Comment: Why there can never be another Milly Tuomey
We can only hope to deal with serious mental health cases among young people if we try to avert disaster early on
Last Thursday, on RTE's The Big Picture - Young and Troubled we saw the Child and Adolescent Mental Health Services (Camhs) of south Galway sit down for a weekly meeting. They were gathered to review ongoing cases and assess those newly arrived.
Dr Cara Prior led the meeting and during its course, a fax arrived that turned out to be an urgent referral.
It was heartening to see how they immediately made time for this referral, a young man who was feeling low and had expressed suicidal thoughts.
We saw him brought in quickly and given time to talk to a professional. We saw him leave, with his parents advised to keep a close watch on him, and heard how the quick response and the feeling of being taken seriously and listened to had already improved the situation.
This was heartening. But if time was given to this young man, in a service that the programme constantly reminded us is chronically understaffed, then it is possible that someone else had lost time allocated to them. Someone non-urgent. Maybe even someone urgent but less urgent. Maybe someone equally urgent.
So, while it was encouraging to see the Galway Camhs act on the case of this urgent referral, it can have been no consolation to Fiona and Tim Tuomey, who also appeared on The Big Picture.
Their 11-year-old daughter Milly Tuomey died by suicide in the new year of 2016. She was an urgent case. But she was an urgent case who did not get Camhs's immediate attention.
Milly's "urgent" referral by her GP in December 2015, which cited self-harm and expression of a death wish, elicited a January 5 appointment from Camhs in Dublin. Forms given to Milly and her parents to fill out on December 15 were hand-delivered by Fiona on December 22. She "assumed" they would get priority, not only given the urgent indicator on the original referral, but because of the terrifying detail with which her daughter had spelt out self-loathing, the desire to die, her feelings of unworthiness.
It was only after Milly's death by suicide in the new year that the Tuomeys discovered that those forms had, in fact, sat in a Camhs inbox for seven days after they were delivered by hand. The relevant Camhs service has said since that at the time they were dealing with an increase in self-harming-related referrals.
In other words, there was an overstretched team dealing with an increased number of people in trouble, potentially all of whom were "urgent".
It's no consolation to the Tuomeys, but it would seem that Milly fell through the cracks because in a situation where the services are understaffed and referrals are constantly on the increase, not everyone can get immediate attention.
Not even everyone urgent.
The Big Picture programme aired in the same week that saw publication of a report from the all-party Oireachtas committee on the future of mental health care. It did not make for heartening reading.
In particular, this report spoke of understaffing and growing waiting lists. It also pointed to the lack of night services for people in crisis, and an over-reliance on prescribing medication to patients in the absence of anyone for them to talk to.
What was thrown up by this report and by the RTE programme was a serious issue around early intervention. In almost all areas of life, we understand that prevention is better than cure, but in relation to mental health, it is crucial.
Last week, Jim Daly, the Minister of State for Mental Health, set out plans for a dedicated phoneline along the model of 999, as part of a referral pathway for mental health services nationwide. He talked about a "more appropriate" system of referrals to what we have now, where almost all cases are ending up at Camhs's door.
"The mental health equivalent of trolleys," he said, "is the Child and Adolescent Health Services waiting list. There are much lower levels of intervention [than Camhs] and that's what needs to be happening in mental health. Not everyone needs to be referred to a consultant psychiatrist and if you go in to Child and Adolescent Mental Health Services, you have to be seen by a consultant psychiatrist."
Essentially, Camhs should be there for the urgent cases and should have the staff and the time to give them. Then, the non-urgent cases should be seen elsewhere and they should be seen earlier, before they become urgent cases.
Early intervention, for young people in particular, can mean the difference between a person being out of sorts and a person being in crisis. In adolescence, diminished dopamine and the urge to create situations that will boost it, can result in young people making decisions that are ultimately unwise and damaging. This dip in dopamine can account for the vulnerability of their self-image, their tendency to self-loathing, their increasing habit of self-harm.
Tools by which adolescents in trouble can manage their moods are key, but according to UK psychologist Mike Shooter, in his book Growing Pains, the need to air and have one's issues acknowledged is also powerful. For an adolescent to discuss with a professional what they may be scared to, or unable to, tell anyone close to them can prove cathartic at the very least.
In a social-media dominated adolescent world that parents struggle to comprehend, family can be the last port of call for a teen in trouble. It is increasingly acknowledged that absorption in social media has led to an increase in anxiety in our adolescents, whose tendency to compare themselves unfavourably and regard themselves as lacking is only exaggerated by their online activity.
Parental responsibility and psychological support are two elements of putting this right, but surely some responsibility lies with social media providers in supporting the mental health of its users, too.
Teens need someone to talk to, but Camhs can't cope or get down the list beyond the urgent cases and so, teens end up either languishing or being prescribed medication, it seems. Without doubt, Camhs needs more staff, but there need to be professionals back along the line, averting urgent situations, listening, reassuring us all that there is a safety net.
"Children and their carers are languishing on ever-lengthening waiting lists or are not referred for help at all," Shooter writes in Growing Pains.
"If they finally get there, their behaviour will have turned into a diagnosis for treatment, or dismissed as a social problem for which the doctor behind the desk has nothing to offer. And their stories will never be heard."
Last week was not the first time we heard Milly Tuomey's story, but last Thursday night we heard about the legacy of pain left by her death. Her father, Tim, talked about days when the pain of his grief begins to lessen, and how he then summons it back again, because to lose the pain feels like a further loss of his daughter. And to lose the pain is to ease the self-blame, which never leaves him.
"We'll never blame anyone as much as ourselves," Tim Tuomey said on last Thursday night's programme, "but we needed help and I don't feel we got it."
"We had an urgent referral for Camhs and that urgent referral took four weeks," Tim also said. "We were worried about our daughter every day that something was going happen. To get an appointment that's urgent, that takes four weeks, was four weeks where something could happen, and in our case it did."
There is a crisis in urgent care for young people with mental health issues and a case like Milly Tuomey's should not be allowed to happen again.
But it's not just how we deal with crisis that counts. What counts, crucially, is how we stop children like Milly Tuomey becoming urgent cases.
We start talking early, we keep them talking, we give them someone to talk to and we let our young people know that their minds matter. When they're urgently in trouble, of course, but long before that, too.