The foot-in-foot-out approach is based upon mental health workers who divide their time between a YOT and a CAMHS service. This could be a lone worker splitting their time equally, or two mental health workers in a ‘job share’ scenario. Foot-in-foot-out approaches may co- exist with other types of health provision in the YOT, but mental health provision is on a part time basis only. This allows mental health workers to maintain links to CAMHS and ensure their clinical knowledge is up to date.
The foot-in-foot-out form of provision was found in one of the participating YOTs, Westley. The provision there reflected Khan and Wilson’s (2010) description well. In this instance, a lone mental health worker, Dan, was seconded into the YOT and spends half of his time based within CAMHS. Westley YOT also had a specialist worker for physical health, also on a part-time basis. At the beginning of his secondment, Dan was based within the YOT full time, but his role
had changed in the last four years to include more CAMHS work. Dan now spends two days a week in Westley CAMHS and three days a week in the YOT.
Dan receives support from both the YOT and CAMHS in the form of supervision and the maintenance of clinical skills. Dan, was not entirely happy with the arrangement though, and would prefer to be in the YOT full time opposed to split-site working. This could be due to his background, Dan had previously worked in forensic environments and was more familiar with criminal justice mental health work. Additionally Dan holds a YOT caseload, which is unusual, he was the only mental health worker in the case study to do so. The caseload was comprised of young people with more severe mental health problems, as it was thought they would benefit from having a mental health worker manage their case as youth justice workers may not have the knowledge or understanding of the specific mental health issue or how this impacts upon their offending behaviour.
“I also carry a small caseload of kind of, probation, erm youth rehabilitation orders. But those young people would have a specific mental health problem.” – Dan, Westley
That Dan holds a YOT caseload is a point of concern and shows how his role has drifted from that of a specialist to a more general role within the YOT. The Westley YOT had been criticised in inspections for this use of provision, and it was being considered by management if this should change. Dan did not seem to have a high level of agency in these discussions though, which may be indicative of management’s perception of seconded professionals and the value of professional judgement.
“It was criticised in erm when we had our latest kind of inspection. My carrying a case load of young people, you know, could be seen as quite an expensive use of resources really. [Long pause] It’s a tricky one really, it’s for the managers to decide.” – Dan, Westley
Having a mental health worker within the YOT on a part-time basis limits access to services, and giving that worker a YOT caseload limits their time for mental health work further. It also creates certain conflicts of interest, for example when a young person breaches the conditions of
their order. Dan felt some dissonance between the dual roles he held in these situations and was unsure of how to act.
“Although I breach when I need to, I tend to try to [pause] be as flexible as I can within the legal parameters that can be taken really.” – Dan, Westley
In terms of meeting young people’s needs, the foot-in-foot-out format is lacking. Whilst having time in CAMHS is beneficial for mental health workers in terms of support and maintaining knowledge, there is also the risk of having to address young people’s needs in a reduced time frame. In Westley YOT, where Dan is a lone worker, carrying a YOT caseload, his time to assess, refer and carry out interventions for mental health needs is severely limited. The foot-in- foot-out models can also operate with two mental health workers. This may alleviate this issue somewhat, but the two mental health workers in this situation would have to discuss practice frequently to ensure consistency and share information.
It seemed that within Westley YOT the general perception of mental health was a medical view. In addition to affecting referrals, this view impacted Dan’s opinion of what mental health workers should address, making a distinction between a disorder and difficulties.
“You know, [oppositional defiant disorder] is diagnosable in DSM isn’t it? But you know, do they have a particular mental illness? I don’t think so really.”
This limits the services that are available to young offenders in Westley, particularly if they are dealing with internalising or non-medical issues such as affective disorders, anxiety, or conduct disorder.
“a proportion of [young offenders] will have a mental health element to that, whether it’s a disorder or an illness, or just an emotional wellbeing kind of issue that’s quite transient.” – Dan, Westley
Gaps in provision were identified by Dan that required specialist input, specifically learning disorders and autistic spectrum disorders. Language difficulties were also noted as being
prevalent in Westley. That Dan recognises these issues as requiring specialist help is positive, however, in Westley YOT there are not resources available to address this. There is also a lack of other sources of support in the local community, making it harder for these young people to have their needs met.
“I think that [pause] yes, in an ideal world you would want a dedicated forensic, you know, team that could meet the needs of all young people that were, that came into contact with the youth justice system, but we don’t have that.” – Dan, Westley
In terms of socially just practice, Westley YOT could improve. It is difficult for young offenders in this area to access services, and if they do, the views of mental health within the YOT are somewhat narrow due to the use of the medical model, and the potential linkage of criminal justice to mental health work; due to Dan carrying a YOT caseload. Regarding this, it seems that the decision to carry a caseload does not rest with Dan, who would like to change this, or local CAMHS, who appear to have little influence on the structure of provision within the YOT.
“Erm, you know I do feel, I know that it is an unusual arrangement, erm, it’s something that, you know, I think that would probably work [pause] probably towards, not doing in the future. But at the moment, that’s just how it kind of is for me.” – Dan, Westley
That Dan has little agency in deciding what his role is and what work falls within that is not indicative of socially just practice. Additionally, Dan having ethical dilemmas regarding breaching young people to whom he is also delivering mental health treatment is concerning. In discussing this, Dan mentioned that this had happened on a number of occasions, implying that despite his discomfort with this, no changes had been made to practice to improve the situation.
“Sometimes I am, I do struggle with it occasionally. You know, one of the criticisms I get for carrying a case load, is that if those cases that I manage don’t comply with their orders, how do I feel ethically with having to take them back to court and breach them. Sometimes it can be a dilemma for me” – Dan, Westley
These issues may be related to the culture and management of Westley YOT rather than being aspects of foot-in-foot-out provision. However, that these issues can occur within this approach implies that it is not appropriately structured to allow mental health workers to maintain boundaries around their role. There are also issues regarding accessibility in this type of provision; perhaps this may be improved if there were two mental health workers, but Westley YOT is an example of one not being enough to meet needs in this format.