Chair of the child and adolescent faculty at the Royal College of Psychiatrists, Dr Bernadka Dubicka talks to freelance journalist Jo Carlowe.
They touch upon the IMPACT study (Improving Mood Promoting Access To Collaborative Treatment), the use of technology among children and young people, including the positives and negatives of social media. As well as brief interventions and the growing landscape of clinicians using a blended approach, offering services remotely.
Deputy Editor-in-Chief of CAMH, Bernadka talks about marking CAMH‘s 25 anniversary this year, the exciting acceptance of CAMH into MEDLINE and the debate section in CAMH, see previous issues on bipolar and gender identity.
Dr. Bernadka Dubicka is Chair of the child and adolescent faculty at the Royal College of Psychiatrists, a Consultant Psychiatrist at Pennine Care Foundation Trust, and is also Honorary Reader at the University of Manchester. She is Deputy Editor-in-Chief of CAMH.
Interviewer: Hello. Welcome to the ‘In Conversation’ podcast series for the Association for Child and Adolescent Mental Health or ACAMH, for short. I’m Jo Carlow, a freelance journalist with a specialism in psychology. Today, I’m interviewing Dr. Bernardka Dubicka, Consultant Psychiatrist at Pennine Care Foundation Trust, Honorary Reader at the University of Manchester. She is also deputy editor-in-chief of the Child and Adolescent Mental Health Journal, CAMH, and Chair of the Child and Adolescent Faculty at the Royal College of Psychiatrists. Welcome. Thank you for joining me. Can you say a little about yourself by way of an introduction?
Dr. Bernadka Dubicka: Thanks very much, Jo. There’s quite a list of roles that I have there. So just in brief, my primary work is a child and adolescent psychiatrist. I worked for over a decade recently in an in-patient unit in Lancashire, and about two years ago, I moved back to community services in Manchester. So I’ve been involved clinically with a whole spectrum of services.
And then I’ve had the privilege over the past three years to be Chair of the Faculty at the Royal College of Psychiatrists. And that’s been a fantastic opportunity to get an overview of child mental health provision throughout the UK. I’ve met many wonderful colleagues and also been in a position where I’ve been able to talk to policy-makers as well, and hopefully try and make an impact in terms of the services we provide for children and young people. And then, obviously, I’ve really enjoyed my role on CAMH.
I was recently promoted to Deputy Editor, alongside our fantastic chief editor, Dennis Ougrin, and that’s been a really wonderful opportunity. I’ve met some fabulous people. And then, academically, over the years, I’ve had a particular interest in mood disorders. And as we’ll discuss, I have a very strong interest in evidence base, which is important in terms of delivering our services, but also in terms of our journal, to make sure we publish the best available evidence that’s out there. And those are all things I feel very passionately about.
Interviewer: Can you tell me about your journey in terms of how you came to be interested in the field of child and adolescent mental health to start with?
Dr. Bernadka Dubicka: Yes. Originally I was interested in general practice. And that was because I was interested in the whole person, really. And as part of my general practice training… I didn’t get very far with it, mind you, because I started doing psychiatry quite quickly… I realised I was really interested in people’s stories and hearing and listening and trying to make sense of what was happening in people’s lives and how that was affecting them.
And then quite soon into that, I realised how important child mental health was. Now we hear the figure quoted time and time again that 75 per cent of mental health problems start in child and adolescence. And it just seemed like a really fantastic opportunity to try and work with children when they’re as young as possible, and with families, to try and make a difference.
And the other thing that really attracted me to child mental health was because we always think systemically. In other words, we think about the environment and the systems around the child, whether that’s the family, the peer group, school, society in general. But as we know, that’s an approach that’s so important in life, that holistic approach.
None of us live in a vacuum. We all live in families and societies, in particular groups, all of which have an impact on us. And that way of thinking, I think, is so important. And I’m hoping that that way of thinking is coming more and more to the fore in other areas of mental health as well.
