“I became what I am today at the age of twelve, on a frigid overcast day in the winter of 1975. I remember the precise moment, crouching behind a crumbling mud wall, peeking into the alley near the frozen creek. That was a long time ago, but it’s wrong what they say about the past, I’ve learned, about how you can bury it. Because the past claws its way out. Looking back now, I realize I have been peeking into that deserted alley for the last twenty-six years.”
― Khaled Hosseini, The Kite Runner

In my day-to-day working life I see many young people. Many of them have been given various mental illness diagnoses. While many of these are correct according to our “diagnostic” manuals, they add little to helping a young person find workable solutions to their dilemma.

As a Child and Adolescent Psychiatrist, I feel that my remit should lie in working to improve mental health and not just in treating mental “illness”. This is supported by the organisation for which I work.

The Recovery Model lies at the heart of its philosophy of care and is one of its guiding principles. This means that we should focus on helping young people, and their families, to enable the young person to lead the best possible life, no matter the nature, or degree of illness, or what sort of difficulties that they have.

Most of these young people have problematic lives. The problems in their present life, and their responses to them, are the reason they have been admitted to the inpatient unit on which I work. They have problems now, have always had problems, and fully expect that this will continue into the distant future. This is a pattern that can often be tracked back over several generations.

Problem saturated lives create a sense of paralysis about change.  They leave people feeling helpless and with little hope that their lives can change for the better. This is made worse when the strategies that they have developed, to cope with the stresses of living their lives, raise high levels of anxiety in those who care for them. These strategies may be effective in the short-term but ultimately have longer term disadvantages.  Such self-treatment may involve the use of drugs and alcohol, self harm, and other dangerous, or just reckless, out of control behaviours. These can put the lives of young people and others at risk.

Problem saturated lives create a sense of paralysis.

The way that services respond can also be unhelpful. When the caring environment is too risk averse, young people with self-injurious behaviours can end up trapped in a cycle of brief admissions and discharges, ultimately creating even more distress for the young person.  Behaviour that generates further anxiety in many professionals, resulting in an even more risk averse response.

The syndrome of revolving door medicine.

Young people who are already struggling to contain their difficult emotions can become increasingly overwhelmed. Services that are intended to help ease their distress, end up teaching them that their feelings are so awful that not even the services that are meant to help, can contain them.

I see too many people whose “successful” short-term coping strategies have become their lifestyle, where maladaptive coping strategies are called into action as they become increasingly overwhelmed.

Adolescents and children, whose problems have often arisen from significant trauma and abuse, are accidentally re-traumatised by the processes of the agencies that are meant to help.  Services that are themselves often stretched to breaking point.

Safety in our relationships is of vital importance.

Pejorative labels are then applied, borderline personality disorder, emerging emotionally unstable personality disorder, cutters, or just attention seeking, are just a few. This results in a descriptive diagnostic category, that was created for other purposes, being turned into a concrete reality.  Thus producing a label that engenders a sense of despair, and therapeutic pessimism, not only in those whose job it is to help, but also in those who are presenting for help.

The patient seems to become blamed for their predicament. This seems to become a reason to justify the way traumatised services may react to those who seek their help.

One focus that services could adopt to help prevent such a culture developing, and to minimise the effects of one that has already evolved, is to develop training packages for the front line staff who deal with such clients on a daily basis. (I always find it interesting that the services in which I have worked always use such military metaphors!!!). 

A training package that enables us to see distressed young people as the emergencies that they are, people who need – and deserve – the same care, and detailed attention to assessment and treatment planning, as ony one else.  Rather than annoying, attention seeking children, who get in the way of the “real” work of the Emergency Department or Mental Health Team.

 

In these cash strapped times, where balancing the deficit rules, it is necessary to focus on the crisis response of treatment, and not on prevention – which has always the best long-term option, and one that underlies the idea of Health Services. Although programmes such as Head Start – which are designed to offer support to families who are seen as being “at risk” – have been demonstrated to be cost-effective in the long run, it is often this kind of programme that is cut to balance the books.

Maladaptive coping strategies are called into action.

This makes it all the more important that those services that do exist, offer the most effective interventions available, and conduct research into new ways of working. If treatments are to be offered in a timely way it is vital for there to be easy access to these services, which need to engage people in treatment, with as little fuss as possible.

