Understanding mental capacity
Understanding mental capacity

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Understanding mental capacity

2.2 Young people aged 16 and 17 years 

Legally, a person aged 16 or over is presumed to have capacity, unless assessed otherwise. However, there are some situations – such as making a will, making an advanced decision to refuse treatment and particular medical procedures – in which a young person aged 16 or 17 is not automatically assumed to have capacity. In these cases, other legislation may be invoked and assessments such as that of Gillick competency carried out, to allow for legally sound decision making. 

Activity 4 Supporting the capacity of young people aged 16 and 17 years

Timing: Allow about 15 minutes

Watch the video below about three young people in Sheffield. As children under 16, they received treatment from Child and Adolescent Mental Health Services (CAMHS). At the age of 16, however, they were no longer eligible for a service from CAMHS and had to register with adult mental health services. They talk about their anxieties and concerns in making this transition.

Download this video clip.Video player: mhc_1_week5_vid3.mp4
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Transcript

[MUSIC PLAYING]
NARRATOR
Transition from child to adult mental health services can be challenging. In the second part of this film, we'll see how one city has been trialling ways of improving the transition process. But what do young people themselves have to say?
NAOMI
I had quite an unstable home life, so I think there was always some form of issue there. I mean, mental health's such a wide spectrum.
JOHN
Around about my 14th birthday, I sort of stopped-- I stopped going to school and things and had to-- my mental health, I suppose you'd say, was really bad.
NAOMI
Moving to secondary school was really, really difficult because it seemed like all my peers around me just suddenly had grown up, and I couldn't handle that. And I think I started to really, really struggle with depression.
CAMHS were so important to me because they were my someone. They were my parent, in a way. They were professionals, but they were the best parent I could have had.
JOHN
I remember I just liked it because it was a friendlier atmosphere than school. It was a bit more of a supportive atmosphere. You know what I mean? So, from that point of view, that was probably very good for me.
JAMIE
One session they looked at my file and were like, oh, you're 16 in a couple of weeks. And it was just sort of like, oh, well we won't be able to treat you anymore. So I only had like-- that was my last session. And I was like, oh.
NAOMI
Around the time of me turning 18, obviously, the change is around me being a looked after child. There's obviously some changes in the system in that as well. So there was that anxiety as well. And I was just kind of scared. I remember just being really, really scared about what people were going to do with me.
JOHN
They don't accept that there's a wider world that you're still going to be in. And if things don't work out in that world, all that medication and counselling is not really going to do anything positive.
JAMIE
They could have, a couple months before, said, look, when you're 16, we are going to stop, but it'll gradually work. It just sort of was cut.
NAOMI
I would describe it as falling down a cliff with rocky bits. So you kind of would fall, and then you would hit something, think you'd finished the bottom, and then you'd just fall even more. And you get lost in the system.
NARRATOR
They all found transition challenging, especially when so much else in life was changing too.
JAMIE
To be treated for eating disorders, there's a certain criteria you have to have for the different eating disorders. But quite a lot of them are like loss of periods and stuff like that which, being a male, you can't-- it's impossible to have a symptom such as that. It's just like you've been kicked out and no one's going to help you. It just felt like they'd given up on me, like I wasn't worth being given help.
NAOMI
Adult services can be very, very scary because you can be with people that are a lot, lot older, maybe more acutely ill. And it's very frightening because, inside, I still feel a child.
JAMIE
So it sort of was confirming what my eaten disorder voice was saying. And so it made it a lot more difficult. So I had to-- there was a lot of demons to battle.
NARRATOR
Moving to adult mental health services confused all these young people, and it felt like a challenge to be accepted.
JAMIE
They started a new NHS adult eating disorder service in my local area. It was run by the NHS, but not everyone was fully aware of the service. So I'd go to my GP and say, oh, there's this new service. Can you refer me to it? And he hadn't heard of it.
All of the different places are battling for the same cause. But they do it separately, so they're not as effective. Whereas if they all teamed up together, they'd make a lot more impact to be able to help people a lot better.
NARRATOR
Better information and communication would have helped everyone.
NAOMI
Transition has to come, but it needs to be made a lot better. There needs to be more communication. There needs to be better support for young people, understanding of the process, preparation for the process, and young people's involvement in the process.
JAMIE
You could say the positives to what you think with those, but then you could also say, this is what I think we need to improve. Because it's fair enough, they might all sit down and say, oh, we need to change this, we need to change this. But if they get someone from the perspective of the patient, then they can say more wider and what they think that needs to be improved, rather than what the professionals think need to be improved.
NAOMI
You don't need anything really magic. You just need someone to talk to and someone who you know and are familiar with and just wants to listen.
