Relational and Physical Safety

06 art - 02

Feeling Safe Inside and Outside



shutterstock_318831245

Feeling safe and comfortable internally and externally: that’s what this theme is all about. Young people, and their families and carers, expect ward staff to be safe and accountable practitioners. Safety is the basis of human development and our social life; in other words, it’s really essential that everyone feels safe.

The young person may be coming from experiences that made them feel, or be, distinctly unsafe, externally and/or emotionally. Young people living in prolonged fear states are often opposed to adult intervention, because they feel anxious about putting their faith in others; specifically, to trust the notion of adult affection. When we feel unsafe, it’s hard to think about anything else other than trying to re-establish safety, and other things that are typically important or of interest are overlooked.
As well as their presenting mental health problems, 11 to 14 year olds are also likely to be worrying about the appearance of their developing body and feeling awfully self–conscious. Parents or carers are the primary source of the safety and security needed by children and adolescents. Parents are hopefully doing their best to cope with their child’s common feeling ‘it’s not fair’, but striking a balance between freedom and over-protection isn’t easy! Parents of young people in the last four years of adolescence often feel anxious about risk-taking, and have to work out how and when to set limits. They may try to discourage activities they consider unsafe, but risk antagonising their child. And although it’s characteristic behaviour of 15 to 18 year olds, parents’ endeavours are especially challenged when the young person tries to guard their privacy and seems secretive.

image_5_6

In fact, parents' anxiety about their child's safety and feelings may make them appear too intrusive, and their natural desire to protect their child may trigger tension. Whether you’re a parent or not, we’re sure you can relate to these issues based on your CAMHS experience. And again, all of this is exacerbated by whatever difficulty they’re in hospital for.
Key relational safety features include:

  • Containment

  • Structure

  • Support

  • Involvement

  • Validation


Source: Gunderson 1978
shark"What would it be like to grow up in an environment where you had to be alert and vigilant all of the time? It must be a bit like the difference between swimming in a shallow swimming pool and being in shark-infested waters. If you see a black shadow under the water, you would probably have two very different reactions: in the shark-infested water you would probably feel certain that the shadow is a shark, a threat to you, even if you cannot see under the water. Your brain would slip automatically into the ‘fight-flightfreeze’ response, a physiological response to perceived threat whereby the body releases a combination of a neurotransmitter called epinephrine and various hormones, which work together to create a boost of energy. Well the same goes for children in chronically traumatic environments. They become hypervigilant to threat and danger, although in their case the threat is their parents."

From Cooper and Redfern, 2015 - read more here

Safety is the basis of human development and our social life: feeling secure and comfortable internally and externally.

306 art - 08

“Ideally consistency in application of treatment and therapeutic approaches will instil a feeling of stability and routine in the unit... Consistency in the team may be heightened by the inclusion of resilient individuals. These [staff members] tend to be good communicators, more empathic and have good coping strategies. Resilience is an excellent quality in inpatient teams alongside humour and optimism. Resilient individuals may ‘rally’ others into looking more positively at challenging situations, such as those which arise in caring for the disturbed adolescent.”

 Source: rcpsych.ac.uk - from here

Containment



CAMHS staff do a fantastic job of providing emotional and psychological support, which is no mean feat! Setting up and keeping up a sense of safety is the main responsibility of the adults young people are attached to. Once safe, young people are able to explore and blossom. This takes consistency, mindfulness and patience, the ability to connect with young people with presence (by ‘presence’ we mean being really tuned-in and alert, opening our senses and truly being with the other person) and give them space, the use of good boundaries and the strength to ‘hold’ even the strongest of feelings and experiences while the young person explores them.
By using your present-moment mindfulness, young people are more able to appreciate that they have your attention, and that you have theirs. You do your best not to become distracted, or do several different things at once while you’re with them. You meet them exactly where they are, without needing them to change according to your own agenda or schedule. You embrace their first-hand, direct experience - honour it, accept it, stay with it and explore what they need to explore with you.
image_4_4
It’s not always easy to keep hold of - to contain - difficult feelings (theirs and yours) and they can feel disproportionately overwhelming. Young people often push boundaries because they know intuitively that they need the safety of an adult’s calm, confident responses, and to offload the painful feelings bubbling inside them (Lansbury, 2014). Thoughtful CAMHS staff encourage emotional expression, and are patient with any outbursts.

Once the team starts to think about noticing their own thoughts and emotions, they can then develop their ability to be more reflective practitioners.
“I remember doing an exercise in a training session where everyone had to stand in front of a partner and slowly walk towards them. The person we faced was asked to indicate with their hand when we were approaching their line of comfort. It felt really odd but it was eye opening. It showed me that while there are some generic boundaries we all share, we all also have our own set of personal boundaries. It’s important to teach young people about this. They need to develop healthy boundaries - ones that reflect their self-respect and worth. Young people whose boundaries are respected have a much easier time setting them appropriately with others."

Occupational Therapist
Although we can’t see containment with our eyes, or easily describe it with words, we all know (often unconsciously) how good it feels; when we feel securely embraced by someone we’re more likely to feel better and move forward through the bad times.

Containment is the soothing space the ward community creates, conveying a foundation of safety to help young people move more comfortably through their recovery journey and move forward emotionally, socially and educationally. A safe and stable space allows young people to move between various thoughts, feelings and behaviour, without getting stuck in one extreme or another. “It gives them a center, a plumb line to use as they learn to self-regulate,” says Kim John Payne M.ED, author of the fab book, Simplicity Parenting. “The emphasis is on creating a calming, supportive atmosphere, so they can get through what they need to get through.” Being in a mindful space stops strong emotions from overpowering the therapeutic relationship, and instils greater trust and non-judgmental acceptance. Stay present and open, beyond all ideas of right and wrong.