As helping services there are four main aspects that we need to consider in our care of this client group.

SAFETY.

• Perhaps the main underpinnings of high quality services for this group is a combination of careful risk assessment and safety planning. This needs to be carried out in a timely and thorough fashion.
• Once this has been completed, we should then  use the least restrictive intervention that enables the young person to mobilise their own resources in a more constructive way.
• Constructive in the sense of helping to build a future where they can act differently, a future based on their best hopes. A future in which hope and some sense of personal power, replace helplessness and lack of hope.
• Safety needs to be considered in a wider sense than just immediate risk.  We need to consider environmental safety, that is both the risk to others around the young person, the risk to the young person from others, and the risk that admission or other treatment settings might offer.
• Personal safety, especially around developing a valid sense of self. Safety in our relationships is of vital importance in young people, it is through their relationships with important others that they develop socially and emotionally. 
• Many of the young people who use these kinds of coping strategies, have a history of relationship trauma, often going back to their early years.  It is during these early years that we develop strong attachments to our caregivers, the prototype relationships that enable us to form mutually supportive liaisons throughout our lives. 
• When these attachment dynamics go awry, relationships can become difficult to both create and maintain.
• Safety is not just for the young people.  We need to make sure that there is adequate supervision, debriefing and support for the staff involved. Working with this kind of trauma  is confronting in its own right, and will tend to exacerbate our own early relationship problems.

MANAGING EMOTIONS.

• Helping young people to recognise the links between their emotions, feelings, thoughts and behaviours is the main stay of treatment.
• Much of the time their fight or flight response is being triggered by stimuli that might seem to an onlooker as trivial., but whose subjective power is out of proportion to necessity. 
• A careful eliciting of triggers, protective factors, distractions etc. is the basis of short-term safety planning.
• This should be undertaken in collaboration with the young person, properly trained staff, and the family or other support person.
• For instance safety proofing the accommodation is important as it can delay the young persons’ ability to respond as rapidly to their emotional triggers. 
• A delay can often mean that emotional regulation has a chance to occur through other means.  This can gradually help to allow earlier intervention in the acute phase allowing resolution of emotional escalation using more adaptive coping skills. Skills that this process of delay allows to develop.

 

ADDRESSING LOSS.

• It is common for those whose attachment behaviours have not been able to develop along more normal lines, to experience minor separations as major losses.
• Loss of a parent in childhood is one factor contributing to depression in later life. 
• Limited emotional availability because of parental illness, separation, or depression is another form of loss that contributes to the difficulties experienced by young people.  These kinds of losses may not be acknowledged or given space to be worked through. It is often in these situations that we see parental roles in the household being reversed.  Here, the younger members of the family effectively become the parents, having to look after both themselves and their parents at the same time.

 

FUTURE ORIENTATION.

• When we focus on the future with young people we are starting the process of allowing them to individuate, and to become their own person.
• One of the main focuses of adolescent development is the move away from being a child, who is part of a family to being a person who is ready to start their own, new family.
• New ways of being are important here, and this underlies the often mercurial way that adolescents try out novel experiences, beliefs and ways of being. 
• The search is on for a sense of meaning in their lives.
• Who am I? What do I believe in?
• Where did I come from?
• Where do I want my life to go?
• Moving away from being a victim, whose actions have been determined by the things that others have done to us.
• Moving towards being a survivor, someone who is getting on with our lives, living the way we wish, despite the horrors of our past.
• What are my best hopes for the future?

If we can direct our focus aways from the current behaviours, and help  our clients and their families to develop a shared view of how they want their future to look, we can then develop a pattern of care and support that is enabling of change, encourages individuation, and allows a perspective on the recovery process as part of the big picture.

Each of these four elements can be addressed flexibly as changing circumstances dictate.  Each element can then move forward at different speeds, and with different priorities, as part of the bigger treatment picture. 

A focus on this pattern of helping will foster a greater understanding of the complex issues that underlie so much of this work, enabling clinicians, families, and patients to have a shared model, one that is inevitably about recovery and strengths.  If we can move away from confusing psychological and pathology based language, it can only help to demystify the processes that are involved in helping to generate change.

Perhaps then, we can bring an even closer atmosphere of collaboration to the treatment of a challenging group of patients, and prevent the development of a pejorative, us versus them mindset.