Interviewer: As you mentioned in your introduction, you have a research interest in mood disorders and you have been an investigator in the Improving Mood with Psychoanalytic and Cognitive Therapy study. That’s the IMPACT study. What have you learned from IMPACT in terms of the best approaches to take when working with young people?
Dr. Bernadka Dubicka: Well, it was a really, really great study to be involved with. We recruited over 400 young people from across the country. And there’s several messages from that study. I think, firstly, we found that none of the approaches that we used seem to differentiate from each other. And what we know from the literature over the years as well, it’s not so much a particular therapeutic modality that’s important.
It’s really the relationship that’s important. And also making sure that that young person’s invested in the treatment they’re having as well. So as a first-line approach, what we learnt was it didn’t really matter too much what sort of psychotherapeutic approach we offered. There wasn’t that much difference to choose from.
But with my faculty hat on and policy hat on, that’s got really important policy implications. Because we developed a briefer intervention, which we can train people up with quite quickly who have got.. what we’ve said or say, at least 6 months’ experience working in child and adolescent mental health services. And we found that that kind of approach was just as efficient and effective as more specialised approaches.
So we know we have a crisis in child and adolescent mental health. We know that, at the moment, only one third of children and young people are getting the services they need. And we know we’ve got a massive workforce shortage. So therefore, surely we need to be offering the simplest, most cost-effective treatments first. And if they don’t work, then move on to use our very scarce valuable resource and more specialist interventions, in a kind of stepwise approach.
Interviewer: Is there a danger though, in doing that, that only time-limited interventions will get funded?
Dr. Bernadka Dubicka: Well, this is hugely problematic. We know that the investment in child and adolescent mental health research is far behind that of adult mental health, for example. And overall, it’s far behind physical health, such as cancer. But we know that the impact of child mental health problems is phenomenonal and can last a lifetime. But in terms of funding, it’s very expensive.
It was expensive to fund the IMPACT study. And our study was important because we actually looked at follow-up at 18 months as opposed to a very short-term follow-up which is usually around six months. But it is expensive to fund the longer studies, but it’s very important to do that. But I completely take your point. It’s so important to think about complexity as well when you’re looking at child and adolescent mental health problems.
And we know one size doesn’t fit all. However, surprisingly, briefer interventions can make a difference even in the most complex situations. And young people always surprise me. You never quite know who’s going to improve and when. But it’s absolutely crucial that we don’t disinvest in those more specialist approaches that we really do need for really complex young people that we see, who’ve had a lifetime trauma, for example.
Interviewer: Earlier this year the Royal College of Psychiatrists published a report exploring the use of technology among children and young people. What conclusions were drawn in that review?
Dr. Bernadka Dubicka: So we decided to try and to look at this because we were getting so many media requests to talk about social media. And we wanted to try and do this from an informed position as possible. And we also felt that a lot of the debate has been so polarised and skewed. So much of the research that’s been presented has being done in large general population samples, not been particularly sophisticated.
It’s just looked at, for example, length of screen time. But we know that young people interact with screens in quite complex ways. Content is very important, for example. And there’s been very little research looking at what types of young people are looking at what content. And obviously, as the Royal College of Psychiatrists, we’re particularly interested in vulnerable groups. So that’s how the review came about.
So the first message I want to give is that obviously technology has got a massive part to play in today’s world, and we’ve seen that obviously through the Corona crisis. And there’s lots and lots of benefits of technology and social media for many young people. But we mustn’t forget that there are vulnerable groups who might be adversely affected.
And obviously the government’s White Paper that’s been recently published has started to look at that. So what we found in terms of the evidence, yes, of course, we need a lot more research, and in particular we need longitudinal research over time. And we need much more sophisticated research looking at particular vulnerable groups and how they’re interacting with their screens and what they’re doing on them.