Before young people can feel contained, it’s crucial that you also feel held, and have enough time to speak about things and get support from others in your team.
It’s sometimes helpful to engage young patients in a relaxed ‘storytelling’ conversation, in which they are totally free to chat about anything. Not only can this feel safe to a young person, but it encourages them to talk about the most difficult things. When they feel safe, young people are more able to be open to, and influenced by, guidance and structure. Conversely, since some young patients (especially those who’ve been hurt in home life) have been deprived of just about everything, more deprivation (the use of seclusion or refusing to listen to them, for example) won’t be of any help. You can’t deprive the deprived. It just doesn’t chime with them.
“I thought I was going to be locked in a bed. I was pleased once I got in and found out what it was like, it wasn't as bad as I thought.”

Source: A young person quoted in YoungMind's Where Next 2

thumb_IMG_9787_1024

Promoting Mind-Awareness


In TalkWell, our guide on encouraging the art of conversation on mental health wards, we refer to the skill of mentalising or ‘mind-awareness’. Mind-aware staff diligently focus on the continuous, complex and often fraught process of talking with people experiencing mental health problems. “The skills required to communicate with us when we’re at our most unwell and not always super-reasonable (!) tend to be under-rated,” says TalkWell’s author, Marion Janner. “Yet they are the ones most valued by patients and which deserve a lot more attention, training and support.”
“Emotional intimacy in any human relationship is caused by maintaining perspective about one’s own thoughts, feelings and needs, while being able to accept another person’s thoughts, feelings and needs without reactivity... Healing the child’s heart means being present for them no matter how the child feels. It means intentional responding out of personal and other awareness. It means remaining secure as the adult in order to provide influence to the child beyond his behavior.”

Sudsberry, 2014
The main principle of TalkWell is that all conversations on wards have a therapeutic value. Being ‘mind-aware’ helps maximise these exchanges, by being in touch both with what we’re thinking and feeling, and what other people are thinking and feeling. By being aware of what’s in the patient’s mind, you will be in a much better position to see things from their perspective, and work out how best to resolve the situation.

It’s also about being aware of your own thoughts and feelings, especially if they’re so strong (perhaps because their behaviour has triggered something in you) that they get in the way of you being properly in tune with your patient. A mentalising stance helps you to identify what you’re feeling (e.g. scared, angry, empathetic, calm etc) and crucially, what your patient is feeling. Here’s a short extract from TalkWell, which, by the way, you can download here.
budtalk
“Laid-back social conversations are a happy part of ward life. It’s possible to have a conversation without either person being mind-aware, but it might be a bit dull and unsatisfactory! It would be like one of them chatting about the programme on purple newts that they saw on TV last night, while the other waxes lyrical about their child’s eating habits. If they’re mentalising, they’ll each be conscious of what the other person is making of their conversation, and trying to connect up what they’re both thinking about and feeling. Sticking with the newts and kids’ example, this could become a more mind-aware conversation if the two people started making links, e.g. talking about their kids’ interest in reptiles, or purple newts’ eating habits!”
While we're on the subject of thinking about our own responses and triggers, Alistair Cooper and Sheila Redfern (2015) provide this helpful list in their very excellent book Reflective Parenting: A Guide to Understanding What's Going on in Your Child's Mind.

Try to work out your triggers for experiencing certain strong emotions. Triggers can come in many forms and may include the following:

  1. A particular situation or interaction

  2. A tone of voice the child uses sometimes

  3. A comment someone makes

  4. A thought you have

  5. A strong belief system


Cooper and Redfern say that being aware of how you're feeling offers the opportunity to analyse whether or not to react, and how. The more you're able to name what you feel, the more you can bring the feeling into your consciousness and moderate it if necessary. By making sense of the feelings you're experiencing, instead of just reacting, you can start to temper your emotions and become better able to express them constructively and therapeutically.

This is where regular reflective practice proves to be an essential part of work on the ward. Being aware of how you’re coming across to others when you're experiencing difficult emotions is really important. Young people are very receptive to subtle communication cues and are sensitive to the whole range of emotions (Cooper and Redfern, 2015).
"When we find ourselves becoming reactive, we always have the option – if we can remember to pause in the heat of the moment – to ground ourselves as best we can in the body and in the breath and bring awareness to whatever we are feeling – whether it be frustration, fear, anger, or something else – with some kindness and acceptance. Our willingness to soften and open in this way in such moments contains the possibility that a wiser way to respond will emerge."

Jon Kabat-Zinn

bluesky

Discovering the Blue Sky Together



If young people can learn to be aware, to find some inner space of clarity, everything will feel easier. Teach them how to be self-aware of their own thoughts, emotions and sense perceptions, and also those of others. Make awareness a central focus - through games or activities like meditation, for example. You don’t have to use the word ‘awareness’; just teach them to practice this way of being. Indeed, the best way to teach it is to practice it yourself. How you are with a young person is more important than what you do with them (although routine and structure are really important). Your acceptance and presence encourages their acceptance and presence. Emotions and thoughts become less destructive, less heavy and static, and are instead experienced within a safe space that’s big enough to explore and contain them; awareness. Like clouds moving through the vast blue sky.
Witnessing and allowing our inner ‘weather’ to alter and move through us is both incredibly powerful and freeing. Provide a background of unconditional spaciousness for the young person to be their true self, until they’re able to find their own inner space - their own blue sky. Do your best to set and promote stable yet peaceful boundaries, as opposed to reactive ones. Reactivity is nearly always the less effective stance to take. Being proactive on the other hand, is about being prepared and having the right understanding to have moment-to-moment positive discernment.

