Lockdown and adolescent mental health: reflections from a child and adolescent psychotherapist

The author, a child and adolescent psychoanalytic psychotherapist working in the UK NHS, ponders the varied impacts of ‘lockdown’ on adolescents, their parents and the psychotherapists who work with them, during the COVID-19 pandemic. She asks, particularly, how psychological therapies are positioned during such a crisis, and whether the pressures of triage and emergency can leave time and space for sustained emotional and psychological care. She wonders how psychoanalytic time with its sustaining rhythm can be held onto in the face of the need for triage on the one hand and the flight to online and telephone delivery on the other. Above all, the author questions how the apparent suspension of time during lockdown is belied by the onward pressure of adolescent time, and how this can be understood by, and alongside, troubled adolescents

Continuity of care for carers of people with severe mental illness: Results of a longitudinal study

Background: Continuity of care is considered by patients and clinicians an essential feature of good quality care in long-term disorders, yet there is general agreement that it is a complex concept. Most policies emphasise it and encourage systems to promote it. Despite this there is no accepted definition or measure against which to test policies or interventions designed to improve continuity. We aimed to operationalise a multi-axial model of continuity of care and to use factor analysis to determine its validity for severe mental illness. Methods: A multi-axial model of continuity of care comprising eight facets was operationalised for quantitative data collection from mental health service users using 32 variables. Of these variables, 22 were subsequently entered into a factor analysis as independent components, using data from a clinical population considered to require long-term consistent care. Results: Factor analysis produced seven independent continuity factors accounting for 62.5% of the Total variance. These factors, Experience & Relationship, Regularity, Meeting Needs, Consolidation, Managed Transitions, Care Coordination and Supported Living, were close though not identical to the original theoretical model. Conclusions: We confirmed that continuity of care is multi-factorial. Our even factors are intuitively meaningful and appear to work in mental health. These factors should be used as a starting-point in research into the determinants and outcomes of continuity of care in long-term disorders

Supported employment: Cost effectiveness across six European sites

A high proportion of people with severe mental health problems are unemployed but would like to work. Individual Placement and Support(IPS) offers a promising approach to establishing people in paid employment. In a randomized controlled trial across six European countries, we investigated the economic case for IPS for people with severe mental health problems compared to standard vocational rehabilitation. Individuals (n5312) were randomized to receive either IPS or standard vocational services and followed for 18 months. Service use and outcome data were collected. Cost-effectiveness analysis was conducted with two primary outcomes: additional days worked in competitive settings and additional percentage of individuals who worked at least 1 day. Analyses distinguished country effects. A partial cost-benefit analysis was also conducted. IPS produced better outcomes than alternative vocational services at lower cost overall to the health and social care systems. This pattern also held in disaggregated analyses for five of the six European sites. The inclusion of imputed values for missing cost data supported these findings. IPS would be viewed as more cost-effective than standard vocational services. Further analysis demonstrated cost-benefit arguments for IPS. Compared to standard vocational rehabilitation services, IPS is, therefore, probably cost-saving and almost certainly more cost-effective as a way to help people with severe mental health problems into competitive employment

Continuity of care for carers of people with severe mental illness: results of a longitudinal study

Introduction: Continuity of care has been demonstrated to be important for service users and carer groups have voiced major concerns over disruptions of care. We aimed to assess the experienced continuity of care in carers of patients with both psychotic and non-psychotic disorders and explore its association with carer characteristics and psychological well-being. Methods: Friends and relatives caring for two groups of service users in the care of community mental health teams (CMHTs), 69 with psychotic and 38 with non-psychotic disorders, were assessed annually at three and two time points, respectively. CONTINUES, a measure specifically designed to assess continuity of care for carers themselves, was utilized along with assessments of psychological well-being and caregiving. Results: One hundred and seven carers participated. They reported moderately low continuity of care. Only 22 had had a carer’s assessment and just under a third recorded psychological distress on the GHQ. For those caring for people with psychotic disorders, reported continuity was higher if the carer was male, employed, lived with the user and had had a carer’s assessment; for those caring for people with non-psychotic disorders, it was higher if the carer was from the service user’s immediate family, lived with them and had had a carer’s assessment. Conclusion: The vast majority of the carers had not had a carer’s assessment provided by the CMHT despite this being a clear national priority and being an intervention with obvious potential to increase carers’ reported low levels of continuity of care. Improving continuity of contact with carers may have an important part to play in the overall improvement of care in this patient group and deserves greater attention

Continuity of care for people with psychotic illness: its relationship to clinical and social functioning.

