‘Creative approaches to developing skills for future CAMHS professionals’ In conversation with Dr. Carlos Hoyos

In this podcast we talk to Dr. Carlos Hoyos, consultant child and adolescent psychiatrist at Southern Health NHS Foundation Trust, undergraduate lead for psychiatry at the University of Southampton and ACAMH’s 2020 winner of the David Cottrill Education of CAMH Professionals Award.

He explains his innovative and creative approaches to enhance and develop skills for current and future child and adolescent mental health professionals, and how it can help students, and CAMHS professionals to get that more experiential, real-life experience.

We talk to Carlos about his inclusive approach, such as the involvement, engagement with parents, and also its benefits this reaps. Carlos also discusses the challenges faced as a CAMHS educator, and ponders on the future for CAMHS more generally in the short, medium, and long term.

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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 for the Specialism in Psychology. Today I am interviewing Dr. Carlos Hoyos, consultant child and adolescent psychiatrist at Southern Health NHS Foundation Trust, undergraduate lead for psychiatry at the University of Southampton and ACAMHs 2020 winner of the David Cottrill Education of CAMH Professionals Award. If you’re a fan of our In Conversation series, please subscribe on iTunes or your preferred streaming platform. Let us know how we did with a rating or review and do share with friends and colleagues. Carlos,  welcome, thank you for joining me and congratulations on your ACAMH award. Can you start with a brief introduction of who you are and what you do?

Dr. Carlos Hoyos: Yes. So I’m a child and adolescent psychiatrist in Southampton and working in a disorders unit in Winchester. I moved to Southampton some 17 or 18 years ago and took up a job with two whole days dedicated to teaching medical students. Over the years I’ve developed the role and branched into other roles and I roughly dedicate half of my time to teach medical students and junior doctors and the other half to clinical practice.

Interviewer: And how did you come to be interested in child and adolescent mental health and also training and education?

Dr. Carlos Hoyos: My first interest was mental health. So I guess  when I was a teenager I wanted to be a psychologist. I was interested in psychology in people’s minds and understanding people. And then what happened is I got much better results in my equivalent of A-levels than than anybody expected and I ended up doing medicine in order to do psychiatry instead of psychology. So my interest in psychology and minds comes from since I was a teenager, I only did medicine to become a psychiatrist. I never saw myself as particularly interested in child and adolescent psychiatry through my early training, I wanted to work out what schizophrenia was. I wasn’t that interested in children, in fact, I wasn’t interested in children at all until I did a placement in a child and adolescent unit in North London, and I became fascinated by adolescents. I had this idea that everything that happens in your life, happens in adolescence, and that’s when you can catch people and you can change things and anything that comes afterwards is just because you didn’t do it right in adolescence. And that was almost 30 years ago and I think I was right. I’m still thinking that. So in terms of education, I was curious about understanding things beyond the patient you had in front of you, and I started having what is normally called academic interest, which at the time involved research and teaching.

Very quickly, I realised that I was much better at teaching than research. And then it dawned on me that when I was a teenager, all my teachers wanted me to be a teacher and one of these people who doesn’t really understand things unless I can explain them. And then I realised that actually it’s not that different to being a child psychiatrist, and actually the skills overlap. And then I realised that whilst a lot of skills overlap, a lot of skills don’t overlap, and I had to take my educational education seriously. So I started studying education as a separate discipline and then I realised that actually most doctors are amateur teachers and that there’s a difference between an amateur teacher and a professional teacher. So I became better and partly I think it was to do with revenge, you know, so I became good at education and I realised that it can be done well. I realised how badly most of my teachers had been and became a bit irritated that people don’t take the time to teach properly and of course, then the teachers who did inspire me, kind of, came to the fore, and I wanted to be like them and not like the awful ones I had had, of which there were many.

Interviewer: So good in fact that you won the David Cottrell ‘Education of CAMH Professionals’ Award

Dr. Carlos Hoyos: Yes. Well, I mean, I got nominated by somebody I’ve worked with for 20 years and she’s very nice, and I thought, that’s very nice of her. But anybody can get nominated, you know, Donald Trump got nominated the Nobel Peace Prize, you know, so [laughter] and I actually made the comment of saying, ‘ah this is just the mafia of academic, they just give prizes to each other, not a chance that I will win.’ And then I won, [laughter] so now I am struggling to explain it to myself.

Interviewer: And you won it because you had a significant impact upon the education and training of child and adolescent mental health professionals. Can you describe some of the innovative and creative approaches you use to help medical students better understand children’s behavior?

