Thoughts and reflections on working in CAMHS

So I noticed I haven’t posted in over a month. Most of the reason for my latest episode of blog-neglect has been completing my work placement in a CAMHS (Child and Adolescent Mental Health Service) team, as well as a bunch of deadlines. Now the placement is over and I’m trying to arrange my thoughts before I move on to try working in a new area.

• Children aren’t terrifying. Nor are adolescents. Ok, the adolescents can sometimes be a little scary. They’re different from adults. But they’re not that different. (Deep, huh?)
• Children can be hard work. But more often, the parents are harder work. Often there’s at least one adult in the family who you really think could do with their own support and therapy. But you’re treating the kid, so you work with what you’ve got and try and feed little titbits to their parents, hoping they’ll take the initiative to get help themselves.
• You can’t just have a chat with a young child about their thoughts and feelings. Sometimes working with them involves playing games or drawing pictures for an hour. Great fun.
• Sometimes teenagers tell you what’s on their mind straight out, and it’s not very nice. But it can be refreshing, it’s not stuck under layers of social acceptability and adult repression.
• Teenagers can be completely pre-occupied with seemingly minor details of social interactions, who spoke to whom, text messages sent, who passed out and got a cock drawn on their face. This is normal. A whole hour of it can be a little tedious though.
• Children need their parents to be consistent and put boundaries in place. That’s pretty hard to do in practice, especially if you have two parents with very different approaches, or are rushed on time and stressed. Sometimes when the children come in to the clinic, it’s the only time when that stability is maintained.
• Professionals seem to have a lot of hope in child services. Maybe because we can’t see people spending decades in and out of treatment. There seems to be less focus on psychiatric labels and a lot of positivity and thinking about growth and recovery.
• Being a parent is a hard job, there are so many different demands. I don’t have children and I’m impressed by the parents I see, even the ones that make mistakes. Although I know parents can’t get it right all the time and only need to be ‘good enough‘, I’m still scared of having children!
• It’s hard to be a parent when you didn’t have a good experience of being parented yourself.
• Parents can be difficult, sometimes treating you like a kind of expert-saviour, and sometimes as a punitive figure who continually withholds and disappoints them. Some parents try to play me off other professionals, in my team and in other services. It’s hard not to get swept up in it, and to take a step back and think about why they might be doing it, or how I might be encouraging it.
• Many little boys are boisterous and energetic. A lot of children don’t get much attention unless they’re badly behaved. Quite a few of these kids will get a diagnosis of ADHD.
• Teenagers can be ambivalent about attending, and not turn up rather than let you know. Parents do this more than I expected also.
• Most parents are scared of social services, being blamed for their child’s problems and attending a group with other parents.
• Children say fascinating and hilarious things. They have such interesting theories about the world.
• It’s hard to know how much responsibility to encourage a young person to take for their own treatment, when they’re not in a position to take on much responsibility in their life.
• I feel quite young, but to a child or adolescent, I’m part of the grown-up world, and I’m old.
• Before young people come to CAMHS, they’ve often seen a school counsellor or two first. Often this has been a religious counsellor, someone prone to lighting incense and wearing long patchwork cardigans. Understandably, they are a bit wary when they come to meet yet another therapist.
• CAMHS is staffed by a bunch of mums and they’re continually leaving to go have babies.
• I’ve been continually worried that I’m either being patronising or talking to young people like they’re adults, and it’s going over their heads. But so far there seems to have been no ill consequence.
• I would consider working with children and young people again. I’d probably still prefer adults, but I’m not as opposed to it as I once perhaps was.

Saying Thank You – When professionals get it right

I had an amazing experience recently. In a lot of ways it wasn’t particularly extraordinary, but it was special in its own way. I’m discharging my first client. We’ve come to the end of therapy and it’s time for them to leave the service and move on. The timing felt right, we’d focused on a particular problem, and now he felt that it was much better. We’d got on well and at the last session I did feel a bit sad to see him go. As he left he quickly gave me a bag, saying ‘this is for you’, and then slipped off. I was completely stunned, I felt a bit like I might cry! I’ve never had a thank-you gift from a client, and it felt really moving, it left me on a high that lasted for days.

