Callie Harrop:
Hi Vicki.
Vicki Curry:
Hi Callie.
Callie Harrop:
For me as a bereavement practitioner it’s about thinking when we’re working with a bereaved child or young person, when would be the right time to refer to CAMHS, if there was one?
Vicki Curry:
I work in one particular CAMHS service in London, but CAMHS services are set up really differently across the UK and one of the things that’s tricky I think sometimes for bereavement services is to work out what different thresholds might be and what different CAMHS criteria are for referrals.
One of the things I would always recommend to a bereavement practitioner is that you contact and make a link and connect with your local CAMHS service or local provider because then you can start to have conversations and get a sense of what happens in your particular local area and equally, I think CAMHS services really value making those links with bereavement services as well because we quite often might be working with a family or young person about a particular issue which might be nothing to do with bereavement and then there’s some kind of loss or bereavement experienced and what is really great for us is to know what else is around there – services that we might be able to signpost families for that isn’t necessarily a mental health type issue as well so it’d be great to have those links going on.
Callie Harrop:
I think that’s a really important relationship isn’t it, and us knowing that our roles overlap so often in that way and I think touched on a really good point there about grief not being a mental health condition and so often with the bereaved young people and children that we work with, we might see presentations of anxiety or perhaps depression or depressive behaviours that other people may interpret as a mental health condition and it’s really important to point out that actually that doesn’t mean that bereavement and grief is a mental health problem that we need to be concerned about and that’s, there’s a really normal process there within that for a child to experience some of those feelings. I guess it’s thinking about when they do experience those anxiety or that depression, when should we be concerned as a service?
Vicki Curry:
I kind of feel like I keep turning questions back to you but one of my first questions because you’re the expert in bereavement in a way. When would you be starting to worry that maybe the young person or family isn’t coping or their difficulties are kind of going beyond what you might expect in a kind of ‘normal bereavement reaction’ …. When would you start to worry, do you think? Are there things that you look for particularly?
Callie Harrop:
I think we would be really concerned if we started to work with a child who was perhaps unable to access their education for a prolonged period of time due to the grief. Or they weren’t engaging in activities that they were previously interested in. A lot of the work we do is around discussing memories of the person who’s died both positive and negative. Perhaps conversations around the narrative of how the death occurred and how that individual has interpreted that and some work around feelings and that almost psycho-educational model there. Thinking about a child understanding their own feelings and being able to name them, the concern would be for us if a child or young person was really struggling to engage in one of those activities… that’s not immediately a concern because obviously every child is individual and it might be just the wrong time for them but I think if over a prolonged period of time they weren’t able to engage in any of those conversation. Perhaps they started taking some risk-taking behaviours or they became more withdrawn or we were seeing different presentations in those behaviours. That might be when we were concerned and we would have a conversation with the family at that point about potentially liaising with another service maybe like CAMHS.
Vicki Curry:
I think you’ve hit the nail on the head and exactly the kind of things that would worry me as well, to be honest. So we’re obviously thinking along similar sorts of lines. Because I think CAMHS would be particularly risk issues, self-harm, suicidality and when it gets really quite extreme. Absolutely thinking about the impact of the difficulties on the young person’s life and when their difficulties get to the point that it stops them from doing the things that they are supposed to be able to do or need to do for their developmental level and I think particularly what we think about in CAMHS – there are obviously lots of different services out there to support children and young people and what CAMHS particularly are interested in, obviously, is this thing called mental health, really. So, I think certainly for a lot of services you’d need to have some evidence of chronic, complex depression, anxiety that goes beyond as you say what you might expect for a normal bereavement reaction.
There are also different types of services out there for CAMHS. So it might be certainly in my area, we have some services that might work with what we call more low intensity difficulties that might not be the complex chronic need that you would get into tier three level CAMHS, but certainly would be available as an early help or preventative type work that would be able to kind of connect in and support young people and then there are other services where things get more difficult and people are more worried and maybe there’s greater impact on the young person’s life and then different services might kick in and be able to get involved as well and things like anxiety, low mood.
The other thing particularly I might think about is trauma. I’m sure you’re working, presumably, sometimes with young people where there’s quite a traumatic bereavement?
Callie Harrop:
I think there’s something in that about acknowledging whether it’s a traumatic bereavement or a traumatic response from the child and what we might be expecting to see as a response and what sort of traumatic response behaviours we might be really concerned about.