Dr. Carlos Hoyos: Well I can tell you what I think I do. I think you would have to ask my students what it is that I do do. I think if I had to sum it up in a couple of points, the first one I would say is that apart from teaching content, teaching kind of, knowledge and skills and attitudes; when you stand in front of students in the role of teacher, what you are, is almost like an advertisement for the profession. So I remember even though I went into medical school only to be a psychiatrist and I was going to be a psychiatrist or a photographer, there’s no way I was going to be a GP or a gynecologist. Even then, I met the psychiatrist who were supposed to be teaching me, and I came very close to giving it all up because they were such awful people. So, they were bored, there were burnt out, they were dumb, and, you know, I mean, some of them were dirty. It was really not impressive. This is in some unnamed city in Spain. And so I am very aware that when we stand in front of them and say, ‘I am a psychiatrist, I’m here to teach you,’ we need to sell them an identity in a way. And I’ve been very careful to enlist people who are attractive or appealing in some way, and sometimes the attractiveness is all to do with enthusiasm and, you know, people who love what they do. And I do love what I do and that comes across. So that’s what I would say point one.

The second point, which is more to do with educational principles, is the idea that I think people learn when they need to. So my theory of learning is that people need to have an experience that drives them to learn in order to make sense of what they have experienced. And then your job is to give an experience and then help people make the most of the experience and then make the most of the thinking that comes after the experience, and then all the knowledge comes in without any problem. So if I go to students and I said, ‘you need to know five symptoms, A, B, C, D, E, and remember them.’ Chances are in 20 seconds they will have forgotten them and they’ll never remember them as they don’t know what why they need to know them or what they mean or anything.

If I get to meet somebody with, I don’t know, with a psychosis, you know, and they get baffled and then they need to know something in order to make sense what’s going on with this patient. And then I say, ‘well, this patient is psychotic because he’s got these five symptoms. Can you see them?’ Yes, they’ll never forget those symptoms. So the idea is learning from experience.

Interviewer: I was thinking, in the 50s of course, people used to sort of wheel out patients as, kind of, guinea pigs for medical students to learn about. You can’t do that in quite the same way so I wondered about your use of things like one way mirrors and things. How do you help students and also CAMHs professionals to get that more experiential, real life experience?

Dr. Carlos Hoyos: So, this is a format that we’ve kind of refined in Southampton, which is we use the family therapy set up of a one way mirror room and we use that if you want that use of space and architecture to design a teaching experience. So we spend the morning talking them through the experience of children and families come into CAMHs, and we do that through a role play and we give them some conceptual framework. They do a role play of a family, coming to see a psychiatrist and they love it that everybody says students hate role play, you shouldn’t do it, but if you do role plays well, they work really well. So they do that in the morning and then in the afternoon we recreate the same structure, only this time they see an actual family. So it is authentic because they see an actual family and we do spend a lot of time reading the referral letter and reflecting on the referral letter, linking it up to the teaching we did in the morning. And then they watch the family come into the clinical space and go through the assessment process and they serve the whole process.

So from the minute the letter is opened to the minute the clinician feeds back, what’s going to happen next, then they leave. And that takes hours because we punctuate it with discussions with the students, so the assessment process is stopped three or four times so students can discuss and understand what’s happening. We’ve been doing this for 15 years so we’ve kind of introduced little modifications every year until we have a format that works very well, gets universal good feedback, and then what happens is it’s not just good for medical students because we have psychotherapy students or nursing students, everybody can fit in the room. We can have 20 students watching the assessment and the more multidisciplinary the group of students watching is, because we have so much time to reflect and understand what’s happening, we look at what’s happening from different professional and ideological perspectives, the richer it is. So you have medics where they would see something and say, ‘oh, yeah, he’s got the symptoms of ADHD.’ But if there is psychotherapy trainees, you know, the psychotherapy trainees will say, ‘oh, they just have to look at the mother and then the mother keeps intervening.’ So the medical students learn from the psychotherapy students, and, you know, so the more people, the more perspectives, the richer it is.

Interviewer: That multidisciplinary approach, though, for you, it also involves engagement of parents with whom you work. How do you bring them in? Can you say a bit more about this kind of inclusive approach and also its benefits?

Dr. Carlos Hoyos: So we have used that in the teaching assessment clinic, which I’ve just described, that sometimes we get one of the parents behind the mirror or we include discussions with their parents. And sometimes what we do is we split the family so that the child is seeing a therapist in one room and another therapist is seeing the parents in another room. And from the observation room we have, because we’re very lucky, we have an observation room with two one-way mirrors, to two different areas, so the same students can can dip in and out of both interviews that happen simultaneously. So that’s quite rich and fascinating,  not particularly in this one but in all the teaching formats, I have included teaching sessions that are carried out by the parents. So we would have a session when we will take a paper case and we will see the referral and the results of the assessments. And then there will be an interview with the parents of that child where they would be able to ask the parents; how was this and what happened after this? And the parents are brought into the clinic for the exclusive purpose of teaching medical students without the child.