JOHN
I guess it was just a sense of being taken seriously, you know? And being like it mattered, I guess, is the nice-- would've been nice.
JAMIE
I want to go forward. I want to be able to say, I'm recovered. But it's just needing that little bit of help to make sure that I am going to get there, someone to help me get there, because it's near-on impossible and very difficult to do it on your own.
NARRATOR
They all agree that if they'd been consulted, transition could have been smoother. In part one, young people needing support with their mental health reported problems at transition to adult services. The second part of the film shows how services in Sheffield have responded to these problems.
The case studies include voluntary sector counselling services, peer study transition groups, and a transition clinic. They're all directly addressing issues raised by young people themselves. Sheffield has a combined health and social care trust.
GUY HOLLINGSWORTH
We're integrated between health and social care. So social workers are still employed by the local authority, but they're managed within the trust, and they're part of our community mental health teams and quite a number of other services too. So we see ourselves as trying to work as holistically as we can with service users.
In many places, CAMHS, the Child and Adolescent Mental Health Services, work up until 18. In Sheffield, they're only commissioned to work up until 16. So the PCT fund us to work with people from 16 upwards. And there are some challenges there, I think.
NARRATOR
What happens next for these young people is crucial. With the aim of reducing their anxiety and improving engagement with adult services, a transitions clinic is being piloted.
JOY OWENS
Come in and have a sit down.
NARRATOR
CAMHS psychiatrist, Dr. Joy Owens, is introducing Chloe, in person, to the adult service.
JOY OWENS
Chloe, this is Helen, Dr. Crimlisk, who is the adult psychiatrist from Eastglade Adult Mental Health.
NARRATOR
She's centrally involved in the discussion about her own future.
JOY OWENS
How have been since we saw you last time? How have things been?
CHLOE
Now I've had the help off the CAMHS and everything, it really has helped me get through. Really has helped me get through school. If I don't think I've come here, then I wouldn't have been at school.
HELEN CRIMLISK
Now that you're 16, the way things work here in Sheffield is that you come over to adult services. Now, what we need to do today is just think a little bit about what you want from that and how we plan that.
CHLOE'S MUM
When Chloe's punched windows and doors, she's quite scary. And sometimes I'll look at her and I'll think, there is a mental issue there, more than just a hyperactivity type thing. And it's a bit scary for us going into adult with them symptoms, like.
HELEN CRIMLISK
The ADHD doesn't give you that thinking time. You know, an emotion comes into your head, and you don't think about the consequences of doing something. You just go off do it. And one of the things that the medication does is to give you a bit of thinking space. So you can learn that as well. There are ways of learning. And as you get older, you'll find that that becomes a little bit easier. Yeah.
I think, for Chloe, it's a way of making a link with adult services. Seeing a face rather than just getting an appointment. Before we set up this system, we had a real problem with young people being referred from children's services to adult services, and then not turning up at adult services.
JOY OWENS
They just kind of got lost, really, between the ending of the plan of care with our service and the next sort of step to adult mental health. And we realised that there was this gap and that we needed to try and do something about that. So we set up the transition clinic.
NARRATOR
The clinic's useful for clinicians too. The next session brings up information not covered in Jessica's referral letter.
JOY OWENS
We're meeting you both today because you're now 16. And if you want to continue on medication, then we need to transfer your care over to adult mental health services. And how are you getting on with the medication?
JESSICA
I missed a day. After that, I were hearing voices. And then I went back on it, and they went.
JOY OWENS
And did the voices say anything to you?
JESSICA
I walked to the shop with my sister and we were arguing. They were just saying really evil stuff.
HELEN CRIMLISK
If you were to have any more of these episodes where you hear voices, we'd really like to know about it, because occasionally the medication can cause that as well, and we wouldn't want that to happen. So do let me know if that happens again.
JOY OWENS
The fact that she's met Helen and engaged with her means it's much more likely that she will go to her first appointment and continue engaging with that service. It does take a huge amount of planning, but it's definitely worth it when you see the outcomes and you hear about people from Helen who've gone on to their service and having a really good outcome.
NARRATOR
Mental health in the world beyond CAMHS might depend on adult services, but they usually have a very different feel and emphasis.
GUY HOLLINGSWORTH
Because we're an integrated health and social care trust, we may have access sometimes to social care ways of responding to people's needs that are more appropriate for individuals. We're very, very keen on the recovery approach within the trust. Recovery isn't just about getting better. Recovery is getting your life back-- feeling more in charge of your own destiny, even if you are still struggling with some of the symptoms of your mental health problems.
Clearly, 16 is a crucial age in terms of individual's development anyway. It's a key time in that transition from the dependence of childhood to the independence of adulthood.
NARRATOR
This pilot transition group bridges the age span of 16 to 25.