It’s all about strengthening an open, honest and on-going dialogue.

Experiment with using the principles of Nonviolent Communication (described below).
Nonviolent Communication

Nonviolent Communication (NVC) is a process developed by Marshall Rosenberg. “It’s a way to communicate with greater compassion and clarity,” says Sarah Newton, a leading authority on how to connect, engage and motivate young people. NVC “focuses on two things: honest self-expression - exposing what matters to oneself in a way that's likely to inspire compassion in others, and empathy - listening with deep compassion.
NVC postulates that conflict between individuals or groups is a result of miscommunication about these needs, often because of coercive language or manipulative language (e.g. inducing fear, guilt, shame, praise, blame, duty, obligation, punishment or reward). One aim of NVC is to create a situation in which everyone's needs are met.

NVC advocates that in order to understand each other, the parties express themselves in objective and neutral terms (talking about their factual observations, feelings and needs) rather than in judgmental terms (such as good versus bad, right versus wrong, or fair versus unfair).”
Process

NVC follows what’s called the OFNR process model. The NVC model has three or four steps, depending on how it’s used.

  1. Observation

  2. Feelings

  3. Needs

  4. Request

All types of observation on the ward - formal or informal - should convey concern, as opposed to suspicion. Learn more about Nonviolent Communication here:

Once young people feel safe, they're are able to explore and blossom. You embrace their first-hand, direct experience - honour it, accept it, stay with it and explore what they need to explore with you.

306 art - 07
"The emotional security that we help our children to build inside themselves should lead to a sense of their being a person in their own right, from which position they can link to others and collaborate with them."

Mirabelle Maslin, 2013 - read more here

Structure and Support



When young people feel a connection with the person making a request, their instinct to work together is awakened, enabling them to receive what is being asked of them. Those who have outbursts when they don’t get their own way, almost always long for their parents to create some real connection and structure (Susan Stiffelman, 2015).

“Most kids, especially adolescents, thrive in structured and predictable situations,” says Dr Greenberg and Dr Powell-Lunder, who are both Clinical Directors at Four Winds Hospital in the US. “Rules offer explanations about which behaviors are appropriate and what is expected of us. They also define boundaries, without which the world would feel chaotic and unsafe. In addition, rules take the emotion out of the equation and tell us what is expected.”
Structure helps create a sense of relational and physical security. Obviously, a mug without sides would be incapable of holding a welcome hot brew! In the same way, the ward needs structure - not just the building features, although they definitely help - but reliable routines and realistic rules and boundaries, in order for it to be a holding and healing place.

mug

Let’s have a quick think about what healthy rules, boundaries and expectations do for young people on the ward. They teach young people:

  • How to make considered choices about their behaviour.

  • To be responsible.

  • To think for themselves.

  • To choose how they behave.

  • Decision-making.

According to school psychologist, Dr Sal Severe (2004), there are three factors to consider when developing expectations or rules. Expectations must be:

  1. Specific

  2. Reasonable

  3. Enforceable

“Sometimes, the hardest thing about introducing a formalized set of rules is selling the concept…” observe Dr Greenberg and Dr Powell-Lunder. “Teens fight hard for their independence and the idea of predetermined rules may sound threatening - especially if this is a new proposal. Just because their initial reactions may not be welcoming, do not be discouraged.” Dr Greenberg and Dr Powell-Lunder suggest we should remember that “teens are supposed to fight against the idea of rules and, in reality, teens from homes with structure and rules fare far better than teens from unstructured, permissive homes.” When expectations are too difficult, young people become discouraged. On the other hand, when expectations are too easy, they may take advantage.

Dr Greenberg and Dr Powell-Lunder also have this advice: “The rules and consequences you create should be written and posted in a place where everyone has access to them. The process of actually writing down the rules makes them real. A system should also be established to discuss and revisit rules that are not working. Think of this as an ongoing interactive process. If a rule or consequence is not helpful or enforceable, do not get stuck. Rules were meant to be rewritten. They should serve as helpful guidelines and become useless if they are not realistic. It is important to discuss with your teens that there will be situations for which no rule currently exists. In these cases your teens need to defer to your judgment, especially if the issue involves potential safety risks. This can be difficult for your teens to understand because again, your perception of high-risk situations may not be consistent with their perceptions. However, it must be clarified that your concerns for your teens’ safety trump any existing rules.”
image_9_1
Staff can set up predictable structures around things such as getting up, bedtime, tasks, meals and school work, as they understand a sense of order is important for young people, especially if their home-life has been unstable. Of course, the ward structure is flexible, focused on the young person and not over-rigid or punitive. Young people need to feel reassured that the team will provide a safe space and accept their need for care and support without them being controlling.
Anyway, attempts to control young people are often futile, as you’ll no doubt know! Staff need to encourage young people to co-operate with the rules, boundaries and expectations in place. Part of this is about trusting them to make their own decisions. Young people need to think for themselves, so when they’re faced with making choices, they’ll ask, ‘Is this good for me?’

Of course, recovery is about them taking back control over their life.
“Children who have been hurt - either emotionally or physically - have fears that differ from those of other children. They are particularly sensitive to their own vulnerability and perceived weaknesses. They are terrified of losing control and are fearful of control by others. They are afraid of anything they think might hurt them and are threatened by anyone they think might not protect them.”

