I'm a CAMHS adolescent therapist AMA

[CAMHSadolescenttherapist]

I have worked for many years in a CAMHS adolescent team in the NHS. We get referrals mostly for high risk and complex presentations: self harm, suicidality, emerging psychosis, intense anxiety, long term school refusal, family crisis and (recently lots of) gender dysphoria. This last year has been intense in our team, with many changes.

As the title says ask me anything. I've name changed for this.

@Merename "OP, what’s your analysis for the rise in girls presenting with gender dysphoria? Is it always dysphoria or more about other issues? Are your team documenting the stats on this rise?"

Excellent question.

Yes we have a significant and very noticeable rise in girls presenting with rapid onset gender dysphoria (meaning it presents in puberty). In fact I have a few in therapy in my current caseload and I often assess such cases. Very very rarely boys with gender dysphoria (though we see it too) and quite often young people who identify as non binary but don't bring it as a big issue

Of course different clinicians would say different things but I can share my own view and the view of almost everyone I know working with adolescents in the nhs

We mostly feel a watch and wait approach is most helpful, treating these young people as whole people and not necessarily presuming they will be trans. I follow myself a neutral approach, not an affirmation approach and no one I know does. We use of course the name and pronouns they want but that happens in quite a natural way. To me it's very sad how many girls hate their body and then to the idea of wanting to be boys as a conduit for that. I do think there is also an issue of social contagion on this matter (and many other matters eg self harm, and that has always been the case with adolescents). The problems usually are complex and way beyond the gender dysphoria. Many many of these girls are autistic

I am also surprised how little young people these days talk about sexuality and how much about gender.

These are my personal view but they tend to be what most people I've worked with or know professionally say.

@KitHenry if your child is self harming and has occasional suicidal ideation they should absolutely be seen and treated, not sure why they were discharged, that's not ok of course

@RosesAndHellebores Camhs doesn't work like physical health, where there is a much more hierarchical model with doctor on top and nurses under

It sounds as if you didn't have a good experience with this particular nurse. But I very much believe the CAMHS MDT structure works well as mental health is complex and doctors are only part of what is needed.

Well trained therapists in CAMHS from all the professions that form the MDT are listened to in my experience as much as psychiatrists are though I would imagine there are teams where things feel more hierarchical- not in any I've worked

There are of course better and worse professionals including nurses. Have some built great therapy skills over time, though it's worth saying their core profession is not a therapy training. But some are naturally and over time very good therapists. Others are better at crisis work

@RosesAndHellebores "Do you agree op, that nurses who work in CAMHS have far too much power over the dissemination of information and ultimately decision making and parents are unable to cross check what is being shared with the appropriately qualified decision makers (paychiatrists)."

Just on this point, no I don't agree. Parents can always call and ask the team manager. Decisions can always be double checked. And I explained above that psychiatrists are not in CAMHS the only qualified decision makers

@ImTeamLogan "Thank you for the answer. I suppose I was assuming something more nuanced - that up to a point a parent looking out for their welfare, approachable trusted teachers etc are what is needed and I was trying to work out when different professional help is the appropriate route."

Let me know if you have a more specific question as maybe I misunderstood

Do you have serious concerns about some clients and are proved right ?

@PickAChew

There is more to camhs than adhd and asd.

@PickAChew well said!

@randomstuff

My DD has been seeing CAMHS for 3 years now. Initially CAMHS thought she had autism then ADHD. We were then told she didn’t meet the threshold for any of these. She was diagnosed with emotional dysregulation. We got this diagnosis 2 weeks ago and DBT was suggested.

What can I do to help DD? What can she do to help herself? No doubt it will be ages before the DBT starts.

One of the worst things for me other than the time it’s taken to get a diagnosis is to hear CAMHS call my DDs self harm cuts ‘superficial’. No mum wants to hear that, especially when my DD went to CAMHS 3 years ago with self harm on one leg. Fast forward to now and she has cuts on arms, legs, stomach and back. A cut is a cut.

@randomstuff first of all, wanting to send my sympathy as this sounds hard

Emotional dysregulation is not unusual in adolescence. It often improves with time. Very simply it means a difficulty in tolerating frustration. The young person needs to understand, over time, their emotional reactions and build ways to contain them and express more calmly. That can be done with a range of therapies, not just DBT. But some therapy built on a trustful relationship will help, as unfortunately a parent is in a more tricky position in terms of helping their teenager

In terms of the "superficial self harm", it's sad you heard it this way as it clearly and rightfully upset you... but shows that often people hear things in very different ways than what clinicians mean. When we refer to self harm being "superficial" we mean that it doesn't require medical attention (the cuts themselves) thus we are trying to reassure the parents about the risk of the cutting itself being manageable. Which doesn't mean the young person doesn't need help. Just that the cuts themselves are manageable and the parent can feel relatively safe. It's really useful feedback though for me to hear the way you experienced it as I hadn't thought it could be heard that way and you're right, it can.

