Media headlines decrying long waiting lists for NHS Child and Adolescent Mental Health Services (CAMHS) and their failure to help desperate children and their parents have become almost daily fare.
The most recent flurry of headlines was prompted by an annual review from the influential Education Policy Institute (EPI) in January 2020.1 EPI gathers its data through Freedom of Information requests to NHS trusts, because the data are not publicly available in any other way. Last year, 26% of children and young people referred to CAMHS were turned away, mostly because they didn’t meet the eligibility threshold. Rejection rates varied widely across the country, with some rejecting up to 66%. Once accepted, children and young people then wait on average two months to start treatment. The rejection rates have remained unchanged since 2016, when EPI published its first review, despite £1.4 billion of extra funding from the Government over the five years since 2015, although waiting times for treatment have reduced by 11 days.
NHS England’s response to the EPI report is that the analysis is ‘flawed’, and that the NHS ‘is actually ahead of its target on ensuring as many children as possible receive mental health care’. An additional 53,000 children and young people were treated in 2019, 14% up on 2018, and 22% more staff are employed in CAMHS than in 2015. ‘It is not the first time we have had to point out why the assumption that every referral should get NHS treatment when more appropriate support might be provided elsewhere – for example, from schools and local authorities – is wrong,’ a spokesperson said.2
However, another survey, published in December 2019, presents the picture from the perspective of the gatekeepers who might be expected to know if a child needs specialist mental health treatment – GPs. Youth mental health charity stem4 surveyed nearly 1,000 GPs3 and discovered that 54% of their referrals for 11- to 18-year-olds were turned away by CAMHS, largely because they did not meet the eligibility criteria. Of those accepted, 27% were waiting three to six months for first treatment, and 28% were waiting up to 12 months.
Yet GPs reported significant increases in the number of children and young people coming to them with anxiety, depression, self-harm, eating disorders and conduct disorders, and only referred on those they considered to be at the highest risk.
The GPs were also asked what they did when a referral was refused: 36% suggested parents contact a local charity offering some kind of support; 29% suggested CBT-based self-help; 31% suggested NHS-recommended digital apps; and 83% recommended counselling – either through their local IAPT service (32%), through the GP practice (6%), or through their school or in the community (45%).
The most recent NHS statistics tell us that almost one in eight children and young people aged five to 19 have a ‘diagnosable mental illness’, and the rate doubles among children from low-income families.4 So, are we seeing an NHS facing a meltdown in its mental health provision for children and young people? Or a failure by the Government to adequately invest in the mental health of future generations?
Mental health practitioners
CAMHS has undergone a major transformation in the past five years as CYP IAPT has been implemented. Rather than establish a separate ‘talking therapies’ primary care service, it was decided to instil IAPT’s main principles – the structured care pathways, evidence-based treatments, standardised outcome measures and data collection – throughout existing CAMHS services. CAMHS has a four-tier system:
- Tier 1, which consists of general advice and treatment for less severe problems by non-mental health specialists such as GPs, school nurses, social workers and voluntary agencies;
- Tier 2, made up of mental health workers and counsellors in clinics, schools and youth services;
- Tier 3, involving a multi-disciplinary team or service working in a community mental health clinic providing a specialised service for more severe disorders, with team members including psychiatrists, child psychologists, psychotherapists and social workers;
- and Tier 4, which is highly specialist services for children and young people, such as day units, outpatient teams and in-patient units.
Headlines that talk about children being ‘turned away from CAMHS’ are usually referring to Tier 3 and 4 services.
Increasing Tier 1 and 2 provision has been the focus of the Government’s 2018 Green Paper proposals for ‘transforming children and young people’s mental health provision’ by putting more trained mental health workers into schools and communities. Every school and college will have a designated mental health ‘lead’ by 2025 to help staff spot pupils who show signs of mental health problems, offer advice to staff about mental health and refer children to specialist services if they need to. Alongside that, local mental health support teams are being introduced in 25 ‘trailblazer’ sites in England, staffed by ‘education mental health practitioners’, who, the Government says, will work alongside school counsellors and existing in-school pastoral and wellbeing provision, offering individual and group help to young people with anxiety, depression and behavioural difficulties and a link to CAMHS. The mental health leads are to be designated by schools by 2024/25; the new mental health teams will reach 25% of the target population by 2022/23. Seven universities are already training up EMHP (educational mental health practitioners) in skills levels similar to those of IAPT’s psychological wellbeing practitioners (guided self-help skills, caseload management, identification and referral on and support for education colleagues to manage children with mental health needs). The posts are being advertised at NHS Grade 5.
The ‘missing middle’
In the meantime, stem4’s survey suggests that much of the burden of care for distressed and disturbed children and young people is being carried by counsellors, whether in the NHS, in schools or in private practice – and, of course, by the children themselves and their families. It is this population of children that the Welsh Government dubbed the ‘missing middle’ in its 2018 Mind Over Matter report:5 the children and young people who fall short of the CAMHS threshold yet need more than simply a caring, supportive family and school environment. It has provided additional funding for CAMHS in Wales to find ways of reaching what is, effectively, an invisible group.