Gregory C. Keck & Regina M. Kupecky

Structure helps create a sense of relational and physical security. When young people feel a connection, their instinct to work together is awakened, enabling them to receive what is being asked of them.

306 art - 06

Involvement



Structure makes a group of people feel like a community and helps everyone feel involved. Playing games and offering other fun activities can put everyone at ease and welcomes acceptance. Laughter is a glorious remedy! Humour and fun let us see things from different perspectives more easily, and helps us to be more playful with new ideas. Laughter is healing - it releases feel-good chemicals into the brain, reduces stress and boosts our mood. As we laugh together, divisions and tensions dissolve, creating a shared understanding.
"… take time to see the funny side of different situations. Laughter can be a good icebreaker and is also a great way of relaxing and relieving stress."

(Burnham & Baker, 2011)
Providing a well-thought-out structure for family work is also important. To help put in place safety, respect and understanding, young people are often introduced to a ‘behavioural agreement’, or the equivalent, as soon as they arrive, and there are regular reminders of this. Getting to know others on the ward and making friends put a stop to some of the understandable anxiety, self-consciousness and fear they might be experiencing. One example of this is being involved in a community meeting - this gives everyone the chance to ‘test the waters’ and say anything that might be troubling them. Here’s a taste of how we sum up involvement in Wardipedia:
Capture11

“Involvement – and information, inclusion, influence, independence. The 5 ins. All key ingredients in inpatients having a therapeutic, empowering, admission, which equips them well for maintaining their stability when they’re back home.”


Read more in Wardpeida

And since we’re on the subject of involvement (and Wardipedia), here’s how we big up the fab term and resources on ‘relational security’ conceived by the Department of Health:

“[Relational security] neatly captures the vital element of safety on the wards - the quality of relationships between staff and patients. Relational security is not simply about having ‘a good relationship’ with a patient. It is best seen as the knowledge and understanding staff have of a patient and of the environment, and the translation of that information into appropriate responses and care. But even when these are robustly in place, it’s the relationship between staff and patients which can make all the difference between preventing fraught situations from escalating and calmly diffusing a crisis.”


Read more about relational security
"The habit of calm starts early, when parents comfort their children and calm them down. Once a child learns this pattern of behaviour, it can be used again and again. Being able to reassure yourself that the storm is not so frightening, that the worst-case scenario is not so terrible, and that you have done your best regardless of what happens is an important tool in managing mood."

- Dr Liz Miller in 'Mood Mapping: Plot your way to emotional health and happiness'

Capture10

A safe ward gives young people supportive and containing boundaries, together with opportunities for the young person to learn, and try out fresh ways of being, relating, responding and functioning. This theme also reflects the importance of personal space, since everyone needs their own private safe base and some temporary distance from the clamour and commotion of others - a comfortable and homely bedroom or the use of a quiet room, for example. Having this base feels validating; it sends a message to the young people that they’re welcome on the ward, and a valued part of the community.
“Belonging somewhere doesn’t mean being owned or dominated, it means feeling a part of a place,” says Andrew Fuller in his book ‘From Surviving to Thriving’, “somewhere you feel recognised for who you are; somewhere an eye will be kept on you and you will look out for others; a place where you are visible and relied upon; a place where you are in an ongoing relationship, for both its highs and lows, with others; a place where, when you call out or knock on the door, they just have to answer.”

A safe ward gives young people supportive and containing boundaries, together with opportunities for the young person to learn, and try out fresh ways of being, relating, responding and functioning.

306 art - 05

Validation



When young people’s emotional worlds are met and validated with sincerity and presence (being there fully with them), they’re more able to safely work out triggers of their distress, get some head space, find personal skills and resources they already have, and explore fresh, positive solutions and possibilities. A solution with which everyone involved can be happy with is only possible after everyone has shown real validation for the young person’s wishes and perspectives.
“When kids are feeling out of control, their behaviors are, at the most basic level, protective reactions to the stress generated by not knowing how to react or respond in a positive way that quells their fears. When the primitive fear centers of the brain are on high alert, the prefrontal cortex (essential for self-control) virtually shuts down in the service of survival. From a neurobiological point of view, a cycle of fear, avoidance, stress and escape is neutralized by…consistency, calmness, competence…”

Jerome Schultz, Department of Psychiatry Harvard Medical School

Source: scientificamerican.com
"New and important doors in our own minds can open just by entertaining the possibility that there are alternative ways of perceiving situations and that we may have more options open to us in any moment than we may realize."

(From 'Everyday Blessings: Mindfulness for Parents' by Jon and Myla Kabat-Zinn)
One of the most important ways of trying to help young people manage, or regulate, how they're feeling is to validate their feelings. This is vitally important because it helps them to be more comfortable with how he or she feels and to be reassured that they have a right to feel this way (Cooper and Redfern, 2015).

Take your time to offer validation of their present experience. Young people thrive when they’re validated for their feelings and supported in feeling them. Validation invites young people to make connections between their thoughts, feelings and behaviours, and to look at them to develop constructive, rather than destructive, ways of living and relating to themselves and others. It can feel liberating to learn that it’s okay - and healthy - to experience the whole range of emotions. Your approval and validation for their thoughts, feelings and behaviours will support them in finding balance and stability.
The latest personality research shows that there’s a genetic factor involved in how young people react to their environment and relate to others. Researchers have revealed that temperament encompasses biological, neurological and physiological influences, that affect a young person’s mood, ability to calm themselves and activity level (Kurcinka, 2006).