Now I’ve checked my trust’s policy, and given that there’s no sign that the gift was meant as a bribe or some kind of inappropriate intent, and it’s of low value, I can keep it. It really took me by surprise. In the kind of work we do, you get quite used to not really expecting a thank-you from the people you see. But sometimes that can mean it’s hard to really know if you’re doing a good job and meeting people’s needs. In my last job I work in a dementia assessment service. People don’t really thank you for giving them a diagnosis, regardless of how sensitively and efficiently you’ve done it! I remember one day a client telling me that he’d found the service really helpful and he’d like to comment on it formally. I was completely flumoxed! We weren’t used to receiving positive feedback and there wasn’t really a system in place to receive it. In the end I gave him the complaints line, I figured they’d know what to do with it! But his comments really touched me.

It got me thinking. I’ve seen countless health professionals throughout my life, doctors, nurses, therapists and others, but it’s never occurred to me to even send a card to give some thanks. Why not? We tip when we get good service in a restaurant, what about healthcare professionals? Admittedly not all my experiences have been 100% positive, but I have met some clinicians who were very considerate and helpful and it felt like they put a bit more into supporting me. Maybe I feel like ‘doing it well’ is just their job, it’s what they get paid for and I needn’t thank them for it. But my recent experiences have really made me think about what it means to get a thank-you, even just verbally, to the individual. We can all suffer from a kind of professional-neurosis, are we actually any good at our jobs, are we just frauds, pretending we know what we’re doing? And there is a difference between fulfilling your job-description, working in a way that your service considers acceptable, and really making a difference to an individual, the client who actually has to sit in the room with you and have your ‘treatment’. Sometimes it can feel a bit removed, am I really helping them at all? And it may seem a bit cheesy, but receiving some positive feedback really does make it all feel worthwhile. The job can be a hard slog, the money isn’t always great, but knowing you’ve really helped someone, that’s an incredible feeling. It pushes me to be better, to become more, to really push to give a strong, person-centred focus, and to not loose track of that important person in the chair, the reason I’m here.

With this in mind, I am sending a card to my old psychologist. I completed a course of therapy with her 3-4 years ago. The therapy was a challenge and I wasn’t happy with the time-limited nature of it (NHS restrictions) and was very upset when it ended, feeling I needed more time. I was probably quite resentful in our last sessions. But I often think of her and the work we did, and I maybe didn’t see it immediately at the time, but it has done me a lot of good. I am using what she helped me to work out every day. I also learnt a lot from her and it has shaped how I think of the professional I want to become. I want to just send her a card and let her know that I am ok and I really appreciated the work she did with me. I know it’s her job to do therapy and she’s good at it, but I felt like she really took the time to get to know me and take my needs and point of view into account. I’d like to let her know that she did a good job, and to keep up the good work, because it means a lot to people like me. Have you ever given a thank-you card or gift to a professional? Would you?

DNA CBA – When people don’t turn up

This week was my first back after Xmas and I feel like I’ve ended it on a high. It may be a bit of a sad reflection or me, or indeed the NHS, but all of my clients turned up for their appointments this week. It might not sound that unreasonable to expect your clients to attend the appointments you’ve arranged for them, but DNA (or Did Not Attend) is very much a reality of mental health services. Two of my clients were new, so given that I’d not met them I thought they were unlikely to feel any personal responsibility to me. And the others had just had Xmas, a notoriously stressful time (for everyone, though particularly those with mental health difficulties). It’s been a couple of weeks, would they have decided they didn’t want to bother any more? Or perhaps they’d want to get back at me for going on holiday and leaving them to carry on without me. Or perhaps still be in ‘holiday mode’ and have forgotten all about it? But much to my surprise, they all came in.

I often hear clinicians laughing that they don’t mind the odd DNA, it gives them time to catch up on their paperwork. This isn’t the whole case. It can feel pretty rubbish waiting around when the person fails to show up. Wondering if something bad has happened, or if they’ve ‘voted with their feet’ and this is the last I’ll hear from them. But things were going so well! Did I do something wrong? Maybe they forgot. Shall I call them to find out? As well as the clinician-neurosis that comes with an absenting service-user, it’s also a waste of time (and therefore, money). The waiting lists are crowded and there isn’t much time to chasing up and coaxing people to come back.  It’s hard not to feel a little resentful, they’re wasting a time slot that could be given to someone else.

