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Meeting the unmet mental health needs of young people who are outside the system

Angela Bagum outlines the main issues she encounters working as a nurse in a non-health organisation

Angela Bagum outlines the main issues she encounters working as a nurse in a non-health organisation


Picture: iStock

For the past seven years I worked as a specialist nurse in child and adolescent mental health for the Tavistock and Portman NHS Trust delivering the pilot NHS England liaison and diversion service.

Primarily the aim of the pilot – developed following the recommendations of The Bradley Report (2009) – was to support an early intervention approach for young people in the criminal justice system.

Assessing needs and vulnerabilities

This was done by assessing for unmet emotional health needs and other vulnerabilities and, where needs were known, to support the diversion of young people in the criminal justice system and give them added support.

By helping early access to child and adolescent mental health services (CAMHS), the ambition was to reduce criminal activity and prevent unnecessary costs to the public by not escalating into court proceedings – and preventing young people from becoming adult offenders.

Using the biopsychosocial understanding gleaned from my mental health nursing background, I provided a combined clinical approach.

Blueprint is formed

Psychodynamic theory is largely underpinned by the work of Sigmund Freud, Donald Winnicott and Melanie Klein. It is based on their clinical research and understanding of the internal world of a person and how this develops in those early pivotal years, for which a type of blueprint is formed that can affect life thereafter.

‘Some teenagers present with a defensive bravado to protect vulnerable underlying feelings – perhaps of inadequacy, sadness and shame – which may have arisen because of trauma’

The child’s development is understood within the context of the family and the relationships between parents and child, establishing attachment styles, underpinned by ‘attachment theory’ created by John Bowlby, who identified the importance of a secure base.

Underpinned by understanding

My practice was underpinned by understanding how those early experiences contribute to adolescent behaviour and how I, as a clinician, can help make sense of this for a young person and the network surrounding them. This could include social services, young people’s offending services and the police.

For example, some teenagers present with a defensive bravado to protect vulnerable underlying feelings – perhaps of inadequacy, sadness and shame – which may have arisen because of trauma.

They may not have the language to describe these feelings. Instead, these difficult feelings can be acted out through aggressive behaviour, theft or other behaviours that fall in the context of criminal activity.

When young people are arrested and brought to the police station, the cold, unfriendly and oppressive environment can make assessment of their needs difficult.

‘Simple mindfulness techniques of breathing and visualisation were offered when some of the young people felt overwhelmed and scared’

Child-like states

It was not unusual to see a young person’s demeanour change over the 24 hours they could be held, with some presenting as distressed, anxious and, in some cases returning to child-like states.

There was a limit to what I could provide because of the setting, but assessments often took place inside the cell due to a lack of available space. Simple mindfulness techniques of breathing and visualisation were offered when some of the young people felt overwhelmed and scared.

As a guest in the police setting, building relationships with custody officers was essential. This helped officers to understand the position I was coming from and led to some collaborative decision-making.

Consequences for the future

For example, the police were able to understand and determine whether the problem was a ‘family issue’ that could be best met through a local authority response, as opposed to being pushed through the criminal justice system using up valuable police time and having consequences for the young person’s future.

‘Holding on to your professional identity is hugely important’

In an autonomous role such as this, working in a non-health organisation, it is vital to maintain a thinking position and be supported; not just through supervision, but from colleagues who understands the practice being undertaken.

I attended a fortnightly team meeting with other CAMHS clinicians where I discuss cases that may already be known to local CAMHS services and am helped to think creatively about where these cases should be held, based on need.

‘It can be easy to fall prey to unconscious bias that may distort thinking’

Holding on to your professional identity is hugely important. It helped me to understand the young person’s experiences and state of mind, something which other organisations may not be best placed to do.

It can be easy to fall prey to unconscious bias that may distort thinking, be driven by network anxiety and unfortunately affect the engagement of young people who need a system around them to interpret what they often cannot verbalise.


Reference


About the author

Angela Bagum is a clinical nurse specialist in the forensic Child and Adolescent Mental Health Service at the Portman Clinic, which is part of the Tavistock and Portman NHS Foundation Trust, London

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