SARAH WALKER
In adult services, the responsibility is much more on the client. That can be quite daunting for people who've come through CAMHS and it's been quite intensive to now being in adult mental health services and maybe having a little bit less input from us. There's only so much that we can do without almost creating a dependency that's unhealthy.
NARRATOR
Young people support each other and learn together about managing their own conditions.
MALE TEENAGER 1
More you know about your illness, better you'll be able to cope with it.
MALE TEENAGER 2
Yeah. I were a bit hesitant about coming to a group, and I've found that I've made friends. I've been able to get a lot more off, and I've de-stressed myself a lot better.
NARRATOR
They've not always enjoyed school. Mental health can improve just by being in a supportive peer group and building social skills.
MALE TEENAGER 1
Before I'd come into this group, I wouldn't really like to talk to new people or owt. I'd stick to-- but now, I'm not as shy. I'm not as shy as what I used to be.
SARAH WALKER
It's become part of their routine to come on a Monday. And so where maybe the rest of their lives are quite chaotic, this is one thing that is stable.
FEMALE TEENAGER
I like to know what I'm doing from the next day to the next. If there's nothing there, then there's no point in doing anything.
SARAH WALKER
There can be lots of changes. One of the people referred to the group was pregnant, lost the baby. Tried to come to the group, couldn't. Tried to go to an apprenticeship, couldn't. So there's lots of different events going on to try and work through. And I can think of lots of different situations with these young people where there's significant events going on in their lives, and they just don't always know how to deal with that.
NARRATOR
Young people leaving CAMHS don't always feel a need or meet the criteria for statutory adult mental health services. Even if they do, the demands and perceived stigma often mean they drop out. In downtown Sheffield, a voluntary counselling service shares a building with other resources they might want to use. So, at times to suit them, and without feeling stigmatised, it's easy for them to drop in.
LEAH BOOKER
It's a sort of one-stop shop approach so that young people can come in and feel comfortable within a building. It's not identified, for example. We've not got a big label outside that says, this is where you come for counselling. So it's very much anonymous when they arrive. For many of them, they've been in and out of different services over a number of years before they come to us, sometimes really engaging with services, at CAMHS level up to 16, but then very much feeling abandoned when they get to 16, and really feeling like they fell through a hole.
JOHN
I went to the doctors, and they just said, oh, what do you want me to do about it? and offered me medication, which I didn't want, because I wanted to try and sort myself out a bit, as it were. I basically ended up looking stuff up myself and finding things and contacting them myself, which I thought, a lot of people with mental health issues probably aren't going to do.
SARAH WALKER
In terms of resources, I think it's worthwhile to put the time and the effort in now and hopefully prevent on going, sort of the revolving door syndrome of people coming back or getting stuck. And hopefully, we're equipping young people now so they can go on into their lives and do positive things and be the people that they want to be.
MALE TEENAGER 1
I feel like I've come on leaps and bounds since I'm not as immature as I was before I started. I don't have no flare-ups or owt like that anymore.
GUY HOLLINGSWORTH
Clearly, if individuals fall through and don't get the service they need, they're then high risk that their mental health deteriorates, and they come back, and there's more costs to service as response. There's quite a conflict between the payment by results agenda in health and the self-directed support individual budget agenda in the local authority. So I can imagine that some areas are struggling with those tensions and resolving them wrongly, in my view, by divorcing. And it has been quite difficult in some areas. But in Sheffield, as I say, we're confident that we can meet those challenges.
LEAH BOOKER
Not all young people will be attracted to our service, and not all young people would be attracted to CAMHS or adult mental health services. But I think, between us, if there was that level of co-creation and commitment and communication, I think we'd have a lot better shot at actually developing services that young people were interested in tapping into.
NARRATOR
Transition can be tough, but the right support makes a difference. And it doesn't have to break the budget.
End transcript
 
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In the text box below, note what you think might have arisen for some of these young people had they not made a successful transition to adult mental health services. Imagine what kinds of outcomes might later bring into question the young people’s capacity to make decisions for themselves.

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Comment

In the video, it seemed that adult mental health services failed to engage successfully with the young people. This may make it more likely that, in the future, they are assessed as not having the mental capacity to make certain decisions. Affording as much opportunity to engage in services is consistent with the general principle in mental capacity legislation that people should be supported to make decisions themselves before an assessment of whether they lack capacity.

While every assessment of capacity must relate to circumstances at the time of the assessment, it is also important that services promote future opportunities for mental capacity to be assessed if needed.

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