Vicki Curry:
Are there any particular things where you start to think actually this is a kind of a more mental health type traumatic response? Are there things that you particularly look for?
Callie Harrop:
I think we’d be concerned if there was a child who was really experiencing flashbacks, really stuck and fully experiencing them. So that this isn’t a memory that they’re telling me a story of, this is something that their full body experiences in a complete traumatic response to and so if that was something that was happening over a long period of time we’d be quite concerned about that you mentioned earlier about self-harm and suicide idealisation and quite often within our conversations around bereavement we might hear children say things such as: “I wish I could die to be with them” or “I wish I wasn’t here anymore” and I think as bereavement practitioners there’s a really fine line there that we have to do that risk assessing to think about is that child talking about that in a sense that they just wish they could be with the person who died, or is this something that we really need to be concerned about and has this child had any serious thoughts about ending their life? Have they any plans to end their life? And obviously as organisation we would have our own risk assessment and safeguarding policy around doing that. Perhaps if we did have those concerns it comes right back to what we said at the beginning and how we’d have that conversation with you as an organisation.
Vicki Curry:
Again, all really helpful points, and very similar in terms of the kinds of things that would make me worried and concerned. In relation to the traumatic stress, I suppose what we’re looking for as a CAMHS service would be things like post-traumatic stress disorder and certainly one of the things that we sometimes suggest is that a practitioner or counsellor or a bereavement practitioner might do something like CRIES the ‘Child Revised Impact of Events Scale’, which is quite short and you can do that with a young person or with a parent just to get a sense of whether they meet the diagnostic criteria to give you a bit more of a clue, and then we might think “oh that looks like PTSD” and then that would be something that we would then be able to get involved with and treat in an evidence-based way if that was something that was outside of the remit of your particular service.
In relation to safeguarding and risk again absolutely following your own procedures. A lot of CAMHS services have a duty line where people outside of a service can connect and sometimes families can call, young people can call practitioners, professionals can call if they’re got a question or concern and there’s often people then who are there to answer the phone and at least have a conversation or consultation. Sometimes the other things we do, certainly in my CAMHS service, to get a sense as to whether really there’s a role for CAMHS is we might attend a network meeting, and have some sort of a consultation with the system around the child whether it’s maybe having a meeting with the bereavement service, like yourself, or maybe with the school, people who know, or the parent, people who know the child well and then trying to think about you know who might do what if there’s a role for CAMHS and if there is a role, it doesn’t necessarily mean that we would say “stop bereavement” because it might work well be that we think can you carry on the brilliant work you’re doing around the bereavement, but it might be that we then add something specially to focus on additional difficulties that are arising as well, like anxiety or low mood or all the other kinds of things. Again, I don’t know if you would be willing as bereavement practitioners to be part of a package of support, I suppose, for a young person.
Callie Harrop:
I think that’s what we are talking about, isn’t it? Finding out for that individual child or young person what is the best way that we can work as a service to support them and sometimes that’s not necessarily needed, sometimes it’s just a conversation between ourselves and you, and then we include the family within that as well as you mentioned, that’s key, isn’t it? And giving them the confidence to, or the skills to be able to respond to that child appropriately.
Vicki Curry:
So the other things I was thinking is that because you also mentioned parents quite a lot and I think sometimes, my sense is, sometimes you might imagine that the young person would have some kind of psychological difficulty as a result of a particular bereavement but they don’t always and sometimes it’s almost more traumatic for the family or the parents who are trying to support the young person. So sometimes it might be that the young person themselves don’t need seeing, but the parent might need a bit of support to support the child, if that makes sense?
Callie Harrop:
We find that too, I think, as bereavement practitioners often that sometimes the biggest part of the work can be helping that parent to support that child and perhaps a conversation like that with yourself as well for a parent would be really valuable and to really empower those parents to be able to support their grieving child and meet their needs if they are presenting with some mental health conditions there too.
Vicki Curry:
I think you’re absolutely right to say it’s basically the young person and the family are at the centre of it really, aren’t they, in terms of what support. And sometimes also schools can be helpful in supporting, can’t they? They can be part of the package of support. So, it’s about keeping them at the centre and then thinking how we can all work together as services really to offer the best support for them.
Callie Harrop:
Yeah, thank you Vicki, that’s really helpful.
Vicki Curry:
It’s lovely to talk to you, thank you, Callie.