But there are some emerging lines of evidence which I think are concerning. So, for example, around self-harm. There’s been work done looking at the contagion effect of young people who self-harm online and the groups that they’re forming, and how that can sometimes be a trigger and encourage further self-harm. And the other line of evidence, there’s been a number of longitudinal studies now looking at early development and amount of screen time for very young toddlers and the impact that might have. Again, this is all early days. But the WHO has also made recommendations around limiting screen time for very young children because of the worries about their development.
And the other difficult issue around this is that, obviously, I very much come from an academic, evidence-based perspective, but as we’ve seen with the Corona crisis, sometimes we just don’t have the evidence there when we need it. And policy decisions need to be made.
And there is such a thing called the precautionary principle and I think we very much advocate that when thinking about the effects of social media and screen time on our particularly vulnerable groups. And whilst we’re still collecting evidence, I think we do need to be mindful about what some young people might be doing and how that might affect them online.
Interviewer: In terms of your own practice, what are you seeing that suggests an association between social media use and adolescents suffering harm or mental distress?
Dr. Bernadka Dubicka: Well, part of my interest in this area was when I worked in an in-patient unit for a long time. And over the last few years, whilst I was working there, some of the effects that we were seeing on social media were replicating effects that we’re seeing within the environment. By that, I mean, for example, self-harm was one issue.
So we often found that young people may be coming into an in-patient environment, and were then adversely affected by other young people who were there. Again, that social contagion. They might not have been self-harming much at the start of their admission, but very quickly they learnt that as a way of coping. As a dangerous way of trying to get staff to pay more attention to them, for example, by increasing their observations.
And then what was also happening was they were communicating with each other between units, between other groups. Telling each other how best to make sure that they got to stay in the unit for longer, which was absolutely tragic, because some of the young people who were there had very sad, difficult lives, and they felt that the environment and the unit gave them more security and protection than being discharged into the community. But again, that was often escalating some of the problems we were seeing. And similar sorts of effects we were seeing with young people with eating disorders who were accessing pro-ana websites as well.
And currently, in my community practice, I’ve had young people come to me, for example, who struggle with self harm. When they’re feeling well they use social media as a way of trying to support their friends who are also struggling with self-harm. But then I’ll see them on another day when their mood is low, their self-harm has started to increase, and then they find those feelings are triggered even further by some of the groups they are accessing online.
Interviewer: And any thoughts about what can be done to mitigate some of the harms or to signpost people to those helpful websites?
Dr. Bernadka Dubicka: Thank you. I think that last point you made is absolutely crucial. So, with our paper we’ve talked about social media companies stepping up to their responsibilities an awful lot more. And I’ve always said you get that with mainstream media, don’t you? So BBC, for example, will always be signposting people to support lines if they’re talking about content that might be distressing.
So it’s completely unfathomable why this can’t happen on social media as well. They have very complex, sophisticated algorithm that signpost people to more of the same content. So instead they should be signposting people to other content. And also, things should have safety warnings on them, potentially, as well. So I think there’s a lot more that social media companies can do.
And we were specifically calling for more research as well. And also for social media companies to be working more with academics to look at this area in more detail, so we can think about how we can signpost young people and help young people more effectively.
Interviewer: As you mentioned earlier, it’s a very polarised debate. So we hear a lot about the harms caused by social media and it makes good headlines as well. But what about the benefits? What does the research show in this regard?
Dr. Bernadka Dubicka: Well, I think that’s an incredibly timely question, isn’t it, with coronavirus? So I think these are very interesting times and I’m really keen to see what research might show about how technology and social media has been used over this particular period of time. So obviously, there’s lots of benefits that are just stating the obvious really.
So, during coronavirus, it’s just incredible how much connectivity we’ve been able to have because we have been privileged enough to have access to technology and to social media. And for many young people it’s an absolute lifeline. And particularly for some vulnerable groups, for example, the LGBTQ community. So some young people who might be struggling with some of those issues, struggle to find people that can support them or are having similar problems within their own face-to-face community, but online they might find safe spaces to talk about these issues. So there are huge sources of support, of education, of entertainment, of connectivity. And so I think all of those things are so, so important.