Interviewer: Can you explain why, because I know you include a module of systemic thinking with your undergraduate medical students but why is it so important for students to grasp that?

Dr. Carlos Hoyos: So doctors are trained in the anatomic clinical model of thinking so when we see a patient, we see a constellation of symptoms and we’re trained to think, okay, what is the one biological thing that will explain all these symptoms? So we get somebody with a complex presentation, I don’t know, vomiting, double vision, headaches, and we say to them and we ask ourselves; what can explain all these symptoms? And we thought, ‘oh, yes, raised intracranial pressure.’ That’s what explains all this and do the same thing when we see patients with mental health problems, you know, oh there is all these symptoms, what can explain? Oh, he’s schizophrenic, that explains it, or he’s depressed, that explains it. When actually everybody with any experience of mental health would tell you that, yeah, that works sometimes, but most of the time, so if you want to understand what is happening, you need to be able to understand the context in which everything is happening, so it’s the opposite approach. You need to be able to understand everything that has any influence in the presentation. The more complexity, the better you understand, as opposed to honing in into the one thing that explains it all.

And of course, that’s the way systemic thinking goes in family therapy. It is complementary to the way doctors think, to think the way family therapists think. But actually the medical profession itself, at least on paper, considers systemic principles pretty important. If you look at the documents from the GMC and everything, there’s a lot of emphasis on doctors should be able to work with other professionals, that doctors should take a holistic approach, doctors should be able to manage complexity, that’s on paper. But when it comes to practically teaching, very few people teach the principles that underpin that way of thinking and that way of working. And that’s one of the advantages us psychiatrists, and particularly child psychiatrists have over the rest of the medical profession, is that we need to know those things for the purposes of, or clinical activity, therefore, we are the ones to teach it to the rest of the world.

Interviewer: These types of training approaches that you’ve described; are they universal or is there a need for them to be adopted more widely?

Dr. Carlos Hoyos: So there are punctual places where some family therapists teach systems thinking, but they’re not universal, they’re not in all medical schools and most of the time they’re not explicit. So I think medical students get taught everywhere that you need to understand the social context and social factors are very important and all that. I don’t know of any other medical school where students are expressly taught how to ask  circular questions. So the principles behind circular questions or even the systemic structure of discrimination or how power works in relationships explicitly as a curriculum point, and we do do that, that’s one of the innovative things that we do in Southampton.

Interviewer: Can your model be transferred to other medical schools or is there some process to enable that to happen?

Dr. Carlos Hoyos: I don’t see why not. They need to be interested. So we are, because we are transferring everything online, we are recording lectures to make examples of, you know, circular questioning or, you know, circularity in causal relationships and, you know, finding of patterns and all the key principles, but we’ll have them in videos and things like that so that anybody can use those. The problem is, I don’t know that many people see those as core curriculum items for medicine.

Interviewer: What other innovative and creative approaches do you recommend to enhance and develop skills for current and future child and adolescent mental health professionals?

Dr. Carlos Hoyos: So I think the focus should be understanding patients and then think, what is it that people need in order to understand the lives of patients or the problems of patients? And I think that’s much wider than medicine. And of course, that involves a lot of psychology and a lot of system thinking, but also a lot of understanding of what people have used for centuries to understand other people, which is the arts and humanities. I guess if you’re asking me for innovations, for the last 10 years, I’ve been running a selected unit, which is an optional unit people do in Southampton, teaching psychiatry and mental health through film. So we watch films and we learn about mental illness and we also learn about films. And the idea is not that, well we will watch Temple Grandin and you will learn about autism. It’s, we will watch Temple Grandin we will learn about autism, and we will learn how watching a film about somebody can help you understand a condition in a way that then will help you understand other people. So learning not just about autism, but learning about autism from film and then learning to watch films in a useful way, where the more films you watch, the better psychiatrist you are.

So the idea is to make the curriculum the widest possible and the closer to human experience as possible as opposed to the current trend, which is the opposite, which is to hone in into the narrow competencies that can be measured and that are appear to be directly relevant to the job at hand, which is how to deliver a self-assessment. What do you need to ask when you see somebody with a deliberate self-assessment? I am trying to move the opposite direction. If you want to understand behaviour, you need to understand the context of the behaviour, even if you want to understand the context of a behaviour, you need to understand a lot of things. If you narrow things down to the exact behaviour, you end up with nothing.