I’m aware therapist isn’t a protected title, so qualifications vary. Did you train as a psychotherapist first - I’m currently training as an integrative psychotherapist. If so, which modality?
If not, can you choose to be accredited to BACP or UKCP through your training?

@Timbucktime

Sadly I’m another who has never heard a good thing about CAMHS locally to me. My child was discharged after 1 useless session so I ended up paying privately for treatment. I was very fortunate to be able to do this but many aren’t hand have to wait a good couple of years for an appointment. There is now a waiting list of people willing to pay hundreds of pounds privately at a local practice as their children have been let down by CAMHS.

@Timbucktime I'm sorry you had a bad experience

However to play the devil's advocate, one session is hardly enough to judge a whole service by. Or even to judge one clinician. And it's also the case that if a particular clinician is not a good match for a family for whatever reason, the family can request a change, no questions asked.

So I would question this idea that "one useless session" says much. We are not magicians. Helping a child is a joined project between family and clinicians. It may be of course that you had additional bad experiences at CAMHS. But one "useless session" does not say much about what that was. Long waiting lists are of course a tragedy we've all acknowledged on this thread, none of us wants that

Why is money available for overnight (sometimes 2/3 nights) acute admissions to childrens' wards pending CAMHs assessments when there was no money for an intervention that may have oriented the crisis? Also why are there not more CAMHS nurses available at weekends to ensure admissions are discharged as swiftly as possible?

How on earth would OP know that?

OP, just out of interest really, was there anything in particular that pulled you towards working with young people rather than adults? Also, would pre-teens also come under CAHMS?

@Calledyoulastnightfromglasgow

Why isn’t their more focus on nutrition?

There is evidence for example about vitamin D helping with mood and omega 3 essential fatty acids helped with other disorders.

We need to look beyond talking therapies to the nuts and bolts basics of nutrition and mental health

@Calledyoulastnightfromglasgow very true. But CAMHS teams can't do it all. I agree, mental health is a complex idea having to do with much much more than only psychiatric mental health diagnoses (which as I've expressed above are debatable and have nuances when it comes to children and adolescents)

The biggest determinant for good mental health is financial stability

Thus the worsening inequality in our society goes way way beyond in explaining what we describe as "mental health problems" in our young people. Indeed, in many cases their reactions are perfectly understandable and normal when they live in overcrowded homes or parents have no money for food. In my book those children definitely need support but in fact it's wrong to say "they have depression" or whatever when actually how else should they react?

The same for young people nowadays with Covid. They are stuck at home with very little to do, cut off from friends, with a pandemic around them. Why should they be happy in that context?

So yes I agree about other factors rather than talking therapies including nutrition, exercise, financial stability, support and respite for parents etc

As a parent I would go back to my GP in that case and insist on a re-referral. I would also work with school who have their own resources. Often when CAMHS get a referral repeated times it will get flagged up

As a GP that is frustrating and unacceptable. For one thing, it's the diametric opposite of what we keep being told - which is not to re-refer (unless the clinical picture has completely changed) as it messes up your referral systems. For another, it's a complete waste of parents' time and ours. You're turning referral into a game where the winner is the parent/GP who shouts loudest, not the child in greatest need.

@givemehope15

I'm currently in hospital with my DD (15) after she has taken an overdose of paracetamol. She has become increasingly agoraphobic over lockdown. She was experiencing panic episodes at school or in groups or when she went out with friends before but now she won't leave the house. We are going to be seeing CAHMS this am. How can they help?

@givemehope15 I'm so sorry to hear this. I'm very hopeful that CAMHS will be able to help. They usually are good when things reach this difficult point. It's very sad to say this, isn't it... that it has to come to this

@Inthevirtualwaitingroom

Do you have serious concerns about some clients and are proved right ?

@Inthevirtualwaitingroom what do you mean?

@jendifer

I’m aware therapist isn’t a protected title, so qualifications vary. Did you train as a psychotherapist first - I’m currently training as an integrative psychotherapist. If so, which modality? If not, can you choose to be accredited to BACP or UKCP through your training?