A young person having a distress outburst, for example, is in genuine pain and needs lots of calm, compassionate support from you. Although ‘tantrums’ can be challenging, they present a great opportunity to help young people develop vital brain pathways that enable them to manage stress in the future (Sutherland 2008). Teaching young people how to regulate their powerful emotions enhances their physical and mental wellbeing. Whatever they’re at war with within themselves, help them soften towards it, understand it and find a place for it.

Photo 24-02-2016, 13 22 39

If they become more practiced at understanding their feelings and managing them more successfully, they'll be less likely to react strongly or behave impulsively (Cooper and Redfern, 2015).
Tips for making validating statements:

  1. Pay attention and actively listen — make eye contact and stay focused.

  2. Be aware of how you are coming across, especially non-verbal communication such as tutting, rolling your eyes.

  3. Can you hear what the young person is saying and communicating? Allow space in your mind to think about what is going on in the inside and try taking his perspective — what is his experience in this situation right now, what is he feeling?

  4. Reflect back his feeling without judgement. The aim is to let him know that you understand his point of view: 'I understand that you are angry because . . .' 'I can see that this really frustrates you.'

  5. Show tolerance. Look for his inside story and how it all makes sense from his point of view; even if you do not approve of how he is acting, you can still try and empathise with how it might feel for him

  6. Respond in a way that demonstrates that you take him seriously.


(Adapted from Cooper and Redfern, 2015)
“… when they reach out, you need to realize that they’re not so much looking for a load of advice, but rather they’re looking for validation and support. They want your respect and your consideration, but not for you to make their decisions for them or to tell them what to do. Keep your ears open and hold your opinions until [they ask] you for advice - never offer it without it being solicited. When you do offer your advice, it’s most important to be genuine.”

Susie Harper, mother of three and a registered childcare professional
Young people need to see adults as being steady and calm - irrespective of their moods or behaviour. They need to feel they can chill out, with the understanding they can rely on you to get them through their struggles. They need help with understanding their temperament and triggers, and someone to emphasise their strengths and provide them with the guidance they need to express themselves constructively, using a strengths-based approach. And what’s also crucial in all situations, is if they don’t want to talk, do your best to honour that. Young people can’t be forced to open up about what’s going on for them, but you can communicate that you’ll be there when they want to talk and make doing so feel safe.

When offered at the right time, mindfully worded guidance, even over difficult subjects, will usually help to increase your rapport with a young person, and get across that you’re trying to support them.
"No young person wants an adult to tell them how they should feel, or how they should deal with a problem."

Sam Gyimah, Minister for Childcare and Education 2015

(source)
The questions that all parents and therapists who help parents must answer:

  • Are we causing relationship responsiveness within this child and within this adult who leads that child?

  • Are we influencing emotional regulation through parent leadership?

  • Am I being someone with perspective, interest, curiosity, empathy, and compassion, who causes this child to benefit from my adult influence?”

  • If the relationship is becoming toxic and insecure, what support does the child need?

  • What supports do I need in order to develop or maintain a secure “good enough” parent perspective?

  • What does each person in the relationship need to receive in order to maintain responsiveness through difficult moments, and to create a healthy reciprocal relationship?

  • If I am not able to do this as an adult leader and if the child is not responding to what I provide, what other supports do I need to bring to the family that will help this relationship mature?


Adapted from Sudsberry, Richard, 2014

Source: Loving Parents: Raising Hurting Children

A safe ward gives young people supportive and containing boundaries, together with opportunities for the young person to learn, and try out fresh ways of being, relating, responding and functioning.

06 art - 01


Safe Spaces



A main purpose of CAMHS wards is to create an environment (both a physical and relational space) that reduces anxiety and enables young people to feel emotionally and physically secure, especially when in crisis. This involves them having both a much-deserved rest and lots of supportive care, so they’re able to face and work through their difficulties, to get new skills and to go back to their normal lives.
“A sense of mental space is important for processing the changes and difficulties faced by adolescents, as these often involve intense feelings.”

Dogra and Leighton, 2009
“One of the simplest, purest forms of stability or predictability in daily life is politeness. It is a level of communication and interaction that can be counted on, that builds trust.”

Payne & Ross 2009

“In simple terms, what a teenager experiences in their environment will be reflected back in their behaviour and will become the pattern of their instinctive personality. A stressful environment with lots of confrontation will be delivered back in combative or anxious behaviour from the teen.”

Downshire & Grew 2014

“Ensuring safety will require adequate staffing and an appropriate environment. Care should be provided according to the principles of the least restrictive environment possible.”

CAMHS Tier 4 Steering Group (2014) Tier 4 Report
Wards can manage a balance between the setting being homely and the need to carefully keep an eye on everyone and run daily activities. Staff can help the ward community feel safe enough to take part in their healing journey, and they do so by expressing and being a good example of respect and acceptance.

Within this safe space, created by caring collaborations and a thoughtful environment, young people and their families can safely explore and grow. If a young person is to feel secure enough to behave reasonably, the adults around them must first form a foundation of trust. Establishing safety is especially tough for young people with insecure attachments, because they’ve learned that the world is not a safe place.

The most conducive space for healing is not merely within a tangible building or the workings of a clever model, but within a palpable relational connection: within a womb of presence, stillness, listening, warmth and immediacy.
Creating a sanctuary area in a school

A teacher in a rural comprehensive school in North Yorkshire, established a 'sanctuary area' in her classroom which allowed students time out from the hustle and bustle of the curriculum.