In England, school counsellors are feeling the strain, says Jo Holmes, BACP’s Children, Young People and Families Lead. She is very clear that CAMHS workers are doing their best in very challenging circumstances with minimal resources and mounting caseloads: ‘No one is blaming CAMHS workers themselves. No one is questioning that they are all very committed individuals doing their best for children and their families. What concerns BACP is the huge expectation for school counsellors to hold that backlog of young people who need to be seen by CAMHS and who either have been turned away or are on the waiting list. That is where we want to see more recognition, investment and change.’
BACP is also aware of the risk that the new mental health teams might be used to cut back on counselling provision. ‘We are keeping a close watch in case schools in the trailblazer areas think they can drop their counsellors,’ Holmes says. ‘The Green Paper is very clear that these teams are intended to supplement existing counselling and pastoral provision in schools.’
Vic Leeson left her job as a school counsellor in Leeds last July when she realised she was burned out and needed to step away. Now in private practice, deliberately with only 20% young clients, she says: ‘I am grieving for the work I was doing with the children, but also for how I wanted the job to be. I was firefighting the whole time.’ She worked for a charity contracted by the local education authority to deliver counselling across three secondary schools and 14 primary schools in the city. She spent two days a week in a secondary school with 1,200 pupils in a deprived area of the city. ‘We were getting a lot more referrals because CAMHS raised its threshold for treatment. Even the kids were saying, “I know I have to try to kill myself just to get through to CAMHS.” You could do some really good work if the child had a secure and stable family environment, but if they had more than one problem, we were still expected to fit them into an eight- to 12-session framework. And we were expected to fix the systemic issues around the child, as well as fix the child. So you were doing things like finding out why social services had closed the case, or chasing a CAMHS referral. The therapy became infiltrated by all the systemic issues.’
She sees a need for systemic reform. ‘If there had been more collaboration with CAMHS, if they’d said, “This child needs trauma-informed therapy and possibly longer-term intervention but there’s a waiting list for our service, so please focus on stabilisation work in the meantime and deliver some psycho-education to both the child and the family,” that would have been a far better use of our resources.’
Her hopes currently lie with ‘relational activism’, an approach based on systemic family therapy currently being pioneered by the social services team in Camden, among others. It seeks to bring about change from the bottom up, through building relationships of equality, fairness, respect and compassion between all the stakeholders in children’s welfare. ‘Our systems currently don’t speak the same language; we don’t communicate with each other,’ Leeson says. ‘We need more respectful and compassionate conversations between CAMHS, social care and education and importantly with the families and children themselves.’
Michelle Higgins has moved on from school counselling too, also partly out of frustration with the failure by the health and education systems to recognise the potential in the role. ‘Even though the school really valued and understood my role, it is an exhausting position, being neither part of the education system nor CAMHS. CAMHS were always seen as the “proper mental health professionals”, the ones with authority and status. I was doing the clinical work that CAMHS couldn’t offer but, because we aren’t part of the mental health infrastructure, our work just isn’t seen or recognised for what we contribute. No one even bothered to collect my outcomes data. I set up my own data system in the end to give to my manager. We are the invisible middle.’
Ordinary problems
Consultant psychiatrist Sami Timimi questions whether there is a massive increase in mental health problems among children and young people and if further CAMHS involvement is the answer. He argues that as a society we are increasingly unable to tolerate our children’s expressions of distress and are too quick to want to hand them over to the ‘experts’. He points to a survey by the Channel 4 Dispatches documentary programme in July last year of 1,000 16- to 30-year-olds,6 of whom 68% said they thought they have or have had a mental illness. ‘The more we popularise the idea that there is an epidemic of mental health problems among young people and that we haven’t enough services and that all these young people need expert help, the more likely it is that young people themselves and those around them – teachers, parents and others who care for them – will start to think that any display of emotion or behaviour that concerns or annoys them or otherwise causes problems is a possible sign of mental disorder,’ he argues. ‘We are becoming afraid of our children’s emotions and behaviours. We are not allowing space for the ordinariness of unhappiness, anger, pain and suffering.’
He argues that involvement with CAMHS medicalises children’s distress and disempowers those who are available to offer ‘ordinary helping’: ‘Teachers feel disempowered to do ordinary, relational things to help their pupils because they think they need to be seen by an expert and that if they intervene they might do harm. The whole mental health industry in schools is just increasing the pool of potential patients we might medicalise.’
Collaboration
Jo Holmes at BACP wants to see more collaborative conversations about referral thresholds and routes that can ease the CAMHS bottleneck and make better use of counselling. ‘CAMHS can’t be the answer to everything,’ agrees Sally Jones, CEO of the Welsh children and young people’s mental health charity Area 43, based in Cardigan. Area 43 runs a drop-in service and an online counselling service for young people aged 16 to 25 in Cardigan. It also has contracts with Carmarthenshire and Ceredigion County Councils to provide school-based counselling to all secondary school and Year 6 primary school pupils in those areas. The charity became involved in schools back in 2008 when the Welsh Government decided to fund statutory school counselling provision. Because the charity is well embedded in the area, Jones sits on various steering groups alongside representatives from CAMHS. ‘It’s really down to personal relationships. I was able to ask the CAMHS service manager how we could refer directly to her service, rather than going through the GP, as happens in most other areas. By meeting face to face, we were able to say to CAMHS, “This is what we can do, this is how qualified our counsellors are and this is the limit to our service”, and they were able to say the same. It sounds so simple but you have to have that conversation.’