@jendifer I'm afraid I can't comment on that as it's too wide a question for me to be able to answer. I know that the core professions within CAMHS have fairly specific training pathways but obviously in the private sector many people work well in all sorts of different ways

Gosh. I called the team manager who refused to listen to my concerns. When I objected told me there were no resources and to go right ahead and contact my MP because she wouldn't be doing anything. Concerns were only dealt with through PALS. Much the same the second time. Funnily enough each time my MP intervened they offered therapy on a 1:1 basis immediately. She was cutting and Od'ing. Largely her care was private due to poor clinical and service standards through CAMHS.

In response to someone uptrend asking about physical stuff dd's private psychiatrist had full bloods done and dd's vitamin D was on the floor. DD also had 4/5 therapy sessions initially which she didn't engage well with and needed AD'S to get to a better place to benefit from therapy.

Compare private to: assessment, therapy, follow-up, AD'S and clinical physical health assessment - 5 weeks to CAMHS: assessment, contact details lost, something inaccessible and inadequate offered, refusal to discuss alternatives and case closed. Took three months and resulted in zilch. Wasted their time and more importantly dd's time. They could have said after the initial assessment "look this is all we can offer". Made worse by the fact that our GP told us to find a therapist off the Internet and refused to help with referrals.

once they have left your service, over the age of 18 or 19? do you ever hear back from them,
or hear about them in a negative situation? and you think I knew this would happen

@Sheepies

Why is money available for overnight (sometimes 2/3 nights) acute admissions to childrens' wards pending CAMHs assessments when there was no money for an intervention that may have oriented the crisis? Also why are there not more CAMHS nurses available at weekends to ensure admissions are discharged as swiftly as possible?

How on earth would OP know that?

OP, just out of interest really, was there anything in particular that pulled you towards working with young people rather than adults? Also, would pre-teens also come under CAHMS?

@Sheepies thanks for making the point that I can't possibly answer or be accountable for all the shortcomings of a huge and complex system!

I was always interested in working with adolescents in particular, in answer to your question for a number of personal and professional reasons

Do you get much support for yourself?

@MissLucyEyelesbarrow

As a parent I would go back to my GP in that case and insist on a re-referral. I would also work with school who have their own resources. Often when CAMHS get a referral repeated times it will get flagged up

As a GP that is frustrating and unacceptable. For one thing, it's the diametric opposite of what we keep being told - which is not to re-refer (unless the clinical picture has completely changed) as it messes up your referral systems. For another, it's a complete waste of parents' time and ours. You're turning referral into a game where the winner is the parent/GP who shouts loudest, not the child in greatest need.

@MissLucyEyelesbarrow you're absolutely right. What else can a parent do though in that situation? If I was that parent, that's what I would do as I'm not sure what else can be done

I'm not an NHS manager, not in charge of triage. I wish like you do that CAMHS had wide open doors.

Over the last few years, we've been trying to get a referral for our increasingly troubled son. The GP says it's up to the school, school say it's down to the GP, the school are now saying it isn't possible due to Covid. What can I do? I'm failing my son, I can't even get a referral. Even if he gets a referral, the waiting list in our area will take him almost to adulthood when he'll be too old for services I'm sure.
He's been told in the meantime to make his own appointment with a GP as it 'isn't your business what he does'. Wtf. What 14 year old would want to make a GP appointment off their own back, especially one with the challenges he's facing?

@RosesAndHellebores it sounds like you had a really difficult experience, which I'm sorry to hear. That could be for many reasons. We did discuss a few times on this thread how there is a postcode lottery with CAMHS but also clinicians and teams really vary in their quality I guess

@Inthevirtualwaitingroom

once they have left your service, over the age of 18 or 19? do you ever hear back from them, or hear about them in a negative situation? and you think I knew this would happen

@Inthevirtualwaitingroom yes we often hear back from them, mostly to let us know how they're doing which is lovely! In rare cases, sadly, we also hear of bad outcomes

I have name changed for this too.
A person I know was telling me that she spent a few months in hospital in a unit for teenagers, the others had anorexia and some had psychiatric things like schizophrenia. She maintains that she has no idea why she was there because she says she was never told but it seems like an odd setup because staff would take individuals out alone in their cars and if she didn't toe the line she'd have her wardrobe locked and would have to stay in her pyjamas. She's a medical professional now herself and doesn't have mental health issues as far as I know, well apart from stress like you all must have right now.

Is this really what it was like, it all seems very, very wrong if that's what went on.