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Do Not Section The Messenger: The Iatrogenic Effects of Disintegrated Care

Writer's picture: Dr Àlex SalesDr Àlex Sales

Updated: Jan 16

Originally posted by the Royal College of Psychiatrists, in the Faculty of Child & Adolescent Psychiatry’s Winter Newsletter 2024


“15yo girl has taken 2 overdoses in as many weeks; currently on a paediatric ward, needs further assessment and stabilisation”.


“17yo trans boy with ASD in A&E refusing to go home; parents do not think that would be safe either”.


“13yo has been in a paediatric ward for 2 weeks; they say they will starve to death if sent home”


Across the country, a likely outcome of scenarios like those above would be for the young person to get sectioned under the Mental Health Act (MHAct) and admitted to a General Adolescent Mental Health Unit (GAU).


These young people are likely to have been known to health and children’s services through exhibiting persistent risk behaviours such as self-harm, overdoses, running away, or threatening to jump off bridges. Often, instead of reading such behaviours as the call for help that they are, we become organised by risk, we deem these young people unwell, we overstretch the purpose of the often-conflicting legal frameworks in which we operate (MHAct, Children’s Act, European Human Rights Act, and others), and we do very little to effectively attend to the actual root causes and perpetuating factors that lead to these young people flagging, in their own way, that something is amiss.


Those admissions can be several weeks or months long, occasionally years. In that process, we often make things worse. For starters, we collude with the negative sense of themselves that life has already drilled into these young people, placing their supposed unwellness at the centre of what needs fixing, rather than looking at their whole story. When we do the latter, we see stories of developmental and multi-generational trauma, ACEs, parental mental health difficulties, and multiple safeguarding concerns. 


In my view, none of the diagnostic labels we currently stick on these children neither fully explain their difficulties, nor justify our persistently restrictive and harmful practices.  Mental health admissions strengthen young people’s identity as mentally ill. Eventually, young people become what they have repeatedly been told they are. Their self-harming behaviours repertoire widens; their hopes for normality sink like a lead balloon. They seek solace in others with a similar predicament, thus accruing membership to a club that it is subsequently hard to give up.


For the young people who, after years of not being properly seen or heard, resort to drastic ways in which to call for help, we need radical change in how we understand them and in how health and social care work together. We need swift and efficient cross-agency interventions which allow meaningful positive risk taking. I cannot cease to be amazed at the extent to which we daily desecrate the concept of integrated care which we so readily invoke. We succumb to splitting, we convince ourselves that we are working together with bitty care plans, and we fill in forms simply, it seems at times, to appease our own internal accountability processes and consciences.


A further consequence of such disintegrated care is the impact it has on staff morale. It can feel rather hopeless to see case after case falling into the same pattern. Burnt out social workers and health colleagues alike cannot be blamed for losing sight of the excellent work they are otherwise doing, when it so often feels as if they spend so much of their time and energy wrestling with each other and against a system so perniciously unfit for purpose.  The financial strain in the public sector, and the politics behind it, are of course huge factors to these problems too. 


I believe that with the resources we have (tally up the cost of escalation meetings alone), we could work a lot better together. That is my call. We need to truly learn from each other, and devise honest, brave and effective new ways of working together.


by Dr Àlex Sales Consultant Child & Adolescent Psychiatrist, Associate Clinical Director, East London NHS FT (views are author’s own)


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