But what’s really interesting now, what’s emerging, is screen time fatigue, really, isn’t it? So, the wonders of having Zoom calls and us talking to each other right now remotely. But I think it’s emphasising even more how important face-to-face time is for social connectivity, which is something that we’ve talked about in our guidance.
It’s really important to try and have a balance between screen time and between face-to-face activities and social connectivity. And also I do worry about the next generation as well because, obviously, we’re growing up with the text-savvy generation, which is really good news for many reasons. But on the other hand, it’s so important to make sure that children growing up don’t lose that face-to-face time as well because that’s so important to social development.
I have a very brief anecdote. Recently I was sitting… When we could still travel, I was sitting on a plane. I was going to give a talk, actually, on this subject. And there was two young men sitting next to me. One was actually reading a book and I thought that was quite positive. I interrupted him to have a conversation.
And he was very interested in what I was going to be talking about because he was actually a manager for social media within their company and also had a background of computing. But he felt absolutely, totally fatigued by the 24/7 social media culture that was expected of him within his company. So we had a very interesting conversation around that.
And then the next person sitting next to me on the other side wanted to join in, and said how interesting it was that we were talking about this subject because he was also working in the same field. And his sister recently gave birth in hospital. He went to the hospital to say congratulations, but both his sister and her partner, completely immersed in their technology and sending things on FaceTime and the baby was completely being ignored.
So I just thought that was a fascinating anecdote and about some of the effects on today’s generation, and touching on some of the concerns and issues that they also have about this sphere.
Interviewer: I assume there will be some longitudinal studies to explore some of those issues.
Dr. Bernadka Dubicka: Yes, absolutely. And that’s something that’s happening. So one of the other things that we’ve called for from the Royal College, is that the government finally did fund a prevalence survey of mental health disorders in the community. Again, it took nearly 15 years for that to be funded. But there were questions on social media within that survey.
And I know my colleagues are desperately trying to get funding for a follow-up of that, because we have a whole population sample here of young people, with and without mental health difficulties, who’ve already told us how they’ve been using social media prior to the coronavirus and lockdown. So it’s so important to follow up this group and find out how this has been affecting them during this particular pandemic and how they’ve been using social media and how helpful or not that’s been.
But those sorts of studies need to be replicated around the world, including much more nuanced studies looking at particularly vulnerable populations. For example, children with autism and how they manage social media and technology.
Interviewer: Bernadka, I want to return here to your role as deputy editor-in-chief of the Child and Adolescent Mental Health Journal, which has just celebrated its 25th birthday. As Deputy Editor-in-cChief of CAMH, what have been the highlights for you so far?
Dr. Bernadka Dubicka: Number one has to be getting on Medline recently. So that was a fantastic achievement and just like to give thanks to the whole team behind CAMH for managing to achieve that. And I think there’s every reason why more and more people should be sending papers and publication in our journal.
And after that, I think it’s the really great team that I’ve worked with over these past few years, both in the office, people like Prabha and Mubasil, the current Editor-in-Chief, Dennis Ougrin, and the whole team. So I’ve met some really great people.
And in terms of the content, I was really excited when we started our debate section last year. And we published a debate on bipolar disorder, myself and Gaye Carlson. And I think that was very well-received and we received some really interesting articles about a very topical issue.
Since then we’ve published a debate on the whole issue around gender identity which, as you know, is very controversial at the moment. And the next set of pieces we have coming up are going to be around people’s experiences of the coronavirus pandemic from around the world. So I hope that people are finding these new features within the journal interesting. And we very much want to keep things topical and accessible.
Interviewer: CAMH is lauded for helping practitioners convert evidence into practice. What makes it so successful at this?