‘Many primary classrooms operate the idea of a "quiet corner" and I decided to adopt this for my classroom with secondary-age students. By rearranging two low level book cases I was able to semi-screen an area in the corner of the room. I fitted this out with a remnant of carpet, some cushions and a floor cushion and added a large teddy bear.


Originally I had thought that this would be just used by my form group — who spent most of their time in the room and spent several of their lessons with me. I explained that it was an area which could be used for "time out" and uninterrupted quiet reading or study, but not for small group discussion work. My intention was to provide a quiet place where individuals could take time to calm down if need be or to seek refuge — in a comfort zone or sanctuary. I was inspired to do this because in a previous school a group of subject teachers with inter-connecting classrooms had used the link-way between them — nominally a book storage area — for a similar purpose.


Anyone could move themselves to the area whenever they wished and wouldn't be disturbed. I had to take a few risks to establish the sanctuary. Perhaps inevitably it was first seen as a novelty and was used to ”escape" tasks, but it was simple to monitor and soon began to be used for its genuine purpose. It also became easy to spot which students used it on a regular basis and who might be using it as a way of getting one-to-one help or alerting me to other problems. I also began to use it myself when I needed time or space to get my thoughts together or finish a task uninterrupted - a situation which my own form soon began to appreciate, happily granting me the time I needed. Over the course of a term a number of unexpected developments took place. Students other than my own form began to use it and soon it became a feature of my room which students in all my lessons began to appreciate and use positively. Students also began to personalize the area, adding extra cushions and soft toys.


The idea of the sanctuary obviously appealed to all ages and both sexes; it was not uncommon to find boys from older forms sitting reading in the corner cuddling a teddy bear! Frequently at the start of a session it would be used as a way of calming down if the student had experienced Frustrations in their previous lesson. It was also very popular first thing after lunchtime.


The sanctuary also became an area which students used at breaks and lunch- times, and while occasionally books went missing they were generally returned (anonymously) when I held an amnesty at the end of a term. There were never any instances of vandalism in the area and when, during a processiol reorganization I removed the area, students who had grown used to it being there lobbied to have it re-instated.


One of the key points was the fact that no-one was ever "sent" there - it was a totally voluntary move. Nor was it ultimately seen as a way of "opting out”. Students who used the facility still completed the work covered in the session but could do it either in the sanctuary or afterwards. It also was not totally removed from the room, so that I could see who was there and what was going on — but choose not to intervene, unless circumstances obliged me to do so.


Introducing the idea was viewed with scepticism by other members of my department, and initially it was designed simply to be used with my form. However, the idea spread by osmosis through other classes taught in the room that then began to use it. It clearly relies on trust and therefore is open to abuse in the early stages. However it can be a valuable tool and a helpful way of catering for situations when students are not ready to learn for external reasons.’


 

Cited in Best and Thomas 2007

The Importance of Privacy



No matter how sociable or outgoing they are, from puberty onwards young people start to need more and more emotional and physical privacy, both of which create a safe space. The environment in which they’re recovering, resting and learning is really significant, and having a space they can call their own is a must. Young people recover, rest and learn better when they feel emotionally secure and physically safe.
“I think it’s important to teach young people how to be okay with being alone and that they can reap the rewards of their own space and company. Otherwise, they tend to see alone time as lonely time.”

Ward Staff
'Ideally, kids shouldn’t spend all of their time alone in their rooms, so community space that is geared to their needs will help to include them..."

Dr Liz Miller, Mind Champion of the Year 2008
Here are a few things to consider:

  • Make sure they have their own territory - a room of their own, if possible, which they can customise.

  • Remember how self-conscious teenagers are about their developing bodies and sexuality.

  • Keep talking to them, despite requests to ‘leave me alone’.

  • Offer help if you think it’s needed, and give it if you’re asked, but be prepared to stand back if they reject it, and respect that they may want to try to solve their problems in their own way.


Adapted from Fenwick and Smith 1998
shutterstock_312718961
“Introverts need their private time. It is often difficult for introverted children to tactfully pull out and play by themselves because of social pressure to be a part of the group. They don’t understand that when they are feeling out of sorts, they need time away. All they know is that being around people bugs them and makes them feel grumpy.... Kids can take a break in many ways. Some do it by finding a quiet corner. Others pull themselves slightly out of the circle at school, allowing themselves more personal space. Reading a book, asking for a walk, taking a nap or disappearing into their room to play quietly by themselves are all socially acceptable ways for introverted children to recharge.”

Mary Sheedy Kurcinka, parent educator

Wards can manage a balance between the setting being homely and the need to carefully keep an eye on everyone and run daily activities.

306 art - 03

Easing Conflict



As anyone who has lived with adolescents knows, there are loads of ways you can inadvertently put a foot wrong! We must model the behaviour that you’d like to see. We cannot expect patients to behave appropriately if they see adults contradicting our expectations of them. Being a good role model and sensitively adjusting our own behaviour is probably the best way of meeting teenage "stroppiness" and calming the relationship. Tolerance is essential, although this doesn’t mean that anything goes. What works is consistency and calmness when managing behaviour. Most of all, young people need carers who are warm, compassionate and accepting - and those who do their best to remain that way even when conflict erupts.
“The healthiest message children can get from us is that their darkest moods and harshest feelings will be heard, accepted and understood by us, even when these feelings are about us.”

