For how long can child and adolescent mental health services continue to exclude couple therapy from their core offer? A blog from Richard Meier, Policy Manager at Tavistock Relationships for World Mental Health Day 2016.
In the section of ChildLine’s most recent annual review which deals with ‘Who contacts ChildLine?’, you’ll find the following text:
"Children aged 11 and under are most likely to talk to us about bullying, family relationships and friendship issues.
Young people aged 12-15 are most likely to talk about family relationships, low self-esteem/unhappiness and bullying.
Young people aged 16-18 are more likely to talk to us about low self-esteem/unhappiness, family relationships, and sex and relationships."
So, across all the three age-groups, there is one common factor which prompts children and young people to contact ChildLine. And it’s not bullying, self-esteem, abuse, self-harm, or problems with schools. It’s family relationships - something which ChildLine defines as ‘Conflict/arguments with family members, parents’ divorce/separation’.
What could be the reason for this?
One answer, I suggest, is that statutory services – e.g. child and adolescent mental health services – do not, in the main, address young people’s concerns about parental conflict and family relationships. Yes, CAMH services do offer family therapy, but we know that a lot of family therapy struggles to engage fathers. And there is also the issue of how effectively children’s concerns about the quality of their parents’ relationship can be addressed through an intervention which largely works with the family system together.
Over the summer, Tavistock Relationships conducted a number of interviews with CAMHS clinicians (from a variety of professions) and CAMHS commissioners about the impact of inter-parental conflict on children, as well as to ask them about what work, if any, takes place in CAMHS currently with the parental couple directly (aside from parenting interventions).
This quote, from a family therapist, we found particularly telling:
“I've noticed that, over a number of years, not one of the couples that I've referred out for relationship support has taken it up. But I do feel comfortable about making that referral, about putting it in black and white, because I then take responsibility, and that blame, from the child. Because I have highlighted it - it's not that this child has an inherent problem, and they will always be with this problem; I have identified how the dynamics impact on the child's presentation.”
This raises a very serious point. How does the way that we treat mental health problems in children make those children feel – that is, how is our tendency to see the child as the locus of the problem experienced by those children?
We know that inter-parental conflict has considerable and long-lasting effects on the mental health of children. The Early Intervention Foundation’s review – What works to enhance inter-parental relationships and improve outcomes for children? – found that:
- parents/couples who engage in frequent, intense, and poorly resolved inter-parental conflicts put children’s mental health and long-term life chances at risk.
- children of all ages can be affected by destructive inter-parental conflict, with effects evidenced across infancy, childhood, adolescence, and adulthood.
Ah, but I hear you say, what evidence do you have that the mental health difficulties of children who actually make it as far as being seen by CAMHS have anything to do with the quality of their parents’ relationship?
Well, we have some, and we hope to gather more soon. A child psychotherapist working in an inner London CAMHS service sat down with nine of her fellow clinicians and went through their caseloads in order to gather some data on this very question. The results of this exercise were startling. Of 313 cases reviewed, clinicians judged that inter-parental conflict had significantly contributed to the child’s mental health difficulties in 40% of cases; and that in almost 60% of these cases the child’s mental health difficulties were likely to continue, the clinicians felt, if the inter-parental conflict was not resolved or improved.
This is but one survey, of course, although 313 cases is a fairly sizeable sample. We will be surveying clinicians in other CAMH services in the months to come in order to find out whether this data is typical.
If, as we suspect, it is, then what can and should be done about it?
We would be the first to recognise that couple therapy, as an intervention, has lagged behind others in terms of the research evidence showing impacts on children’s outcomes. While there are oodles of research studies showing the effectiveness of couple therapy on improving couple communication and couple relationship quality, researchers have largely chosen not to include children’s well-being and mental health as an outcome in their studies. This needs to change, and we are hopeful that we will be able to undertake some research in this area in the foreseeable future.
In the meantime, however, we are encouraged by the fact that many of the CAMHS commissioners we speak to acknowledge that they are not hidebound by NICE guidelines, and are open to the possibility of testing some couple work in their services. After all, we know that inter-parental conflict is a major driver of child mental ill health, and we know that couple-focused groupwork programmes (such as our Parents as Partners programme which gained the highest rating of all programmes reviewed by the Early Intervention Foundation’s review) has significant impacts on children’s mental health (as seen in improvements to SDQ scores) - so there is a very reasonable basis to believe that couple therapy within CAMH settings may be a useful and effective addition to the suite of interventions offered by CAMHS.
This is not, we must stress, a pitch for taking money from children’s services and diverting it to treat adults. Rather, it is a desire to ensure that couple therapy can be provided to couples – where appropriate – alongside the treatment of a child.
And it’s not just us who believe that the addition of couple therapy is overdue. I’ll end this blog with the views of one of the people we interviewed over the summer, a former director of YoungMinds no less:
“I think the parental couple element in child development, in child psychopathology, is highly significant. If I were to open a clinic, in addition to a family therapist, I'd have a couple therapist.”