This meant that Area 43 had to be clear about what it could and could not offer. ‘School-based counselling needs to be available and accessible to the widest range of children across the widest range of age brackets. This means we can only offer short-term therapy,’ Jones says. ‘Children who have a diagnosable mental health condition are readily identified and referred on. We work with the ones who are struggling to cope with what they have to live with every day.’
Alongside this, Area 43 also seeks to build on the children’s own resources. The counsellors have recently introduced a new question to their assessment session that asks the child, ‘What do you identify as your support system?’
‘It helps them look at what is around them that they can access and that can be a very telling piece of work,’ Jones says. ‘The children don’t realise they have this resilience until they talk about it.’ And, as the waiting lists for counselling have edged upwards, Area 43’s team has also gone into schools to discuss the resources they might have that aren’t being used. ‘Sometimes they haven’t joined the dots. They have their own pastoral systems, and it’s a case of pointing out that teachers don’t have to take the crying child to the counsellor. They could suggest they see the youth worker or the school nurse, for example. Most schools in Wales have some kind of chill-out room where there’s a member of staff who can help the child calm down and sit with them. Our counsellors are doing five or six sessions in a day. Having teachers knocking on the door and interrupting sessions because a child has become upset in class can be disruptive to the therapeutic process.’
The pathway to CAMHS also runs the other way, of course. If a counsellor is concerned about a child, they can ring the CAMHS screening team, go through their checklist and have a conversation about whether they should be referred to CAMHS. ‘The mental health nurses on the screening team will say if it is one for them or not. It’s as simple as that. If not, they may suggest strategies that could be used or tools the young person might find helpful. We work together for the best interests of the young person, and this can often be an ongoing conversation.’
Youth counselling charity TIC+ has a similarly fruitful relationship with Gloucestershire Health and Care NHS Foundation Trust’s CAMHS. The Trust contracts TIC+ to provide seven sessions of counselling to 240 children a year, either in school or in another community setting. The counsellors go to the child, to make the service more easily accessible, rather than expecting the child to come to them.
Before embarking on the partnership with CAMHS, TIC+ needed to work with them to upgrade safeguarding policies and procedures. It was worth doing, says Judith Bell, TIC+ Director of Counselling. ‘They are helping us but we are helping them. We are able to recruit counsellors and have the supervision and other systems and structures in place. If a counsellor has any concerns, they phone through to CAMHS and they advise us if they feel it is someone they can work with. They respect that we have qualified staff, and if we say we can’t help the child then they will take it seriously and accept them, at least for an assessment. But sometimes just having the conversation with a CAMHS colleague is enough to reassure the counsellor that they can go on working with the young person, and sometimes we will continue to work alongside the psychiatrist or psychologist even if CAMHS does take them on.’
Gloucestershire is also a Green Paper trailblazer site and has funding to support four mental health support teams. Counselling from TIC+ is part of the support teams’ core offer. TIC+ is also funded by the NHS clinical commissioning group to run an online counselling service. On top of this, TIC+ has other funding from the Future in Mind government programme, which pays for 1,340 self-referral counselling clients a year. ‘We feel extremely fortunate to be in this situation,’ Bell says. ‘It makes a big difference to the young person, as they are able to independently access the help they need, in a timely way and at a suitable venue of their choice. We are also very flexible and can offer a variety of ways to work with children and young people. This means we can do a lot to help address the needs of children and young people in our county.’
Catherine Jackson is a former editor of Therapy Today and has written a book about IAPT and its impact on counselling.
References
1. Crenna-Jennings W, Hutchinson J. Access to child and adolescent mental health services in 2019. London: Education Policy Institute; 2020.
2. https://www.theguardian.com/society/2020/jan/10/one-in-four-children-with-mental-health-referral-rejected-nhs
3. Stem4. The failure of children and young people’s mental health services 2019: another year in decline. Wimbledon: stem4. https://stem4.org.uk/four-in-10-gps-suggest-seeking-private-care-for-mentally-ill-children/
4. NHS Digital. Mental health of children and young people in England, 2017. NHS Digital; November, 2018. https://digital.nhs.uk/data-and-information/publications/statistical/mental-health-of-children-and-young-people-in-england/2017/2017 Children, Young people and Education Committee, National Assembly for Wales.
5. Mind over matter: a report on the step change needed in emotional and mental health support for children and young people in Wales. Cardiff: National Assembly for Wales; 2018. Bay www.assembly.wales/laid%20documents/cr-ld11522/cr-ld11522-e.pdf
6. Channel 4. Dispatches: Young, British and depressed. 29 July, 2019. https://happiful.com/documentary-reports-mental-health-crisis-amongst-young-people/