Dr. Bernadka Dubicka: We do try and make content as accessible as possible. So, for example, we’ve got an innovation in practice section. And that’s a really important area for clinicians, for example, if they’re looking at quality improvement projects, if they’re developing innovations, for people to hear and read about. And, as I say, we’re trying to make the content as topical as possible and the debate section has been part of that. And we keep having… We’re having ongoing conversations how we can increase accessibility. And it’s really good to hear that people are finding, that clinicians do find the journal of value.
Interviewer: Why is evidence-based research so important when it comes to children and young people’s mental health?
Dr. Bernadka Dubicka: Well, as I said earlier, child mental health is so important because it sets a blueprint for the rest of that child’s life and our future generations. And we have to get things right as early as possible. And the thing with evidence is that… and practice, there are so many things that we do which, on the face of it, seemed like a good thing to do. But once we actually do the research and do the evidence, we find that sometimes we inadvertently, we can be causing harm.
So one example I can give of that, the whole issue around debriefing post-trauma. I remember many, many years ago, when I was still a trainee, I was working in a service. And we had a very long waiting list at that time. That’s something that has moved on.
It was two years’ long. And there was a fire in a neighbouring school and the team decided that we were going to stop seeing all referrals, everybody on the waiting list, and the whole team would decamp to debrief all the school children of the school. And I felt very uneasy about this at the time, because we had a long waiting list. Children and young people we knew needed urgent help. But there was no evidence that we will be doing any… we will be helpful in the immediate aftermath of this fire within the school.
And sure enough, quite soon after that, a well-known study was published demonstrating that professionals can do more harm than good in the very early stages of post-traumatic events like this.
So I think it’s so important that we do do the research and that we don’t do any harms. And it’s so important to also think about the harms that we might be doing. And I guess, from a medical point of view, do no harm is the mantra that we live by, really. That is why it’s so important to have evidence-based practice. And that we invest in evidence for children and young people because the investment in research has been so far behind other areas of health.
Interviewer: In an age where so much unregulated material can be accessed, what more can be done to promote evidence-based science?
Dr. Bernadka Dubicka: Well, again, I mention the technology companies because that’s a massive important source of information, particularly for young people these days. And they have shown more responsibility during this crisis and taken down misleading content. But I do think it’s important that that debate continues within the social media sphere.
Obviously our leaders are really important as well, that they promote evidence-based practice and science. And we’ve seen good and bad examples of that during this pandemic. Journals like ours are very important. And so there’s many. And of course, from the Royal College of Psychiatrist’s position, we do try and promote evidence-based practice as much as possible in the teaching that we do. But it needs to be at every level.
So quality improvement, for example, that’s one part of the spectrum of trying to collate evidence and looking at best practice within services. So quality improvement moving through to formal research activities. That whole spectrum of activity is really important within our service and needs to be embedded in everything that we do.
Interviewer: Bernadka, as we mentioned earlier, you are Chair of the Child and Adolescent Faculty at the Royal College of Psychiatrists. It’s well documented that there have been significant problems filling child and adolescent psychiatrist specialist training programmes and difficulties recruiting child and adolescent psychiatrists. What is it about child and adolescent psychiatry that makes recruitment so difficult, and what is being done to change this?
Dr. Bernadka Dubicka: I think that’s quite a complicated question, isn’t it? I think firstly to say, there are challenges recruiting across the whole of mental health, and child and adolescent psychiatry I think is particularly difficult within that sphere. It’s also difficult recruiting mental health nurses, for example. From a psychiatry medical point of view, there’s always been a stigma associated with that which goes back to medical schools. So I really call upon all my other colleagues within the medical profession to be assigning the same amount of worth to mental health as to physical health.
