Community Adolescence Mental Health Services (CAMHS)

Predisposing factors – Her mother had post-natal depression (PND) and was alcohol dependent. Her father was in the military and had symptoms of complex post-traumatic stress disorder (PTSD) but did not seek support for this and was also alcohol dependent. Olivia has three younger siblings; all were physically and emotionally abused by both parents. This led to her and her siblings becoming ‘looked after children’ (by the local authority).

Olivia was separated from her siblings and has moved from placement to placement over the last five years. Olivia has previously been assessed by CAMHS, but has been unable to engage with them meaningfully. As Olivia is under Section 20 of the Children and Families Act (2014), she has a social worker, and her parents are still involved in her care.

Presenting factors – Olivia 17 years 10 months old has experienced complex trauma and is struggling with emotional regulation, she has been diagnosed with attention deficit hyperactivity disorder (ADHD) and she restricts her eating to lose weight as a form of self-harm. She uses recreational drugs and states this is self-medicating and the only way she can manage the effects of the trauma she has experienced.

Olivia is currently in a CAMHS inpatient unit due to a recent suicide attempt which resulted in an admission to intensive care. She continues to restrict her eating. On admission to the CAMHS unit her risks of absconding, self-harm and suicide have all significantly increased. Prior to admission she had been living in ‘independent living accommodation’ which had been put into place by the local authority. The MDT have assessed this environment, and it is not currently considered suitable.

Precipitating factors – As Olivia is nearly 18 years old her care will soon be transferred to adult services. In addition to the this, she has recently moved to the area and is now one hour away from her family home. She demonstrates intense emotions that change quickly and she is increasingly relying on her self-harming behaviours and doesn’t feel like she is coping very well.

Olivia feels unable to attend college at present and she continues to have poor relationships with her parents. Both of her parents have attended ‘parenting courses’ and received support and are now more involved in her care planning. Olivia is still not able to live with them and does not want this. When she speaks with her family, she has intrusive thoughts, which has led her to thinking about self-harm and ending her life.

Perpetuating factors – Olivia’s childhood experiences, her difficult family relationships and her reliance on self-medication and self-harm all contribute to and maintain her current situation. Within the next eight months Olivia is due to transfer to Adult Mental Health Services and be discharged from CAMHS. This change may be very difficult for her to manage (Singh et al., 2017).

Olivia is caring towards others but at times has problems with her boundaries, so she can become over-attached or push others away because she worries that people will hurt her emotionally or physically, or might abandon her.

Protective factors – Olivia has a social worker, and a CAMHS practitioner (Jasmine), and has recently got back in touch with one of her sisters. She loves art, biology, and maths. Previously she attended college and really liked this.

After completing the 5 Ps assessment, (based on the recorded information) Isabella feels more informed about Olivia’s background and how she became unwell and in addition she has gained some insight into the contributing factors to her recent admission to hospital. Isabella asked Jasmine about the best approach to keep Olivia safe, and whether remaining in hospital under Section 3 of the Mental Health Act (1983, amended 2007) is best for Olivia, or whether exploring returning to her supported living placement in the community is appropriate.

Using a coaching approach Jasmine supported Isabella to consider the consequences for Olivia remaining in hospital. Reflecting together Isabella started by expressing her concerns about a recent phone call from Olivia’s care placement to the CAMHS teams, stating that Olivia was ‘becoming unmanageable’ because of her level of self-harm, her recreational drug use, and her restrictive diet. They don’t feel able to keep her safe. By staying in hospital Olivia would be monitored 24 hours a day, seven days a week. This would reduce the risk of her harming behaviours and using substances. Isabella also reflected that keeping Olivia in the inpatient facility would mean that she continues to be isolated from her support network, could lose her overall freedom and control, and would be delayed in re-engaging with college. Both Jasmine and Isabella continued to consider a positive risk-taking approach, i.e., supporting Olivia in the community verses use of the more risk averse approach of keeping her in hospital.

Jasmine and Isabella then chaired the MDT Care-Programme Approach (CPA) meeting to support Olivia and explore her options. Olivia exclaimed “I feel trapped, here and I have nothing left to lose!” The team felt it was likely her risks would increase by staying in hospital, and previous admissions had not resulted in progress. Jasmine advocates for Olivia and recommends finding a suitable placement for her in the community so she can continue to build on her relationships with others, attend college and continue to develop an independent life.

After the meeting Isabella asked Jasmine for a debrief, Isabella was still making sense of not only this meeting, but Olivia’s overall situation and her options. Jasmine asks what might help with this and Isabella says, “there is so much going on from so many different areas, and I am concerned about keeping her safe”. Jasmine suggests looking at a recovery model, for example, the Tidal model (Barker & Buchanan-Barker, 2010) as this recognises experiences of health and illness as fluid and diverse, and explores contributing factors as well as cumulative effects, that could relate to Olivia’s experiences and circumstances. This is explored further in the reflective account.