and familiesâsuch as general practitioners, schools, nurseries, health visitors, midwives, social workers, the police and so onâin a shared commitment to improving childrenâs lives. While many of these structures were abolished in the 2012 NHS reforms4 the principles of working in the community and joining in partnership with other professionals and with community organisations continue to inform our CAMHS work.
In keeping with the 2012 NHS reforms our CAMH service is jointly commissioned by a Clinical Commissioning Group chaired by a local general practitioner. This group jointly with the Local Authority and Social Care (formerly Social Services) commissions all the mental health work with children and adolescents in the borough including Mosaic (integrated service for disabled children), MALT (Multi-Agency Liaison Teamsâsupporting families known to Social Care), Youth Offending Teams, Infants and Early Years Services and Pupil Referral Units, as well as two community CAMH services for children and adolescents, divided into North and South. The budget for all these services is shared, and regular meetings between the service managers take place, in which both macro and micro clinical decisions are taken or approved. These services together operate a single point of entry (Joint Intake), which is a meeting in which referrals from health and social care professionals are considered and distributed according to clinical need, where clients live, where the identified young person goes to school or where the familyâs general practitioner is located. At the time of writing, the CAMH service (both South and North) overall was managed by a male consultant child and adolescent psychiatrist. The two sub-teams were managed by two team managers, both women, one a senior social worker/psychotherapist and the other a consultant child and adolescent psychotherapist, who attended the Joint Intake meetings. Approximately half of the referrals came through Joint Intake; the other half of referrals arrived directly from what was referred to as âoutreachâ, namely from CAMHS work in schools and general practices.
The CAMHS staff are members of a larger training institution/clinic, which is also a national resource for the training of adult and child psychotherapists and other mental health clinicians. The North/South structure of the CAMHS team was created in 2008 out of other clinical teams working in the clinic in accordance with the aforementioned mental health reforms. At the time of writing each sub-team had the equivalent of nine full-time clinicians. These clinicians were also clinical trainers, and trainees from different professions made up another twenty members on each team. Few were full-timers as trainees have other aspects of their studies to see to, and trainers tend to be involved directly in academic training activities. Given that few members of staff worked for the service full-time, and the two teams are large, at times up to forty persons took part in a full clinical meeting. The multidisciplinary teams included administrators, assistant psychologists, child and adolescent psychiatrists, child and adolescent psychotherapists, systemic psychotherapists/family therapists, clinical psychologists, mental health nurses, social workers and educational psychologists. Many clinicians on the team were and still are dual trained in their core profession and a particular psychotherapy modality.
The North and South divisions were further divided into weekly clinical discussion groups, in which cases were discussed with colleagues of different modalities. The CAMH service (both North and South) as a whole carried approximately 1,170 cases of which 670 were new referrals during the 2014 to 2015 financial year (that is between April 2014 and April 2015), including those arising from work in the community. A significant number of these cases were judged by staff to be medium or severe risk. The teams had no waiting lists, but this was because of the high commitment and regular overtime working of staff rather than a surplus of resources. Demand was ever increasing.
Diversity and responsiveness
A book about an urban CAMHS is a book about diversity. The populations of cities all over the UK are heterogenous and multicultural. Therefore providing access to services for people and populations who speak different languages, who may think about their relationships, their bodies, hearts and minds in ways which do not fit with dominant mental health professional frameworks, who may expect different treatments from those on offer or who may feel estranged from the professionals who work in the services, requires a responsive approach. In such a service professionals themselves gain new experiences; they may become in touch with a range of their clientsâ ordinary issues that are perhaps not directly related to health, such as financial pressures, political pressures, housing pressures, religious persecution, discrimination and so on, from which they might have been protected in the past. Responsiveness may not simply be a question of how to apply professional and theoretical models, it may also be a question of how to develop new models and new theories, albeit against the background of those already in use. This is what the contributors to this book aim to do. We may think of community CAMHS as being at the forefront of contemporary changes. And yet, because assessments of community CAMHS have been based on quantitative, centralised measures, they have not always been able to reflect more subtle changes and outcomes, and as a result CAMH services have been criticised and found wanting. We believe that CAMHS work is demanding and complex but also positive and hopeful, and this book is an attempt to show this.
But what do we mean by community and community CAMHS, and is it possible to be based in the community but not truly responsive to it? Responsiveness and flexibility necessarily imply that while a community-based approach can be advocated and prescribed generally, it is difficult to be directive about detail and each professional group and practitioner will need to reflect for themselves about what community means and find their own style of being responsive to it. This is clearly demonstrated in the chapters which follow. The professionals in our service communicate and collaborate with each other, but they do not all do the same job, nor do they approach the work in the same way. This is partly because of their particular professional orientations, but also because of personal values, preferences and experiences. For example, while all professionals in the CAMH service work with relationships and therefore keep families and carers in mind, we differ in terms of how much we involve families in the actual work carried out. We also differ in terms of how much we emphasise external circumstances and contexts or internalised processes, which may echo past relationships. We differ in how comfortable we are in disclosing details about ourselves. We also differ in the terms we use to refer to those who seek our help; some of us prefer the term âclientâ, whereas others prefer the term âpatientâ. While this choice of how to refer to the persons and people to whom we offer our services sometimes is understood to be a hallmark of the difference between âcollaborativeâ and more âhierarchicalâ approaches, the background to these terms is complex. For example, one might argue that âpatientâ medicalises the person coming to services for support and focuses our attention on internal pathology, whereas âclientâ gives the service user agency and encourages the service providerâs humility. On the other hand, âclientâ also fits in with the commodification of services and implies a business-like transaction between service user and provider, whereas âpatientâ has more reflective overtones. Finally, while all chapters address diversity in the giving of examples of how the authors work, the CAMHS professionals who are the contributors to this book vary in terms of the way in which they consider culture, class and âraceâ differences to be issues which radically challenge our practice. What we hope to do is demonstrate the possibilities which may emerge, despite significant differences in perspectives, experience and theoretical orientation, when CAMHS clinicians prioritise âcommunityâ and âresponsivenessâ in their work with service users and with each other. We hope that the distinctiveness of each chapterâs âvoiceâ is regarded by the reader as testimony to the ways in which CAMH services can honour and embrace the opportunities and challenges of diversity both within its service and within and between communities.
The chapters
The rationale for this book is to weave together different strands of mental health work undertaken in one inner-city CAMH service. This certainly requires taking a critical look at services, but it also requires spelling out what we mean by communities as well as the interface between âservicesâ and âcommunitiesâ. In addition it requires demonstrating what responsiveness may look like in different contexts. The book addresses these issues and is divided into four parts.
Part One sets the scene in terms of the challenges of CAMHS professionals moving their work from the âclinicâ to the âcommunityâ. In Chapter Two Inga-Britt Krause discusses the meanings and complexity behind the term âcommunityâ and argues that in the health service, the term âcommunityâ is often pitched against âthe clinicâ or âthe hospitalâ and in this way possibly counteracts the aim of increasing accessibility and preventative work. Britt describes the CAMH team in more detail and discusses the special case of the urban context. She concludes with a discussion of her work with a family and warns against using âcommunityâ as a homogeneous ...