Because we hear time and time again within medical schools that psychiatrists are not perceived to be real doctors. Well, I would really challenge that, and particularly from a child psychiatry point of view, because I do think real doctors are doctors that look at people as a whole, as I was saying earlier. Look at people in a holistic way, living in their communities, living in their families, and treating people as a whole. And I do think that the rest of psychiatry, as well as the rest of health, has got a lot to learn from the systems holistic approach that we try and adopt within child mental health and child psychiatry.
And I’ve been really gratified because I think things are slowly moving in that direction. For example, I went to a talk recently about training and there was a talk from the General Medical Council as well as from the Royal College of Surgeons.
And both the speakers were talking about a prevention, well-being, resilience approach and an integrated systems approach to health. And that was just music to my ears because that’s what we’ve been saying in child mental health and child psychiatry for a long time. But I think people are gradually waking up and realising that a doctor and psychiatrist can’t alone save a child or provide the one single intervention.
And we don’t have the health workforce, not only nationally, but throughout the globe, really. There is a shortage of health professionals worldwide. And the only way we can deliver the best physical and mental health is if we have a preventative approach working, and a lot more focus on how people can help themselves, including young people, and how families can support each other, how communities can support each other.
And then only moving towards a more health delivery model for those people who really need it. But without that kind of integrated approach, looking at prevention, resilience and starting with the very early years, we’re not going to make huge strides in this area. So that’s a very long answer to a short question, but I think it is quite complicated.
And just to say, one of the other things to point out, the College have been doing a lot of work on this, including the Choose Psychiatry campaign, which has been successful. But there’s also a message there in the media which we do need to balance and that’s quite difficult to do at times.
So we do need to call for more focus on investing in children and young people in terms of health services, in terms of research. And we do need to bring attention to the fact that we do need that. Sometimes, however, that can then put people off because they worry about coming into a service which appears to be underfunded. So it’s really important to balance those messages and also send out messages around all the good work that we do do and how we can make a difference at a very young age, and families are very, very grateful for that.
Interviewer: What else is in the pipeline that you’re working on?
Dr. Bernadka Dubicka: Well, in terms of research, I’m still very interested in brief interventions and particularly how they can be adapted remotely now. So we’ve been working on a brief intervention, and a manual that we’ve developed in my particular service found it’s very easy to adapt that to working remotely.
Because I think obviously we need to do that during this pandemic crisis, but also we need to look at how services are going to be changing. And remote working is not going to replace face-to-face working, but it’s certainly going to be part of our delivery model in the future. So I’m hoping to get funding for that particular study.
And within the College, sustainability and the climate change and also the current… the environmental disaster that we’ve got is absolutely of primary importance. That’s been so for our particular Executive Committee, but also for the College as a whole, we’ve just set up a climate and ecological emergency committee. We’ll be producing work from that, including feedback from young people.
Because we know this is something that matters to young people so very much and this is the rest of their lives, which is why it’s so important. And then within the Executive, we were looking at revamping our paper on sustainable CAMHS, and that’s a very appropriate word for these days.
But I think particularly in light of this Corona epidemic, we do need to look at how we’re delivering services. And so I very much hope, over this next year, that’s something that we’ll be doing, including looking at the values that drive our services and our work, both from a younger people’s point of view, and looking how we can best deliver services that meet young people’s needs, based on their values, and that are sustainable. And also very important that we do have a sustainable, healthy workforce.
Interviewer: Finally, Bernadka, what is your takeaway message for those listening to our conversation?
Dr. Bernadka Dubicka: So always please shout out for children and young people, because if you don’t, they will be forgotten. So anybody who works with children and young people, please keep shouting out about them. And then please, please read CAMH, and please submit to CAMH. We’re on Medline now, we’re accessible, we’re readable and looking forward to getting lots more submissions from people. And also looking forward to developing the journal further to make it even more topical and accessible.
Interviewer: Thank you ever so much. For more details on Dr. Bernadka Dubicka, please visit the ACAMH website, www.acamh.org and Twitter, @ACAMH. ACAMH is spelt ‘ACAMH’.