NAPAT PRASITSIRIGUL
Dear Mr. Javid,
CAMHS is a joke.
Like many others my age, I enjoy mindlessly scrolling through TikTok in my free time. Occasionally I come across a teenager parodying their experiences at CAMHS. These clips usually follow the same pattern: a teenager comes to their CAMHS appointment and discloses worrying information about their mental health to their CAMHS worker, only for their problems to be trivialised and easily solved by ‘taking a bath’ or ‘having a warm cup of tea’. Though I was initially entertained by the absurdity and dark humour, I began to question whether there are deeper issues at hand with our young people’s mental health services.
#CAMHS sees millions of young people engaging in issues of mental health on TikTok; the hashtag has received over 200 million views, where 40% of videos raise awareness on mental health symptoms and management and 27% portray CAMHS in a negative light (Chadee and Evans 2021). On the one hand, we should be delighted to see that young people are actively promoting mental health. On the other, we should be concerned that so many feel their care is inadequate, absurd, and essentially, a joke. More and more young people are seeking help, seeing that the number of monthly referrals to CAMHS in England has doubled between 2017 and 2021 (NHS 2021). But what kind of help are they getting?
I am delighted that the COVID-19 pandemic has already brought the severe insufficiency of our youth’s mental health services to your attention, and that you have singled it out as the main problem to address in your ‘reset’ of the NHS Long Term Plan (Hacker 2022). I wholeheartedly agree with you on the need to reset the plan, though I implore you to push further.
What we need is a reset to the system.
Sure, mental health services for young people have been overstretched by COVID-19, but they have never been sufficient regardless (Fuggle et al. 2016). Year after year, we see accounts of mental health services failing our youth, leaving them helpless (Burns 2016; Harvey 2012; Triggle 2021). As I will soon demonstrate, the problem is chronic, complex, and structural, and thus requires a complete reconceptualisation of what we consider to be good mental health care. I desperately urge you to read this letter; to realise the messy realities of our youth’s mental health services and to consider acting on my propositions.
It isn’t surprising that mental health gets the short end of the stick when it comes to our medical system. Gordon illuminated to us that biomedicine is supported by our inclinations towards materiality – it’s hard to believe that something is wrong when we can’t see the problem (1988, 32). We take what we can see to be self-evident, treating it as a “criterion of truth” (1988, 33). Oftentimes, mental illness is hardly visible and has to be materialised to be taken seriously, thus the bureaucracy, the criteria, and the checklists we have created to fit mental health into our biomedical worldview (Jousselin 2018, 5). These practices are crucial for the functioning of the NHS, but they leave many young people with mental health problems falling through the cracks, in particular, those who are not considered ill enough to receive care (Jayanetti 2021)
Because services are so overstretched, there is no room for complexity. Young people on TikTok and internet forums have expressed their frustrations with reductive treatments from CAMHS workers. For example, one person said their CAMHS worker refused to accept they were depressed because they “got 10A*s in [their] GCSEs”, despite them trying to explain that they use schoolwork as a coping mechanism. As you can see, the current state of CAMHS reduces the complex mental health needs of young people to a checklist exercise.
On TikTok, we can see that young people try to game the system. They share advice on how to get their cases taken seriously: to access these specialist services, there must be material signs that they are ill enough to receive help, such as dressing poorly or explicitly saying that they are suicidal (Maller 2015).
Health workers often don’t understand why service users want a diagnosis. Anthropologists have demonstrated that a diagnosis legitimises a person’s illness and makes them visible and actionable to medical professionals (Street 2014). It also allows them to engage in identity politics, where they can gain support from those who share the same illness (Behrouzan 2015). All this is to say, an initial CAMHS assessment must be timely, such that a service user’s problems can be promptly identified, legitimised, and escalated to receive appropriate treatment. This is not the case right now.
In 2019-20, 23% of under-18s referred to mental health services were never contacted by a health worker to discuss their care (NHS 2021). Access to specialist CAMHS services is reserved for those with the most severe mental health issues, leaving those with mild-to-moderate issues to face prolonged and agonising waiting times – with some having to wait years before being seen (CQC 2017, 18).
What’s worse is that whilst waiting to be seen, young people do not have appropriate support, leading their conditions to worsen (Jayanetti 2021). In a survey of 1000 parents, 72% reported feeling unequipped to deal with their child’s mental health difficulties (STEM4, 2019). 43% of GPs recommend parents to pay for private services, which severely disadvantages those who could not afford them and perpetuates cycles of inequality. The general narrative is that these parents and children are left to fend for themselves (2019, 5).
It isn’t that CAMHS isn’t trying. In fact, due to the NHS internal market model, CAMHS are under pressure to meet waiting time targets and various bureaucratic deadlines that sustain the reputation of the business (Briggs 2018, 3). Whilst trying (and often, failing) to meet these targets, the quality of work is compromised. Jousselin, an anthropologist who conducted fieldwork in an ADHD clinic noted how these pressures have led staff to cut corners and impose more responsibility on their patients to remember their own appointments – a task their illness makes particularly difficult (2018, 13). Briggs, on the other hand, illuminated how psychotherapists are finding their work meaningless as they do not have time to develop close relationships with their patients and understand their complex needs – a key part of their job – to attend to these bureaucratic activities (2018, 3).
What do we do when service users desperately need to ‘wait less’, but service providers desperately need them to ‘wait more’?
Anthropologist Wright offers some solutions in her concept of “making good of crisis” (2022, 315). When we have competing temporalities i.e., the acuteness of the service user’s need for help and the chronicity of our overstretched mental health services, we must learn to “create time” (2022, 321).
Waiting does not have to be a period of paralysis and subjection (Bourdieu 2000), it can also be an opportunity for action and self-cultivation (Jeffrey and Young 2012). Waiting can be a period in which patients can become an expert on their illness and prepare themselves for their long-awaited treatment. Even though funding for CAMHS is expected to cover 345,000 more young people aged 0-25 by 2023 (NHS 2019), it is still far from covering every young person who needs care. Thus, we need to know how to sufficiently accommodate young people whilst they wait. I propose the following solutions:
- Diagnosis must happen early
A diagnosis allows the patient to identify with their illness, feel empowered, and begin to educate themselves on their condition. It also helps medical professionals legitimise their suffering when they are referred for treatment in the future.
- Improve collaboration with third sector services
The 2021 Care Quality Commission report suggests that there is poor collaboration between organisations offering young people’s mental health care. Young people should be confidently signposted to appropriate community services such as support groups whilst they wait for treatment from CAMHS specialists.
- Mental health training programmes for family members, teachers, and GPs in all communities
These people are on the frontline of mental health care for young people yet have reported feeling unable to handle their children’s mental health difficulties (CQC 2017, 23).
- Remove waiting time targets apart from diagnosis
The pressure of waiting time targets leads services to deliver compromised care. Young people value close relationships with CAMHS staff who understand their complex individual needs, thus much time is needed to deliver good care (CQC 2017, 27).
More funding is vital and very welcome, but that alone won’t solve our longstanding problems with CAMHS. What we need is a restructuring of the system, such that care can be delivered in an efficient, uncompromised manner with our limited resources.
I strongly urge you to consider implementing my suggestions in your reset of the NHS Long Term Plan. CAMHS shouldn’t be a joke for our young people; it should be a beacon of hope.
Yours Sincerely,
Napat Prasitsirigul
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References
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