Janet Lansbury, parent educator
Again, school psychologist Dr Sal Severe (2004), offers this helpful advice: “Use conflict as an opportunity to teach them acceptable ways of expressing disappointment and resentment. Teach them how to manage their feelings in a prosocial way. Communication is always more effective when everyone has had time to calm down. It also helps to intervene early, before tempers explode.”
“Come alongside the young person, rather than at her, so she feels you’re her ally and advocate.”

Staff Member
In her magnificent book Toxic Childhood, Sue Palmer (2006) offers a four-point ‘conflict resolution’ technique for bringing calmness and resolving arguments, which can be taught to young people. Staff can model this themselves, and whenever a problem arises young people can be helped to go through the four points:
When someone upsets you so much you want to start a fight, stop and:

  1. State what they've done to make you upset or angry.

  2. Explain how it's made you feel and why (this will usually be because you are hurt or afraid of further consequences).

  3. Say what you'd like the other person to do to help sort it out.

  4. Ask for an acknowledgement that the other person has understood.


(The other party should be helped to listen and show they've understood, then engage in discussion/negotiation about how to solve the problem.)
“What we now know is that some children by their very nature are more easily stirred up. These children, the spirited ones, when surprised or faced with a potential threat startle more easily, their pulse races, blood pressure rises, stress hormones flood into their system, and on an EEG, their brain even shows more activity on the right side. It’s no surprise, then, that it takes much more effort and skill to calm them and to ultimately teach them how to compose themselves.”

Mary Sheedy Kurcinka, 2006
Although it isn’t always easy, almost every dispute can be more effectively calmed by negotiation, rather than by direct confrontation or simply ignoring the young people involved (or even worse, shutting them away). Adolescents who feel they’re being persecuted feel totally justified in using challenging behaviour in response. Moreover, under-sixteens especially, tend to see things in rigid or absolute terms.

Following confrontations about behaviour, staff can make sure they notice positive attempts by the patient to behave considerately, even if these are small, praising them makes a big impact. They'll be more likely to repeat the positive behaviour, as they'll get positive attention for it.
Sometimes, just acknowledging the tough time they're having can make the difference between their feeling alone and feeling connected, between feeling judged and feeling held in mind. The importance of connectedness with young people around times of conflict is most important. Within a safe and secure relationship, conflicts can be resolved in a positive way, without leading to distancing in the relationship (Cooper and Redfern, 2015).
So as you’ll know, this takes heaps of patience and flexibility, and negotiating always means that everyone needs to give and take a little and make some concessions. And ultimately, clear thinking and calm emotions play a big part in neutralising otherwise explosive disagreements. Tough conversations go far better if we put aside our negative stories and judgements, which would otherwise affect how we respond.  We can acknowledge and attend to our own distress, so we can be the cool, clear-headed adult (and role model) a young person needs when they’re upset, angry or aggravated.

It’s always crucial to explore the meaning your team are assigning to a young person’s problematic behaviour. Taking a reflective stance to managing young patient's difficult behaviour means seeing the times when they 'act out' as an opportunity to support their emotional development, and to help them to understand themselves and others (Cooper and Redfern, 2015).
Ideas for Post Reflection of Challenging Behaviour

  • When things have cooled down, help the young person to identify the specific challenging behaviour.

  • Offer a brief statement on the impact of the behaviour on the young person’s life/environment.

  • Offer a clear and defined statement of the consequences of actions (if any).

  • Offer suggestions for future alternative behaviour.

  • Agree a statement of appropriate expectations.

To help young people be comfortable with anger:

  1. Insist that they use words instead of actions to express anger. Encourage them to say out loud that they are angry, and if possible why.

  2. Help them to connect their feelings with reasons. Talk with them to check out what is behind their outburst. Soon they will be able to tell you what is wrong and why - instead of going straight to impulsive actions.

  3. Let them know that feelings are heard, and accepted (but may not always change things). ‘You’ve got a right to be angry with me. I wasn’t listening. I’m listening now.’

  4. Teach directly that hitting is not an acceptable way to handle anger. Confront this directly, give a negative consequence for each and every hitting instance, and insist that a child do what they should have done in the first place (usually use words)!

  5. Help children to say what they DO want. Often they will start to whine and complain about what they don’t want. They need your help to be more positive.

  6. Show them by your own example. When it's all added up, they are more likely to do what you DO, than what you SAY. So be sure to role model what you want.


Adapted from Steve Biddulph, 1999 - read more here
"If we are observant, over time we can begin to identify the early warning signs that a storm is brewing. We can then work with our children in peaceful moments, when they are more receptive, and encourage them to pay attention to how they feel in those prestorm moments."

From 'Everyday Blessings: Mindfulness for Parents' by Jon and Myla Kabat-Zinn
"Because of the architecture of our brains, the emotional centres have greater power over the rest of the brain, including power over our thoughts. This means the emotional brain can take over the rational brain quite easily. We can be hijacked by intense feelings and have explosive outbursts, not always knowing why this happens or understanding what came over us. In terms of how we act then, our feelings are often more in charge than our thoughts."

From Cooper and Redfern, 2015 - read more here
"A child’s expression of happy feelings is likely to be received without any difficulty. However, in cases where events have provoked anger or sadness inside the child, a parent or other carer might struggle with this, particularly if they themselves are feeling distressed or are under some kind of pressure at the time. In such situations it is always possible to revisit the event later on, demonstrating an understanding of the child’s attempt to communicate his feelings."

