1. Managing variation in Closing Cases
What makes it easier to close? Usually when the endpoint is clear such as:
- Symptoms resolve such as menstruation returns in anorexia nervosa or psychosis goes
- You are leaving and, as you won’t be there, families don’t want to start again
- Limited session models and the family have used up the sessions (but the work may not be done)
- When the family/young person have made the changes they wanted.
AND
- You have time to think
- Time to have proper reviews with families and networks
- Admin/liaison time in your job plan
- Multidisciplinary discussion and supervision.
Many of these factors are under our control - i.e. are due to artificial variation (how we do things, nothing to do with the families! See the Demand and Capacity Theory chapter in the 7 HELPFUL Habits section). How is it that we can close cases when we are leaving? The family’s problem hasn’t changed. We have!
In our work with teams the reasons people give for difficulty in closing have included:
- Nowhere to support them in the community
- Worries about risk
- Pressure from referrers not to close
- Long waits into the service, or for intervention
- Liking the family
- Not closing stops you having to take on a new case because you are ‘full’
- Believing that families will always need support
- A team culture of dependency.
And these make it easier:
- Problems that get fixed quickly, and we know that they’re fixed
- Easy re -access back to the service if needed
- Good multiagency working and ongoing referrer involvement
- Support from your team and organisation in managing risks - being clear that we cannot ever make it zero
- Having regular reviews of progress towards goals
- Use of outcome measures
- Supervision
- Time
- Creative time in the week that gives us relief from high pressure, anxiety - producing work
- A team culture of empowerment.
Individuals and teams quite often have strong feelings about what the work of CAMHS is - and this can affect how we think about closure.