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Child mental health: Norfolk Family Support Teams

Richard Brook
MA/CQSW DipHG
Primary Care Mental Health Worker
Norwich Family Support Team
For further ­information on this project you can contact:
E:richard.brook@norfolk.gov.uk

As the rate of serious mental illness rises in young people, children's mental health is rightly becoming a major cause for concern among health professionals. In Norfolk, a pioneering scheme, now in its fifth year, is offering an early intervention service for young people with emerging mental health problems. Richard Brook describes how Norfolk Family Support Teams have evolved, and outlines some of the techniques practitioners have found helpful in steering ­families towards solutions.

"We asked 'you lot' for help five years ago, and there was nothing you could do"
These words were spat at me outside the County Court in 1997 by an angry mother who had just unsuccessfully opposed the Local Authority's application for an order that ended her contact with her daughter. As a social worker dealing mainly with child protection, I had heard this complaint before, as had my colleagues in other helping agencies.
It does of course make perfect sense, both therapeutically and economically, to intervene early when families first come to the agencies to request services. Therapeutically, because the motivation that drives people into our offices to seek help is an invaluable resource for change. Economically, because early intervention is usually less complex and consequently brief. A "stitch in time" very often does save nine!
I reported the parent's comment to my managers back in 1998, where it sat, presumably among a pile of similar complaints dating back many years. More recently the scales have been tipped, and the realisation has dawned among politicians that there is an alternative to the firefighting approach to family problems and young people's mental health.

Norfolk Family Support Teams
Norfolk Family Support Teams began as a pilot project in 1997, covering a fragment of the county, and staffed by a social worker, a health visitor, CAMHS (Children and Adolescent Mental Health Services) nurse, an occupational therapist, and a clinical and an ­educational psychologist. All were seconded, some for as little as half a day per week. Their brief was to develop and deliver an early intervention service for young people with mild or emerging mental health problems. The achievements of this small team were outstanding and provided the first anecdotal evidence of the effectiveness of early intervention.
Take, for example, William, a 10-year-old who, having seen his parents' marriage and his own sense of security dissolve around him, had become a whirlwind of emotions - kicking out at siblings, teachers, classmates and his mother. Mum turned to her GP, who was able to enlist the help of the newly established team. William was offered five sessions with a CAMHS nurse, who helped him express his thoughts and feelings through creative media, painting, model making and so on, and encouraged him to talk about the changes he had experienced. He was helped to gain more control over his emotions and express them in ways to which his mother could better respond. Mum was given the opportunity to reflect on her experiences and, more importantly, to begin to understand William's behaviour from the point of view of the bewildered child. This "normalisation" helped to break the cycle of stress that had been escalating for weeks, and William's behaviour calmed down considerably.
This case made a great impression on the social workers in the team, who recognised the seeds of frustration and emotional escalation that can give rise to physical abuse and neglect. The health workers saw the spiralling stress levels that frequently precede serious mental health problems, and the educationalists saw the kind of disruptive behaviour that often leads to exclusion and educational failure. All of them saw in the outcome evidence that effective early intervention can hold the key to prevention of serious difficulties.
The subsequent four years saw a steady widening and consolidation of the service, such that family support teams now cover the whole of Norfolk. The service has been positively evaluated via a two-year research project by Anglia Polytechnic University, and in 2002 it won a Health and Social Care Award. Funding has now been ­established on a permanent basis from mainstream ­funding, so early intervention in CAMHS is here to stay in Norfolk.

