CAPA is all about empowering people and helping them access their own resources – and those in their communities – to move their lives forward. Part of this is not to assume they need services and if they do, to focus on the time that they, once again, will not need to come to see us. This ability to ‘Let Go’ is important in helping people regain control of their lives – and for us to smooth flow through the service. In our survey of 100 CAMHS teams in 2005 we found that in the 7 HELPFUL Habits of Effective CAMHS, Letting Go of Families was one of the areas most teams felt they struggled with.
There are two parts to this – 1) how you ‘discharge’ people but also 2) how you actively plan to work with those who have chronic difficulties. It is with this last group that we often feel stuck; worried that we cannot stop seeing them for fear they will not cope, or knowing that they have a problem that will not go away (e.g. living with autism).
Outcomes in mental health often seem grey. There is always more we could ‘do’. In CAMHS, as children grow and develop, and families reach different stages and transitions, problems change and new issues arise. Some clients may do best with bursts of crisis contact, or planned infrequent ‘booster’ sessions.
It is important for those with multiple, complex health and social care needs that we work effectively with other agencies and extended family and communities. Support can come from a range of places and it does not necessarily need to be us. The big changes in CAMHS in England, with the focus on extending skills and services in universal services can help families be supported in a way that is most helpful, rather than sitting chronically with CAMHS. In adult health, the move is towards self management.
We tend to have well thought through processes for opening cases but less robust processes for closing, except perhaps for admin processes. We also know that many people just stop coming – rather than having a planned ending. Are they telling us something? Have they had enough, we just didn’t realise it?
Thought moment – how often is your last contact with a family a ‘DNA’?
Letting Go of Families is so important that it is a HELPFUL Habit – see the 7 HELPFUL Habits section of the website, www.capa.co.uk. There are three items in this Habit:
- Manage variation in closing cases
- Use Care Plans
- Have a systematic approach to long -term problems.
1. Managing variation in Closing Cases
What makes it easier to close? Usually when the endpoint is clear such as:
- Symptoms resolve such as menstruation returns in anorexia nervosa or psychosis goes
- You are leaving and, as you won’t be there, clients don’t want to start again
- Limited session models and they have used up the sessions (but the work may not be done)
- When the person has made the changes they wanted.
- You have time to think
- Time to have proper reviews
- Admin/liaison time in your job plan
- Multidisciplinary discussion and supervision.
Many of these factors are under our control – i.e. are due to artificial variation (how we do things, nothing to do with the families! See the Demand and Capacity Theory section of the website, www.capa.co.uk). How is it that we can close cases when we are leaving? The family’s problem hasn’t changed. We have!
In our work with teams the reasons people give for difficulty in closing have included:
- Nowhere to support them in the community
- Worries about risk
- Pressure from referrers not to close
- Long waits into the service, or for intervention
- Liking the client
- Not closing stops you having to take on a new case because you are ‘full’
- Believing that people will always need support
- A team culture of dependency.
And these make it easier:
- Problems that get fixed quickly and we know that they’re fixed
- Easy re -access back to the service if needed
- Good multiagency working and ongoing referrer involvement
- Support from your team and organisation in managing risks – being clear that we cannot ever make it zero
- Having regular reviews of progress towards goals
- Use of outcome measures
- Creative time in the week that gives us relief from high pressure, anxiety – producing work
- A team culture of empowerment.
Individuals and teams quite often have strong feelings about what the work of mental health is – and this can affect how we think about closure.
Using Care Plans helps you and the family be clear about what you are all aiming at.
We find these things help:
- Use plain English
- Make realistic goals with the client – that are measurable so you all know when you have achieved them
- Review progress regularly – have a system in place to ensure this happens and monitor it
- Involve the network early
- Always focus on ending – be clear why you are offering another appointment. Could someone else do it (e.g. shared care in ADHD); could you do it another way (an interim review or booster with the school nurse)?
3.Long – term problems
Many problems that we see in mental health are lifelong issues – autism, learning disability, recurrent disorders such as OCD, psychosocial deprivation, psychosis and parental mental health problems.
Acknowledging that these things may need ongoing help is being realistic – but this may not have to be with you, unless you are commissioned to do this of course! Quick access back to your service or infrequent boosters may work best. Being honest with the client (the Choice philosophy) helps them understand the nature of the difficulties and that there may not be a quick fix, whilst promoting hope and development.
Helping people to manage their own difficulties is important. CAPA helps to mobilise strengths and resources – make use of these in their family and community. Can you help a support group get off the ground? Could you start multi-family group work? Is there a Staying Positive workshop locally (part of the Expert Patient programme)?
One way to think of problems are in terms of duration (long-term, chronic), multiple issues
and agencies (complex) and intense problems or behaviours (severe).
Managing chronic problems
These things are worth a try:
- Self-management strategies i.e. moving to the person planning how to cope for themselves
- Support groups
- Rapid access to services in crisis
- Being creative in finding solutions outside an agency response.
Complex problems across agencies
- Multiagency planning is essential
- Have multiagency agreements for managing complex cases
- Use in CAMHS of the Lead Professional and Team Around the Child/Family (Every Child
- Matters framework in England) across agencies
- Be clear about different roles of Lead Professional across agencies and role of Key Worker within your team.
Usually involve significant risk e.g. suicidality, risk taking behaviours, child protection:
- Be clear about who does the ongoing risk assessments
- Sharing risk assessments across networks is helpful
- Frequent contact
- Be clear about roles of different agencies and team members
- Zoning of risk (red, amber, green – who are you really worried about this week?) – can help.
Letting Go does not mean abandoning your client! It is strengthening them. Certificates not tissues required…