Mirabelle Maslin, 2013 - read more here
In the words of one parent:

“If you have a teenager who is behaving badly it is easy to assume that you have bred someone who is a monster or that they hate you. But once you learn that much of their behaviour can be explained by something that is physical, temporary, inevitable and universal, it takes the pressure off. You lose some of the emotional grief that you feel when your teenager is giving you a hard time. . . because I know what’s going on in her brain I just don’t get so angry. It really does help.”

A mother cited by Rob Parsons, 2007

Ultimately, clear thinking and calm emotions play a big part in neutralising otherwise explosive disagreements. Being a good role model and sensitively adjusting our own behaviour is probably the best way of calming relationships.

306 art - 04


Featured Tools and Ideas


Click on the headings to read more and add a selection of ideas and tools to you own "Palette"

A unique identifier for vulnerable children

 “Develop a unique identifier for vulnerable children and young people"

“...we know that factors such as social deprivation and disability can have an effect on mental health, which in turn can have a negative impact on health and educational attainment  - which is why we want to see the development of a unique identifier for children and young people across sectors, so vulnerable young people don’t fall through the gaps.”

Dr Max Davie, Consultant Community Paediatrician (from here)


Internet Safety Tips for Parents

 

There are a number of key actions parents (and staff) can take to be effective in lowering the risk to children.

View it here on the YoungMinds site




Supporting Young People Online

Internet safety guide: Supporting Young People Online - Information for Parents and Carers from Childnet International

The internet is an amazing resource which enables children and young people to connect, communicate and be creative in a number of different ways, on a range of devices. However, the internet is always changing, and being able to keep up to date with your children’s use of technology can be a challenge. You may sometimes feel that your children have better technical skills than you do, however children and young people still need advice and protection when it comes to managing their lives online.

Issues that your child may encounter on the internet will vary depending on their age and online activities. We have grouped potential online risks into these 4 categories.

  1. Conduct
  2. Content
  3. Contact
  4. Commercialism

Download the guide here


Internet safety guide from UK Safer Internet Centre

Internet safety guide: This is a guide containing information, factsheets and online resources from UK Safer Internet Centre.

Download it here

UK Safer Internet Centre: The European Commission appointed UK Safer Internet Centre is made up of three partners; Childnet International, the South West Grid for Learning and the Internet Watch Foundation. Together we raise awareness about internet safety, develop information materials and resources and organise high profile events such as Safer Internet Day. You can access a range of resources from across the UK, Europe and wider afield at www.saferinternet.org.uk/parents.


Children and the Police

 

In July 2013 the All Party Parliamentary Group for Children began an inquiry into 'Children and the Police'. This explored the police's relationships with children and young people, how the police seek to engage with children and young people; and children and young people's views of the police.

The inquiry's final report, published in October 2014, set out recommendations for policing and government bodies to support police forces to improve the way they work with children and young people.

On 30 November 2015, the All Party Parliamentary Group for Children published a new report that examined progress made over the past year and the remaining gaps and challenges, focusing on four key areas:

  • the promotion of good practice
  • reducing the prosecution of children
  • the detention of young people in police custody
  • stop and search.

Download the report here


Self-harm handbook

Self-harm in children and young people handbook

This handbook is designed to provide basic knowledge and awareness of the facts and issues behind self-harm in children and young people, with advice about ways staff in children’s services can respond.

View it here


address factors that lead to aggression and violence and reduce the use of physical restraint

Project aims to address factors that lead to aggression and violence and reduce the use of physical restraint

A project led by the University of Central Lancashire is seeking to minimise harm by reducing the use of physical restraint on people being treated in acute mental health settings. They’re using the ‘Six Core Strategies UK’ to help address factors that lead to aggression and violence from patients, and improve policies around the use of restraint. From here

Read more about the 6CS-UK project here


Closing the Gap in Patient Safety programme

 

Hertfordshire Partnership University NHS Foundation Trust wants to reduce suicide and self-harm among people using community mental health services. They’re using a prospective hazard analysis tool and human factors training, to help staff gain patient safety skills and enable care teams to identify and solve their own safety issues. A key feature will be improving communication skills and team working, in order to strengthen the safety culture, improve service user satisfaction and reduce harm. From here

Read more about the Safer care pathways in mental health services project here


Safewards

‘Safewards’ (the clue is in the name!) and CAMHS

A major new piece of research from Professor Len Bowers and his team at Kings College, has demonstrated that simple interventions can help wards be safer. Prof Bowers says that Safewards takes inspiration from Star Wards and focuses on small, practical changes that can have a dramatic effect.

Safewards comes with a model which highlights that flashpoints can happen on any ward.  What the model then suggests is that both staff and patients can create a culture where these flashpoints don’t have to result in harm to anyone - either through patients getting upset and angry or staff using coercion to gain control. The ten practical interventions suggested are all doable (and very Star Wards friendly), although some will need to be adapted for CAMHS wards.

Safewards comes with a webpage offering support - here is a link to the model.

http://www.safewards.net/model/model-diagram

And here is a special page on the forum, dedicated to CAMHS wards!

http://www.safewards.net/forum/camhs


Search

Ideas and Tools Palette Ideas and Tools Palette 0
View, edit or print your palette
What does this mean? - learn more


A Random Idea:

Provide a consistent approach for children - coordinated support, particularly when they move between services.





COLOURFUL Themes Menu

Caring Relationships
Opportunity and Expression
Leisure and Therapeutic Activity
On and Off the Ward
Understanding
Relational and Physical Safety
Family and Friends
Unique Recovery Journeys
Leisure and Growth