Effective delivery of services
It is, of course, one thing to establish the need for a service, and the resources to provide it, but quite another to develop effective ways of delivering services to families. This important area has largely been the province of workers "on the ground", and we have learned a great deal about effective therapeutic approaches in primary care settings.
The first indispensable ingredient of effective work is assessment. We take time to listen carefully to children and families, and let them tell their story comprehensively, before agreeing with them a strategy for intervention. This can entail any combination of family work and individual sessions with parents or children. We meet families in their home, or other suitable ­locations such as schools or health centres.
Group work is an increasingly important part of our repertoire of provision. We know that people can learn a great deal from others in similar circumstances, so we look to provide places where parents and children can meet and support one another. Parents are offered the "Webster Stratton" parenting programme, and parents of preteens may take part in a "communication skills" group. Young people have benefited from an "anger management" course, an art group and many tailormade programmes we have put together with schools.
My own work with families tends to take the shape of a "solution-oriented" model. Individual practitioners vary widely in their professional and intellectual interests and practise a range of approaches. However, our general rule of 12 weeks' intervention dictates that we seek to offer some form of "brief" therapy. Many families find our preference to look towards the future rather than rake over old ground both refreshing and liberating. Often, when I explain to people that I intend to concentrate on their hopes, their resources and their successes, I see them visibly relax.
Most of the workers in the teams do not have an extensive background in therapeutic work, and our desire to develop effective methods has put us on a steep learning curve. My own practice is indebted to the numerous influential writers and trainers whose ideas shape my daily work, for example:

  • Australians David Epston and others have given us "narrative therapy".(2) This is the art of externalising problems, rather than pathologising, so that the difficulty is seen as something separate from the person. This enables the counsellor to enlist the client's help in overcoming the problem, instead of the client feeling  embarrassed or ashamed. Creative use of language helps young people to talk confidently about problems that might otherwise just cause them to clam up, and it opens up many playful and ­creative ways for us to seek out solutions.
  • An emerging and highly influential idea in therapy is "human givens".(3) Pioneered by Joe Griffin and Ivan Tyrell of Mindfields College, it highlights the notion that most psychological problems are the result of unmet needs, or misuse of the resources human beings are born with to meet those needs. Arising from this, very simple and practical interventions using relaxation, guided imagery or assigning simple tasks can help young people move on quickly and rediscover their competence to solve problems.
  • William O'Hanlon's refreshing and practical approach to solution-focused therapy and therapeutic language inspires much creative practice. His book, A field guide to possibility land,(4) should, in my view, have a place in every worker's briefcase.
  • Daniel Goleman has given us the term "emotional intelligence"(5) and the notion that emotional health rests on skills that can be learned from parents, teachers and counsellors. As workers who are dealing daily with the adverse life events of children, we are interested in how they can build resilience and can be ­protected from the psychological effects of adversity.

Norfolk Family Support Teams currently meet about 1,000 "Williams" each year. We use our basic human attributes of communication and rapport building, combined with our specialist knowledge and skills, to inject optimism and hope, and to impart essential problem-solving skills, at the time when these activities can be most effective.
The Family Support Team is a fulfilling and challenging place to work - creativity and innovation are requirements of the job description. "Primary child mental health workers" drawn from a variety of professions within health, social services and education are rapidly developing their own professional identity and hoping to divert young people away from the serious problems that concern the more specialised services.

The future
Our hope is that eventually statistics will provide us with concrete evidence of the value of our service -  maybe a dent in the child protection figures, or a randomised controlled trial that can attach a percentage figure to our conviction that this kind of approach works. The anticipated Department of Health and Social Care publication (2003) on the evaluation of the 22 CAMHS Innovation Grant projects will give more information on the outcomes for families receiving a range of supports and services, including early intervention.(6)  In the meantime, we remember the story of the child who threw a starfish back into the sea, only to be confronted by a cynic retorting "There are thousands stranded; what difference will that make?" It made a difference to that one!

References

  1. Audit Commission. Children in mind. London: Audit Commission; 1999.
  2. Epston D, Lobovits D, Freeman J. Playful approaches to serious problems. New York: Norton; 1997.
  3. Griffin J, Tyrell I. Human givens: a new approach to emotional health and clear thinking. East Sussex: HG Publishing; 2003.
  4. O'Hanlon W, Beadle S. A field guide to ­possibility land. London: BT Press; 1996.
  5. Golman D. Emotional ­intelligence. London: Bloomsbury; 1996.
  6. Kurtz Z, James C, editors. What's new - learning from the CAMHS Innovations Projects. London: Department of Health And Social Care; In press 2003.