Written evidence submitted by Nottingham Centre for Children, Young People and Families (CYP0055)

1. Executive Summary

Our submission is based on a body of research conducted with young people with mental health needs between 2014 and 2019. We make specific reference to two projects: the You Know Your Mind Evaluation (2020) and the Talk about Self-Harm Project (2016).

We provide evidence in relation to the following two areas:

• The wider changes needed in the system as a whole, and to what extent it should be reformed in favour of a model that focuses on early intervention in children and young people’s mental health to prevent more severe illness developing.
• What measures are needed to tackle increasing rates of self-harming and suicide among children and young people?

The You Know Your Mind (YKYM) Project aimed to provide personalised care, based on a model of social prescribing, for young people with mental health needs. It used non-clinical support plans for young people in the looked after care system and for care leavers. 

The Talk About Self-harm Project (TASH) was a project across three GP surgeries to gain insights into the barriers and enablers to helping conversations in the 10-minute window of a primary care appointment.

Common findings across both bodies of research:

• To be successful, early intervention must involve the young person feeling listened to; 
• Ease, speed, and transparency of referral processes are key to prevent crises;
• Young people are capable of having informed, articulate conversations about difficult circumstances in ways that promote good mental health;
• Clinicians need training to respond better to young people without pathologising their behaviour as mental illness;
• Co-presenting anxiety and depression were the most common conditions affecting young people;
• Trust is key to helping relationships and can be transformative;
• Youth services offered by local authorities were highly valued and important to the young people to have helpful non stigmatising conversations about their mental health.

Findings specific to our research on young people who self-harm:

• As many as one in fifteen young people engage in self-harm in the UK;
• Young people’s access to mental health support remains focused on pathologising young people’s reactions to difficult circumstances and disadvantage rather than working with them to find personalised solutions to the issues they face;
• Most young people report that their self-harm is a coping strategy that is used as an attempt at self-help, and they would like help to manage this;
• Clinicians need support to develop a better understanding of young people’s help seeking behaviours for specific needs such as anxiety and depression as distinct from self-harm connected to personal stress/problems.
• There is a dearth of good quality information available to support young people to manage non-life threatening self-harm. Clinicians need training to work with resources that are informed by young people’s experience;
• Appointment times are a limiting factor for effective GP support;
• Some young people who talked about self-harm to professionals experienced being dismissed because of their age.

Findings specific to young people in the You Know Your Mind project:

• Giving young people a ‘voice’ in their own care and needs is crucial to the success of interventions. This can also develop independence;
• With non-clinical support plans in place, young people’s CAMHS usage dropped significantly, and they were better able to support themselves to deal with symptoms of common mental health conditions such as depression and anxiety;
• Support plans were significantly more cost effective than CAMHS interventions and contributed to a reduction in risky behaviours such as self-harm and substance misuse. For some young people their support plan was a life-changing experience;
• Young people saw the support from YKYM as different to the support received from CAMHS services. YKYM was more likely to be experienced by the young people as a tool to help them manage their emotions. This encouraged young people to engage. We think that young people may find it easier to take part in an activity that for them is experienced as personally therapeutic, rather than engage in the clinical support typically, offered through CAMHS.

We recommend that:

• Referral processes should be rapid and fully explained to young people;
• Clinicians should be trained to listen to young people and respond appropriately, and to involve young people in decisions about their treatment;
• Clinicians should be supported to provide support to young people’s distress that treats it as a response to life events or difficulties, rather than always as an indication of mental illness;
• Funding to local authority youth services which give young people opportunities to socialise should be reinstated.
• Young people should be given more time and support from primary care to manage their self-harm;
• Young people should be provided with good quality information to support them to manage non-life threatening self-harm, and professionals should be trained to use such materials that are informed by young people’s experience;
• More use could be made of longer GP appointments;
• Given the effectiveness of the YKYM model, funding for similar initiatives should be provided and the linked activities supported.