Interviewer: Carlos, who have been your mentors and who are you still learning from?

Dr. Carlos Hoyos: Oh, many people. How long have you got? I mean, when I did my one minute acceptance speech in ACAMH, I narrowed it to three. So my first one was a transformational teacher I had when I was a teenager who was a maths teacher who sold me the idea of the humanities as learning. So my father was a doctor who didn’t want me to do anything other than get A’s everything so I could be a doctor. And anything other than that was a waste of time,you know. This teacher convinced me that actually going to the cinema or reading a good book is not a waste of time. This is actually good for your education and then it’s not just good for your education, it’s what life is about. And that I got from a teacher and not not even a medical teacher, just a good teacher. And I often refer to my experience of good teachers as a teenager, as fundamental to who I am and also what I do.

Number two, I mentioned was Robin Murray, Professor Robin Murray. When I came to the UK in 1991, I serendipity, I landed in a ward at the Bethlem Hospital with this consultant who I could barely understand what he said because he had a very strong Scottish accent and my English wasn’t very good at all. But this guy, at lunchtime on Wednesdays, would sit me and tell me about psychosis and things and explain it. And I remember understanding most of what he was saying, but most of our understanding just how passionate this guy was about what he was telling me. This guy was loving, teaching me. I had never had that experience throughout medical school of somebody who takes an interest in you and actually, you can tell they enjoy teaching. It happened to be Robin Murray, one of the most important psychiatrists in his generation, and I was the lowest of the low. I was a clinical associate, you know, I was way behind a junior doctor. With the years later, I understood just how much he must have loved to teach to do this with a clinical associate.

So I keep that in mind all the time when I’m teaching. You want the humility, but also the pleasure in teaching. That’s what I owe Robin Murray. And the third one I mentioned was Lionel Herzov, which is one of the kind of big characters in ACAMH who I met at the end of his career when he was an emeritus professor and they just had him nominally to run the training of the SPRs in the Tavistock and because I was a lecturer there, that was my job too. So he supervised me organising the training program for the SPRs. And that was my first experience of being an educator, so training people in child psychiatry and not being in child psychiatry but being an educator and developing a curriculum. And he was instrumental in me understanding that education was a different activity from clinical work and it deserved attention. And actually, a bit selfishly, he made me feel like I was good at it and he was really encouraging. And actually he was the guy who allowed me to say, ‘actually, I’m going to pursue a career as an educator.’

I hadn’t thought of that until my contact with Lionel so I think that would be the third person. I didn’t say this in the speech at the time, but the team of educators I’m working with is phenomenal, you know, so the Monica Roman-Morales a family therapist who is equally passionate about systems as I am about child psychiatry, who’s converted the whole team to teaching the principles of systems as valuable to medicine or I don’t know, some Sam Cortese you know, sort of the academic, you know, that knows every paper and who publishes everything, every day, everywhere, it’s amazing, you know. Or Cathy Bradbury, the person who nominated me, who was a consultant nurse who chose to stay in clinical practice, was supposed to become a manager. And who was one of these people who remained curious until the day she retired, was learning. And the example of that kind of approach of, ‘I am learning all the time,’ so I learned that from her.

Interviewer: What for you remain the main challenges as a CAMHs educator?

Dr. Carlos Hoyos: So I think we have layers upon layers of stigma. I think, all activity is not valued. So when I introduce myself to medical students, I use a bit of shock tactics. I say to them, so I’m the first psychiatrist they ever meet in Year 2. I start by saying, ‘well, you know, psychiatrists are the wishy washy end of medicine, don’t you?’ And they all giggle because they all know what I’m what I’m saying, you know. I say, ‘well, what you don’t know is child psychiatrist are the wishy washy part of psychiatry.’ And they all laugh and within child psychiatry, the child psychiatrist that work with little children are the wishy washy part of child psychiatry. Well, that’s what I do. I work with little children. I play with them on the floor. So how’s that for wishy washy? And they all laugh. And there is a tension because that’s their beliefs they bring in. I don’t do this, but I could go on and say, ‘well, if you think child psychiatry is wishy washy teaching child psychiatry, that’s even more wishy washy.’ So there is less of stigma around what we do. So psychiatry is looked down from medicine and child psychiatry looked down from psychiatry. And education is look down from academia, so all academic departments get assessed on publications. Nobody gets assessed on the quality of their teaching.

