Unique Recovery Journeys

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"Looked-after children should have the right to the support they need to promote good emotional wellbeing at the earliest opportunity, rather than waiting for a crisis before they can access support."

Source: Alliance for Children in Care and Careleavers quoted by BBC News
“There is a quiet revolution taking place in the delivery of mental health care. For too long services have been operating using approaches that match treatment to diagnosis rather than tailoring treatment to each patient’s and families’ unique circumstances and choice."

Professor Sami Timimi (more here)

Moving Forward



It’s often the case that apparently ‘small’ triggers (or symptoms) build up over time and put a strain on a young person’s ability to be resilient: mentally, emotionally and physically. These stresses affect concentration, overshadow any inherent emotional calmness, and destabilise a young person’s normal sense of security, which would usually help them to cope with childhood’s unavoidable (and essential) ups and downs. Increasingly, they distract a young person’s focus on educational tasks, hinder important relationships, and hamper the overall task of childhood: an emerging, developing sense of self (Payne & Ross 2009).
How well young people adjust to life on the ward is hugely dependent on how sensitive staff are to their thoughts, feelings and perspectives. The more reflective the team is, the better the young person will be able to work through their difficult experiences and find their feet on their own unique journey.

Young people need to learn ways to cope with challenging situations, as part of discovering their special potential. Learning to emotionally and practically deal with every day stuff is a normal part of life, and helps build and develop character. Amazingly, children are biologically predisposed to take control of their own learning. It’s when this stuff becomes too overwhelming that an inpatient stay might be a good option. Of course, it’s recognised that an inpatient admission (and CAMHS in general), is only one part of many services and organisations responsible for helping children and young people with their emotional and mental health issues.

Recovery is unique to each young person; they are sovereign individuals. While this is most certainly the case, others can help them learn how to navigate life, and encourage the blossoming of their resilience, confidence, decision-making and self-awareness.
Although being on the ward is tough, it can provide a secure base that nurtures young people to be mindful of these triggers, think about pathways, develop new relationships, learn new, healthier patterns of behaviour, and check out their internal working models (how they see themselves and the world) and develop more positive, helpful ones. A ward stay can be a profound opportunity to begin to release the past and embrace the future.

As a staff member working on a CAMHS ward, you have the very privileged opportunity to help fortify young patients with tools and skills to deal with the difficulties, stressors and challenges of life as they approach adulthood.

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Here are a few shiny new ‘behaviour templates’ which a young person might absorb while on the ward:

  • A growing confidence and positive attitude.

  • An improvement in their attention, learning and enthusiasm in their journey.

  • An improved ability to weigh up and make the right choices and decisions, when facing novel experiences and pushing into unchartered territories.

“The vast majority of mental health problems are treatable and have a very favorable prognosis, especially if caught early before they become more severe and cause subsequent problems. With psychotherapy and/or medication therapy (often both), adolescents absolutely can grow up to succeed in school and later employment.”

Source: Katherine Lamparyk, paediatric psychologist (read more)

Young people need to learn ways to cope with challenging situations, as part of discovering their unique potential. A ward stay can be a profound opportunity to begin to blossom and embrace the future.

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“There seems to be only one definite statement one can make about bringing up children - and that is that they should be accepted as individuals in their own right and their differences from their parents and each other tolerated and encouraged. Children develop most satisfactorily if they are loved for what they are, not for what anyone thinks they ought to be.”

Anthony Storr, psychiatrist, psychoanalyst and author

Recovery is Deeply Personal



Recovery, like human development, is deeply personal; while there are common themes and milestones, there’s no ‘one-size-fits-all’. Recovery is supported, not by trying to impose techniques and models on young people, but by aligning with where they are at present, helping them unearth their inherent skills and intuition, and deeply honouring their unique journey of building a meaningful, valued and satisfying life.

​All journeys begin with finding out about the road ahead.
This list just about sums it up, we think …

  • Recovery is about people's whole lives, not just their symptoms.

  • Recovery isn’t a professional intervention like medication or therapy.

  • Recovery isn’t the same as cure.

  • Recovery is about growth.

  • Recovery doesn’t refer to an end product or a result: it’s a continuing journey.

  • Recovery can and does occur without professional intervention.

  • A recovery vision isn’t limited to a particular theory about the nature and causes of mental health problems.

  • Recovery is about people taking back control over their life.

  • Recovery isn’t a linear process.

  • Recovery is possible for everyone.

  • Carers, relatives and friends also face the challenge of recovery.