It’s difficult to fully understand why people don’t turn up to appointments. By it’s very nature, this topic is hard to research. If someone doesn’t turn up for their appointments, getting them in for an interview to expecting them to return a questionnaire is reasonably unlikely.  Analysing demographic data suggests that non-attenders are more likely to be young men, of lower socio-economic backgrounds and of black and minority ethnic groups. Non-attendance has also been correlated with being more mentally unwell, co-morbid substance use and detention under the mental health act, which suggests that these people may be at significant risk, but this won’t necessarily be know to the clinician. Individuals with very chaotic lifestyles, histories of abuse and significant difficulties relating to others can also show a pattern of missed sessions.  It makes sense that people who are more impaired might struggle to get to their appointments, but data linking to gender, race and background suggests that stigma might also play a role in whether people attend.

Please turn up!

I know first-hand from my experience of using service that missing appointments isn’t necessarily out of laziness or rudeness. I was a repeat offender, frequently turning up on the wrong day, at the wrong time, sometimes even at the wrong building. I’d turn up 20 minutes late then be upset that the professional didn’t have enough time to have a full appointment with me. I’d get very upset, begging the reception staff to call the day before and remind me so I’d make it in, but this was never possible. Looking back on it, I don’t think it can be a pure co-incidence that I wrote the wrong date in my diary so many times. Turning up later gave me the opportunity to have a tantrum with the staff and have the appointment ‘denied’ to me. I felt victimised, when in reality I was the one who wasn’t following the rules. I claimed to really want to be seen, but I sabotaged my own opportunities to get support, and made the experience really distressing for me and everyone around me. I don’t think I was aware of quite how ambivalent I was about being seen.

Appointment-missing isn’t unique to mental health, but the rates are significantly higher. I’ve seen many GP surgeries take a hard-line and refuse treatment to individuals who miss a certain number of appointments. It’s difficult to know what is best to do ethically, as evidence suggests that those who don’t turn up may be the most in need of support, but chasing them up uses time and resources that could be used for more willing individuals. Many MH services have started using an opt-in system where individuals are called with an appointment and asked directly if they wish to keep it. This has seen some increase in attendance rates. Indeed, I find it helpful to telephone people to make an appointment, it saves the letter getting lost in the post, time wasted over re-arranging inconvenient appointments and also gives me a chance to speak to the person and answer any initial queries. It feels more personal, but it’s hard to find the time to always do this.

It strikes me this is one down-side to our public NHS. In a privatised health service where you can be billed for missing an appointment I’d imagine people would be much more likely to turn up. Are people too comfortable with the idea that the NHS is ‘free’ and some kind of human right, a service that we’re all entitled to, to use as we want, when we please? (You only have to look at the amount of tax being taken off your paycheck to know the NHS is far from free!). The service is open to all, but it needs to be treated like any other business, not as a commodity that will be there waiting when get round to turning up. A quick telephone call is often all that is necessary, even at the last minute, to say you’re not coming in. Indeed funding cuts and costs relating to DNAs may mean that services have to get stricter on who they see and what they offer. My current NHS service has a clear policy: if a service user is telephoned to be offered their first appointment, they accept, and then do not turn up, they will be taken off the waiting list. This is explained to them when they are called. This may feel uncomfortable, but seems to be a compromise between offering person-centred choice and flexibility but also putting across how important it is to keep appointments. It is known that mental health services work with a group that find engagement challenging, so measures can’t be so strict as to prevent people accessing the service, but the current rates of non-attendance are an expense that isn’t sustainable.

A few references:

http://tinyurl.com/6m3pkss
 - Hawker D. Increasing initial attendance at mental health out-patient clinics: opt-in systems and other interventions. Psych Bull 2007;31:179–82.

http://tinyurl.com/6q7ytfg
 - McIvor, R., Ek, E. & Carson, J. (2004) Non-attendance rates among patients attending different grades of psychiatrist and a clinical psychologist within a community mental health clinic. Psychiatric Bulletin, 28, 5–7.

http://tinyurl.com/865z3hb
-  KILLASPY, H., BANERJEE, S., KING, M., et al (2000) Prospective controlled study of psychiatric out-patient nonattendance characteristics and outcome. British Journal of Psychiatry, 176, 160 -165.