Wednesday, 15 May 2019

The simple bit of equipment that will transform your child and adolescent mental health assessments


Mental health problems in children and young people (CYP) are common and on the rise.  Identifying these problems in CYP is particularly challenging due to a variety of barriers.  Some of those barriers exist within ourselves (misconceptions) or our working environments (time pressures).  Often the barriers come from the child or young person.   All of these barriers can be overcome.  Let’s look at how that is possible.

The first place to start is with ourselves.  We need to make sure that our attitude towards CYP and their mental health is such that we are open to see and hear the signs that indicate what is going on.  A positive attitude is also essential so that the CYP and their family are likely to want to disclose what they need to in order to get a good picture of what is happening.   All the usual things that apply to working with young people apply in a mental health assessment but are more important than ever due to the patients mental state.
Next we need to look at our working environment.  The time pressure issue is a big one.  The bottom line is that unless we find a way to make time for mental health presentations, we can’t expect these contacts to be effective.  There are many other environmental factors to consider which are key to helping CYP access the help that they need.
Finally there are the barriers that seem to come from the CYP.  As suggested above, it is a good thing to see any such barriers as expected.  The worse the situation, the bigger the barriers are likely to be, and the greater the need to have these barriers overcome.  The right attitude and environment are both hugely important in overcoming these barriers.  It also helps to name them with the patient and their family.  That goes something like this:

With the family present- "I know that it is really difficult to put how you feel into words.  It’s also usual to be thinking that if you tell me what you’ve been thinking, I will think you’re crazy.  I won’t.  Anything that you can tell me will be really helpful.  Just tell me in your own words and take your time.  You’ll get a chance to talk to me without your family being there so feel free to save anything that you’d rather talk about without them there for then."

With the young person on their own – "We always give people a chance to talk about what is happening without their family sitting in.  That’s important for a couple of reasons.  Firstly these things are complicated and quite often young people feel that their family either don’t understand what’s happening or have strong opinions that make it difficult for you to say things the way you see them.  Here on your own you can talk about things and know that I’m just interested in what you want to tell me about what’s happening and how you are feeling.  Secondly, there are some times that there are things that really need some privacy to be able to talk about.  That can be things that you feel you can’t tell your family about, like taking drugs, or it can be things that I need to know such as if someone is harming you in any way.  I’ll treat things you tell me with confidentiality wherever possible.  If someone is harming you then I would need to act on that to keep you safe."

Even when you go through all of that, it is sometimes the case that all you get is shrugs and a marked lack of usable interaction.  At that point, you have another ace to play.  It is a valuable piece of equipment in CYP mental health assessment and it looks like this:
Giving the patient the opportunity and the space to write instead of speaking is a game changer in ways that you might not expect.  In a spoken interaction, CYP in a mental health crisis are likely to find it difficult to find the words to say how they have been feeling and thinking.  They will worry about the response that they will get to what they say.  This fear of being appraised can be paralysing.  Even if the person they speak to does everything perfectly in terms of verbal and non-verbal communication, the CYP may over-think everything they see.  Such is their hyper-acute mental state that this happens easily.  “They just frowned slightly.  Does that mean that they don’t believe me?  Perhaps it means that what I said is completely mental.”

A piece of paper doesn’t have an opinion and there is no response to misinterpret.  It doesn’t rush you and you don’t have to worry about getting your words right.  You can write it down and see if it looks OK before anyone else sees it.  A piece of paper accepts everything you put on it without interrupting or giving your family the opportunity to tell your story differently.

Try it out as a strategy the next time a child or young person is struggling to communicate in a mental health consultation.  You might be very surprised and pleased with the results.

Edward Snelson
@sailordoctor

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