Lara* was brought to A&E by her parents after she took paracetamol with suicidal intent. When mental health staff tried to understand her state of mind, they heard that Lara had been struggling to concentrate in school and was overwhelmed about exams and friendship issues.
She often felt sad and low. She had developed habits and rituals, packing her school bag and getting to school at a particular time to help her manage, but she also would at times over-eat or self harm.
Every day, more and more young people like Lara are brought into A&E, but a recent report highlighted the problems they have in accessing services. It described support services as “buckling under pressure”, leaving children “ricocheting around services” which are “over-medicalised, bureaucratic, unresponsive, outdated and siloed”.
As a psychologist working with young people and child and adolescent mental health services (Camhs) for 25 years, the report resonates. Services are organised by diagnosis, but medical psychiatric diagnoses are not a perfect science even for adults, let alone for developing children and adolescents, whose stress responses are subject to change. A child who struggles to concentrate and is feeling pressure about schoolwork, for example, may on some days feel sad and low and on others anxious and worried, and may use both self-harming and not eating as strategies to cope.
Labelling these feelings as “ADHD” or “anxiety” or “depression” or “eating disorders” or “OCD” can be a quick shorthand to summarise their experience and guide treatment. But, as this report highlights, they are instead being used as a ticket of entry to different parts of Camhs. Given that services are full already, children with multiple tickets are told to go elsewhere; that their “disorder” doesn’t reach clinical severity. Managers pull up the drawbridge to protect their services.
Why do managers do this? Because Camhs workers, as in almost all NHS sectors, are completely overworked. Clinicians are being pushed to do more with less, managing larger caseloads with fewer resources – and the higher levels of distress is affecting morale and retention. I am seeing staff ask for career breaks, work fewer hours or move to the private sector where a better work-life balance is possible.
NHS staff do not leave lightly. People enter healthcare because they want to help, and leaving is a tortured decision. As Adam Kay’s memoir, This is Going to Hurt, illustrated; NHS staff become disillusioned when demands on them exceed their capacity. We have seen it happen with dentistry and midwifery, and I fear Camhs will be next.
Government investment in mental health, such as it is, has focused on mental health support teams employing education mental health practitioners, who are generally new graduates given minimal training, on low salaries. They are using these positions to start their careers before moving on after a year or so. This is a major design flaw: it takes time for distressed children and adolescents to trust adults, and it is that trusting relationship which allows them to heal and take therapeutic advice. An adult may arrive to therapy primed and ready to accept advice, but adolescents are more sceptical about adults’ opinions, and successful therapy with this population requires earning their respect before they will listen. Making these relationships is the challenge (and the joy) of Camhs work. It is less likely to happen if education mental health practitioners move on after a year.
Good mental health for children and adolescents requires positive, long-term relationships with adults who care and value them. Ideally, this happens in the home, but can additionally or alternatively happen in communities, schools, youth clubs, sports grounds and dance troupes. Mental health services are a last resort. But what I do know is that kids become disenfranchised from society without links to positive adult role models and interests that engage them.
Covid exacerbated the mental health problem, but even prior to that diagnoses were soaring. Given the evidence that one in six children are suffering a probable mental health condition, it’s time the government considers every policy’s impact on the wellbeing of younger people. My heart sank when Liz Truss promised new selective grammar schools and Oxbridge entry interviews for all triple A* students, because I see every day the victims of these exclusionary “race to the top” education policies. These policies harm not just the young people who fail the crucial exam or exams – and often suffer from a sense of “not being good enough” into their adult years – but also for the anxious perfectionists who are on a relentless hamster wheel of academic excellence until they break emotionally.
As a therapist and a Camhs worker, it won’t surprise you that I think we need more investment in fully trained staff and a focus on staff retention. But the answer lies not simply with just more Camhs, but with better Camhs. We need joined-up thinking about entry to mental health services at a regional health level, so that young people and their families are no longer “ricocheting” between services, with managers forced to play pass the patient to protect their overworked teams.
We need a distress-led service, rather than a diagnosis-led service. We need services, both for mental health and in the community, which prioritise long-term care, not short-term repair, and government policy that is mindful of the mental health of the next generation. We must tackle the root of young people’s problems, not just their symptoms. They will thank us.
*Name and patient details have been changed
In the UK, the charity Mind is available on 0300 123 3393 and Childline on 0800 1111. In the US, Mental Health America is available on 800-273-8255. In Australia, support is available at Beyond Blue on 1300 22 4636, Lifeline on 13 11 14, and at MensLine on 1300 789 978
Dr Tara Porter is a chartered clinical psychologist and author of You Don’t Understand Me: The Young Woman’s Guide to Life. She has worked in Camhs for 25 years