I’m writing this on the day that news has carried stories around mental health services for children and young people, following a report by CentreForum, a think tank “that develops evidence-based research to influence both national debate and policy making”, with a particular focus for “those in disadvantaged circumstances”.
The news headlines and the report itself make stark and worrying reading. Factors such 23% of referred young people being turned away, threshold criteria which apparently require repeated suicidal presentations to receive support, “Anorexia” access being based on BMI… all of these will raise concerns for anyone with an interest in the emotional well-being of young people in the UK (surely, therefore, everyone in the UK?).
As you can see from my overview, I want to use this blog to offer critical appraisal of mainstream reports around distress and “mental health”. My initial thoughts about this report are that it represents the incorporation of a broad church of expertise from various public bodies and professions – including two leading clinical psychologists, which I’m always going to like! Unfortunately, it doesn’t make clear how much use has been made of Experts by Experience in the process (either young people or parents), a process which should increasingly be a feature of any mental health design or evaluation process in my – and many other people’s – opinion. Interestingly, after my critique last week of Labour’s supposed “Basic Questions”, this report provides a clear example of how complex the questions are that need to be asked, and the complex ways in which data needs to be gathered and interrogated in order to answer them appropriately. I’m not going to go on now to seek more critique of their methods, as I think they seem good enough for the intended purposes.
So my critique this week? It is more of a query and reflection around the way our nation approaches significant distress in young people. This is part of the wider debate which is present around how we conceptualise distress as “mental illness” in mainstream perceptions, but I think that the place of children, young people and families in this discourse will benefit from further emphasis.
The report starts by describing prevalence. The data on prevalence is taken from the most widely used source, a 2004 report by the Office for National Statistics with a sample of nearly 8,000 children identified for further investigation through questionnaire and interviews with themselves, their families, and/or their teachers. Now, there is clearly value to this data – however, we need to be clear that it is offered unambiguously from a “Mental Disorder” perspective. The figure of 1 in ten is based on there being ten per cent of children who would be diagnosed with a “Mental Disorder” based on a psychiatric classification systems which suggests that difficulties in children can be “clinically determined”. As with any classification process, this requires that there is a cut-off point for decision-making. Practically speaking, this means that there is a nominal point at which one child’s distress levels are below the threshold (they don’t have a disorder), whilst another child’s are above (they do have a disorder).
Across all psychiatric diagnoses, there is a critique frequently offered which suggests that there is insufficient evidence to make such confident categorisations; the sceptics amongst us suggest that the practice persists for a number of socio-political reasons, but that the foundational science does not support this process as fully as mainstream medicine and media would have us believe. Many people have made better arguments than I about this, and so I will not waste your time by trying to re-hash them in a less eloquent way here. However, let me emphasise that the very developmental nature of childhood and adolescence makes this life-stage an even more “messy” area in which we could or should be seeking to determine a psychiatric diagnosis.
None of this means that I am undermining the extreme difficulties that face our young people. I have worked with a number of families where the level of suffering related to their psychological experiences (thoughts, feelings, behaviours, relationships, and so on) can only be described as extreme, and can be incredibly damaging in a number of ways, including physically. However, that does not mean that I believe we need to apply a health model to understanding these difficulties.
Why is this relevant to the awful stories of access described in Centre Forum’s report? Because I believe that part of the problem is a result of a system design, not JUST resources. The fact that we discuss childhood distress in terms of “Health”, “Disorder”, and “Illness” leads inevitably to the fact that categorical decisions are required at individual levels, and also within services. CAMHS stands for Child and Adolescent Mental Health services, and the primary provider is the NHS, the National Health Service. Immediately, we have to apply paradigms which make sense of the severe distress as a health-related issue, and both explicitly and implicitly this means that inappropriate health-based processes are going to be used.
Threshold criteria based on categorical clinical levels may well be appropriate for some medication decisions made in order to influence blood levels of certain chemicals in clearly physiological conditions (I don’t know for sure, you’d have to ask a medic, but that’s my understanding of many aspects biomedical science…). When you take psychological distress, a human experience where (despite the huge research bias towards biomedical perspectives, also highlighted in the report) we have a very limited understanding of underlying physiological process, the idea of threshold criteria becomes far less meaningful or appropriate. However, situated as they are within health services, the dedicated support for young people experiencing significant distress inevitably adopts this approach. This is also notable within Centre Forum, whose commission was led by Norman Lamb, an MP for whom I have a great deal of respect in terms of his drive for equality and his work around mental health whilst in government, but who nevertheless frames childhood distress in terms of “mental illness”.
Within a CAMHS service, there are normally many clinicians who would not choose this health framework as their primary explanation for the distress they are seeking to alleviate, but their situation within health services leads inevitably to an approach which is determined within this framework. Even my professional identity – a clinical psychologist – holds health-related meanings which don’t entirely fit with the formulation-based philosophy that is primarily held by practicing clinical psychologists. This is not quite the right time to discuss further the kinds of professional dynamics that such a position can bring, but I don’t think many would disagree with the platitude of “it’s complicated”, and maybe I’ll explore that further another time. The problem is that the system in its current form holds access to many who would prefer not to be acting on an illness model behind thresholds that require criteria based on an illness model. Arguably, it also means that early intervention - so widely recognised as the most important process - is not supported in development or application by the expertise of some who could bring incredible value to the process because they have to sit behind threshold curtains in the more expensive “specialist services”; it is my firm belief that the value for money of breaking down some of these barriers would come in bringing a wider level of expertise to the processes of many services and systems. I would take this a step further, and argue that we need to explore an entirely different system for offering appropriate support, one which separates from the health paradigm. This doesn’t mean either losing the benefits of health input, nor am I suggesting that medication is never useful, even for children and young people; however, we can move away from needing a full health-based paradigm to understand distress without losing the ways in which such interventions can be useful.
I am not the first person to suggest that an entirely different approach is needed for understanding and supporting people in distress. Primarily, I believe that the biomedicalisation of distress contributes to communities being disempowered from feeling they are able to address needs which they might otherwise approach. In addition, I subscribe to the movement which suggests that in fact, socioploitical factors such as austerity are driving factors in increasing people’s distress (and the original 2004 report notes significant socio-economic differences within “disorder” prevalence that would reflect this). As such, I do believe that the main process by which we will see improvement for the young people whose suffering is so vividly described in reports such as this one are a wholesale change in society based on compassion, driving or driven by a government which begins to employ compassion related to our nation’s well-being as a more important measure than apparent “economic success”.
I am a pragmatist. Despite all of my critique of psychiatric diagnosis, I have been part of the team which set up a dedicated “CAMHS Eating Disorders” service, because I had good research and experiential reasons to believe that a specialist service would certainly bring more significant benefit to some people in extremely difficult situations – the fact that we had to use this terminology seemed a small philosophical price to pay for ensuring appropriate resources were targeted in the right way. Sitting now slightly on the outside of CAMHS but still closely aligned, I do see that there is not going to be an overnight change whereby young people’s suffering is managed by an entirely different system. In that context, it is vital that the current system is resourced and changed in a manner which will allow for much more support from a group of professionals who – in my experience – are passionate and dedicated about alleviating young people’s suffering, be they nurses, social workers, psychiatrists, psychologists, teachers, or any of the other professions working tirelessly in this field. However, I fear that whilst it is always within a health service framework, there will always be a mismatch, and no matter how much money goes this way, it will not quite meet the needs that the young people and families of our country so desperately need. An overhaul is needed.
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