2. Submission

Our submission is based on a body of research conducted with young people with mental health needs between 2014 and 2019. We make specific reference to two projects: the You Know Your Mind Evaluation (2020) and the Talk about Self-Harm Project (2016).

We provide evidence in relation to the following two areas:

• The wider changes needed in the system as a whole, and to what extent it should be reformed in favour of a model that focuses on early intervention in children and young people’s mental health to prevent more severe illness developing.
• What measures are needed to tackle increasing rates of self-harming and suicide among children and young people?

Our research included involvement from underrepresented groups of young people:

• young people in the looked after care system and care leavers with mental health conditions;
• self-identified LGBTQ young people who self-harmed.

The You Know Your Mind (YKYM) Project aimed to provide personalised care, based on a model of social prescribing, for young people with mental health needs who were currently in the Looked After Care System or were care leavers in either Nottingham City or Nottinghamshire. It used non-clinical support plans for young people in the care system and care leavers, developed through a ‘different’ conversation with their social workers. 

The support plans were nested within helping conversations that began by asking young people to describe their ‘best day’. This shifted the focus on support, to solving problems and promoting self-care to manage mental distress rather than relying on mental health treatments. Support plans reflected:

• improving young people’s relationships with others
• resources to support hobbies and interests
• resources to enable education/learning/employment

The Talk About Self-harm Project (TASH) was a project across three GP surgeries in Nottingham, to gain insights from young people, GPs and practice nurses about the barriers and enablers to helping conversations in the 10-minute window of a primary care appointment. Analysis of patient records for 296 young people revealed information about their self-harming behaviours, the referral processes engaged in to lever support from specialist services and patterns of self-harm types by gender. The analysis of patient records was followed by separate focus group research with clinicians and young people.

Common findings across both bodies of research:

• To be successful, early intervention must involve the young person feeling listened to; 
• Ease and speed of referral processes are key to prevent crises. Referrals need to be explained to the young people, for example who they are being referred to and a likely timeline. Young people suggested that such information giving, should be augmented with information they could access again later as a reminder of what was discussed.
• When young people experience trust and feeling listened to by professionals, they are more than capable of having informed, articulate conversations about difficult circumstances in ways that promote good mental health;
• Without exception, all the young people involved in the research disliked being referred to as having mental health problems. They preferred to talk about self-care.
• Young people need to experience helping conversations with health and social care professionals that treat their distress/symptoms as something that is a response to difficult life circumstances, rather than one that trivialises it as unimportant or pathologises it as a sign of mental illness. However, this is an area where staff need training to develop their skills;
• Co-presenting anxiety and depression were the most common conditions affecting young people;
• Young people in both projects had experienced difficult life circumstances arising from trauma, abuse, and being let down by adults. Trust is key to successful helping relationships. Where this is established, for example with a GP or a youth/social work professional, this can transform the young person’s previous experience;
• Youth services offered by local authorities in the form of group opportunities for young people to socialise generally were highly valued and important to the young people as an outlet to have helpful non-stigmatising conversations about their mental health. Such services have been depleted significantly in recent times and this has had a knock-on effect in curtailing support opportunities for these groups.

Findings specific to our research on young people who self-harm:

• Self-harm, typically with an onset in adolescence, is a major public health concern with as many as one in fifteen young people engaging in self-harm in the UK.
• Young people’s access to mental health support remains focused on pathologising their reactions to difficult circumstances and disadvantage rather than working with them to find personalised solutions to the issues they face.
• Most young people report that their self-harm is a coping strategy that is used as an attempt at self-help. They would welcome more time and support from primary care to manage their self-harm. This requires a focus on supporting young people to help themselves in other, less damaging, ways.
• Insufficient detail is recorded in medical records about young peoples’ intentions when self-harming. There are pros and cons with this. More detail may afford a better understanding of the types of self-harm behaviour young people engage in. However, many entries in records are direct transcripts from letters, made by administrators. This often leads to misreporting and judgemental comments being included which are not helpful.
• We need to know more about young people seeking help for self-harm that involves cutting as distinct from other means, such as burning.
• Clinicians need support to develop a better understanding of young people’s help seeking behaviours for specific needs such as anxiety and depression, as distinct from self-harm that is reportedly connected to personal stress/problems.
• There is a dearth of good quality information available to support young people to manage non-life threatening self-harm that typically presents as a strategy to manage distress. ‘Self-help' materials about self-harm, designed and created with the involvement of young people, can provide an object of focus for some young people and professionals to begin a helpful conversation about the behaviour. Such conversations allow the young person and health professional to co-construct meaning regarding the behaviour, and how the young person understands and might manage this. For such conversations to happen the helping professional already needs the skills and confidence to work with self-harm; the research shows than many do not.
• Appointment times are a limiting factor for effective GP support. Practical arrangements, such as double appointments, are used by some GPs and practice nurses and likely to be needed to explore self-help materials effectively with young people during a primary care consultation.
• Some young people who talked about self-harm to professionals gave accounts of being dismissed because of their age. These accounts testified to this experienced being unhelpful.
• Young people held mixed views about the role of social media in interventions to help them manage their self-harm, because of issues relating to confidentiality online.

Findings specific to young people in the You Know Your Mind project:

• One of the crucial elements of the YNYM project was that the young people felt listened to and participated in the development of their support plan from the outset. This involvement was highly valued by the young person as it allowed them to have ‘a voice’ in their own care and needs. Consequently, the young person was taking part in activities that they enjoyed or had chosen to do rather than something that had been chosen for them or imposed on them. This was important to young people’s mental health and the success of the project.
• The YKYM project was able to cut through the bureaucracy usually connected with referral. This benefitted young people because it supported a timely engagement before a young person entered crisis. Unlike specialist mental health services such as CAMHS young people were not placed on a waiting list for support, and the support plan was developed with the young person immediately. As YKYM was offering immediate support to the young person, this could act to prevent their mental health needs increasing in severity, and therefore guard against more intensive support from other professional services. 
• The different conversations they had with social workers resulted in young people feeling listened to and supported them to develop their independence. The young person’s own involvement in designing their support plan from the beginning better enabled them to deal with their mental health. It encouraged the young people to reflect on their own lives and what they felt would help them. More than half (61.8%) of young people reported that they felt more independent following YKYM support. The young people were empowered to take control of their own mental health.
• With non-clinical support plans in place, young people’s CAMHS usage dropped significantly, and they were better able to support themselves to deal with symptoms of common mental health conditions such as depression and anxiety.
• Support plans were significantly more cost effective than CAMHS interventions and contributed to a reduction in risky behaviours such as self-harm and substance misuse. For some young people their support plan was a life-changing experience. To try and quantify this type of transformation in respect of the cost savings to services detracts from the impact of the intervention on the young person’s life.
• We found that young people saw the support from YKYM as different to the support received from CAMHS services. YKYM was more likely to be experienced by young people as a tool to help them manage their emotions. This meant young people were more likely to engage, as they did not view YKYM as an intervention to improve their mental health. It was suggested that young people may find it easier to take part in an activity that they deem to be personally therapeutic rather than engage in the clinical support typically offered through CAMHS.

3. Recommendations

• Referral processes should be rapid and fully explained to young people;
• Clinicians should be trained to listen to young people and respond appropriately, and to involve young people in decisions about their treatment and referrals to other services;
• Clinicians should be supported to respond to young people’s distress in ways that treats it as a response to life events or difficulties, rather than always as an indication of mental illness;
• Funding to local authority youth services which give young people opportunities to socialise in a variety of different kinds of groups should be reinstated;
• Young people should be given more time and support from primary care to manage their self-harm, including supporting young people to help themselves in other, less damaging, ways;
• Young people should be provided with good quality information to support them to manage non-life threatening self-harm. This should not only be provided online. Professionals should be trained to use such materials in direct helping conversations with young people;
• More use of longer GP appointments to support young people more effectively;
• Given the effectiveness of the YKYM model, funding for similar initiatives should be provided and the linked activities supported.

February 2021