Background: The relationship between continuity of care and user characteristics or outcomes has rarely been explored. The ECHO study operationalized and tested a multi-axial definition of continuity of care, producing a seven-factor model used here. Aims: To assess the relationship between user characteristics and established components of continuity of care, and the impact of continuity on clinical and social functioning. Methods: The sample comprised 180 community mental health team users with psychotic disorders who were interviewed at three annual time-points, to assess their experiences of continuity of care and clinical and social functioning. Scores on seven continuity factors were tested for association with user-level variables. Results: Improvement in quality of life was associated with better Experience & Relationship continuity scores (better user-rated continuity and therapeutic relationship) and with lower Meeting Needs continuity factor scores. Higher Meeting Needs scores were associated with a decrease in symptoms. Conclusion: Continuity is a dynamic process, influenced significantly by care structures and organizational change

‘Maybe you don't actually exist’: Containing shame and self‐harm in a school counselling service

In this paper, I argue that the school counsellor occupies a liminal position in the school environment, on the boundary between the private and the public, and that this position intrinsically reflects the paradoxical nature of shame, at once hidden and viewed. I review arguments that locate the development of primitive shame in early containment failure, with shame being defended against by rage against others or the self. I argue that the school counsellor's position commonly oscillates through the three positions of the child–home–school triangle, but that this is felt particularly acutely when the dynamics projected through this triangle are those of shame and shaming. For adolescents, the paradoxical nature of shame also finds a counterpart in self-harm, a simultaneously hidden and viewed act which I see as a mapping of shame on the body. In exploring the operation of shame in self-harming students, I also argue that chance encounters between counsellor and student in the external school world render projections about intimacy, intrusion and shame particularly powerful

Out of time: adolescents and those who wait for them

This paper draws on the scholarship of an inter-disciplinary project about time and waiting in healthcare to explore questions of urgency and risk in clinical work with depressed and suicidal young people, and how the feeling of being compelled to act can be meaningfully explored from a psychoanalytic perspective. The paper examines adolescence as both a time of inherent crisis and one in which self-harm and suicidal ideation represent particular challenges. It then considers Child and Adolescent Mental Health Service practice in relation to acute mental health crisis, and in the context of the chronic crisis affecting the UK National Health Service. Considering both formal psychoanalytic psychotherapy and the contribution of psychoanalytic thinking to multidisciplinary discussions and emergency work in CAMHS, the author then considers the anticipatory anxieties that affect such work, and the particular role of psychoanalytic thinking for young people burdened by suicidal ideation and the professionals caring for them

Compassion, sadism, words and song: Development and breakdown in the intensive psychotherapy of an adopted boy.

This paper describes the intensive psychotherapy of a late-adopted boy who had been severely traumatised in his first five years of life. In describing the progress and then deterioration of his mental state and his psychotherapy, I examine the development of his compassion for the vulnerable side of himself, as part of a battle between identification with the vulnerable and sadistic aspects of his internal world. I trace how this compassion was reflected in his concern for others in his external world and fantasised others in his play. I also describe the use of sound and rhythm in enabling him to experience sufficient containment in his psychotherapy for his deepest preoccupations to begin to emerge. In so doing, I examine literature on music and musicality, and seek to demonstrate the relevance of Suzanne Maiello’s advocacy of listening with a ‘musical ear’ to psychotherapy with looked-after and traumatised children, whose life ‘rhythms’ have been so catastrophically disrupted