Dr. Carlos Hoyos: So that’s another layer. And I don’t see that changing anytime soon. So I think that is one of the difficulties. So when you find interesting, attractive, bright, ambitious people, to convince them to go from being a neurosurgeon to being a psychiatrist, that’s one big step. To convince them from being a psychiatrist to being a child psychiatrist, that’s another one. And then to convince them to become an educator, that’s even a bigger one so those layers of stigma, I would say that’s one.

I’ll say another one. The other one, which I think is also pretty important, is the lack of resources for the job. Never mind the lack of resources for education. So the health education in England sends hundreds of thousands of pounds to the trust, so they educate their students. Tariff is an equivalent of £30,000 per student per year, you know, and the amount of that money that ends up funding direct teachers or education is minimal. I think that’s to do with the stigma I was talking about, but it is the sense that there’s not enough resources to seek it, never mind to teach you to seek it. So CAMHs budgets have been shrinking, the numbers have been exploding. So the demand for clinicians is so huge, people are so desperate that education takes a second part. So it is very difficult to argue for education when you have barely enough money to develop a clinically safe service. So education gets underfunded because it’s housed within an underfunded clinical service.

So I think to my mind, that is the second. And so the first one is the layers of stigma, and the second one is the lack of resources and the place of education in between clinical services and academic research. The trust have budgets for education, the universities have budgets for education, but the trust will prioritise clinical service over education any time, and the academic institutions will prioritise research over education anyway. I understand why that happens, but what happens is education is always the poor sibling.

Interviewer: Carlos, what do you feel are the challenges for CAMHs more generally in the short, medium and long term?

Dr. Carlos Hoyos: I think we are at a crossroads. I think the perspective from a Spanish guy, you know, has had the best social psychiatry, and that was one of the reasons why I came here. So the sense that mental health of children is a social responsibility of the state and that that’s not just narrowly medical, but in general. So that is something that Britain had above any other country, you know, sort of the mental health services for children in Spain are ridiculous compared to here. What Britain, in my view lacks, is that set of values within the family and work fabric. So the state understands that and social services understand that. The families themselves, not so much. So the status of children within families is below what it should be, I think. And I think what’s happening now is that as the social state is shrinking, the slack is not being picked up by extended families, like is happening for instance, in Spain. So in  Spain, you wouldn’t have a psychiatrist to take an ADHD kid to be seen. You know, you could only see it if you afford it privately and even that, you would have to find one, you know. But there was always six or seven cousins or aunties, and so they would look after the kid on the weekend so their parents would have a break and nothing would break. I think what we have in the UK is we don’t have the extended families that are ready to pick up the slack of suffering and mental health problems of children. And the state who was filling in the gaps is no longer filling in the gaps. Mental health services are shrinking very fast. The demand is increasing very fast, and the pandemic has just accelerated that even more and there doesn’t seem to be any alternative to medicalising kids. So we are medicalising kids and putting them into a system that has less and less resources. I think we could do one of the two. We could stop medicalizing kids and make child wellbeing the business of everybody, not just doctors and nurses and mental health services. And that would work.

Or we could fund child mental health services to what they need to take the slack from all the other things children don’t have. But at the moment, we’re having neither. I think the long term implications is for the next five or six or ten years we might be able to juggle this until the kids we fail, start having children themselves. And then they will have the children of children who were very miserable themselves. I mean, that’s already happened, but only in a certain sector of society, you know, the underclass that’s been going on for generations, but I think it’s beginning to move up the social scale.

I think lower middle class and middle class kids are entering that loop of becoming adults of reproductive age without having had their childhood and adolescence achieve what it should be.

Interviewer: Carlos, what else is in the pipeline that you’d like to mention?

Dr. Carlos Hoyos: So personally, I think what’s in the pipeline is to be able to make the most of this new ways of delivering education and mental health services, you know, sort of the mastery of the Zoom, Zoom consultations and sort of thing. But actually, I mean, you can see how kids have taken to having meaningful social relationships online. I am optimistic in the sense that I think probably not the NHS, but somebody will find a way to harvest the potential of for communication and for wellbeing and for connection and understanding each other.

Interviewer: And finally, Carlos, what is your takeaway message for those listening to our conversation?

Dr. Carlos Hoyos: My take-home message would be that mental health is really, really important. So the psychological wellbeing of children and adolescents extends to the whole of the population. And learning how to do that is even more important. In 20 years time, we will only be as good for doing that as we are now at educating people to do that.

Interviewer: Carlos, thank you so much. For more information on Dr. Carlos Hoyos, please visit the ACAMH website www.acamh.org and Twitter@acamh. ACAMH is spelt A-C-A-M-H. And don’t forget to follow us on iTunes or your preferred streaming platform. Let us know if you enjoyed the podcast with a rating or review and do share with friends and colleagues.