  • Everyone’s recovery journey is different and deeply personal.

  • Recovery isn’t specific to mental health problems, it’s a common human condition.


Julie Repper & Rachel Perkins 2009

Cited in Mental Health Nursing Skills
Recovery gurus* Julie Repper and Rachel Perkins (2009) say that a recovery-based approach:

  • Positively promotes health and wellbeing.

  • Maximises people’s life chances.

  • Enables people to take control over their lives and their own self-care.

  • Helps people to do the things they want to do and live the lives they wish to lead.


*actually, everyone is their own guru/expert when it comes to recovery.
So in summary, recovery comprises four key components:

  1. Finding and maintaining hope.

  2. Re-establishing a positive identity.

  3. Building a meaningful life.

  4. Taking responsibility and control.


Anderson et al 2003
"Children and young people are not an homogeneous group and the health service must be flexible in responding to their diverse needs, backgrounds, capabilities and interests."

Source: rcpch.ac.uk
CAMHS care plans should reflect the young person’s needs in the following domains:

  • Mental health

  • Developmental needs

  • Physical Health

  • Risk

  • Family


  • Social functioning

  • Spiritual and cultural

  • Education, training and meaningful activity

  • Where relevant includes a Carers Assessment

  • Where relevant includes accommodation/financial need

If their family already belongs to a particular religion or culture, adolescence is the time when a young person will want to explore their own feelings about it, and how it relates to their mental health.
“Adolescents have a strong spiritual side, which doesn't necessarily mean that they're conventionally religious. They may be forming their own views about the concept of God and what it means to them, about whether human beings have a soul or spirit that persists after death. They're usually fascinated by ideas of reincarnation, out-of-body experiences or anything to do with the paranormal.”

Fenwick and Smith (1998)

Adolescence: The Survival Guide for Parents and Teenagers

Recovery, like human development, is deeply personal; while there are common themes and milestones, there’s no ‘one-size-fits-all’.

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“We know there’s not just one approach, each person will require different support at different times, but whatever kind of resilience is needed, public health can help build resources for young people to draw on when they need it.”

Viv Bennett, Public Health England's Chief Nurse. From here

Building Them Muscles of Resilience



Easing mental health problems is more effective if the young person’s strengths, self-efficacy and resilience are boosted. Building character and emotional resiliency has been compared to developing a healthy immune system. A CAMHS ward stay is a good opportunity for young people to get some intensive nourishment and rehearse new coping skills, so they’re better prepared when these skills are needed. The best way to prepare young people for moving forward is to help them develop and optimise their natural skills.
Here are some ideas on helping boost levels of resilience in young people:

  • Cultivate behavioural strategies through strong social connections, including using peer-support to learn from each other.

  • Teach and show young people that it’s OK to ask for help, that’s it’s a sign of strength not weakness.

  • Help young people to develop healthy traits like grit, self-control, realistic optimism, zest and social intelligence. These are important for long-term success and happiness.

  • Be a role model of healthy persistence, focus and self-confidence.

  • Help young people generate options for responding to life situations.

  • Help young people find fresh meaning in ‘negative’ experiences, and gain learning from setbacks.

  • Inspire an openness to change.

  • Nurture young people’s curiosity and their sense of exploration (and willingness to explore).

  • Model an attitude of openness.

Teach and model ways to stay cool when triggered, for example:

  1. Know yourself. Identify your values and look out for situations where they’re stepped on, so you can practise ways to deal with this.

  2. Pre-empt your reaction by recognising your physical warning signs (speeding heart rate, fists clenching etc), so you can take control.

  3. Calm yourself down. Deep breathing delivers more oxygen to our brain. This helps us to calm down, so we can take a break from the stress and give our brain time to engage and plan our responses.


Adapted from Obi James, 2015 - see here

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In this short video, Ann Hagell from the Association for Young People's Health talks about resilience in adolescence and why it matters.

The environments in which children and young people thrive and become emotionally well are supportive, nurturing, affirmative, safe and have clear boundaries. Creating an environment that will strengthen young people’s resilience means showing concern for their psychological wellbeing through:

  • Leadership

  • Policy

  • Example set by adults

  • Respect shown between adults, as well as between adults and young people


Adapted from National CAMHS Workforce, 2011 - read more here
“Mental wellbeing is a measure of people’s emotions, as well as their ability to function as individuals and as members of society, often defined as ‘feeling good and functioning well’. Mental wellbeing widely affects individuals, their quality of life and wider society - with research showing that high levels of mental wellbeing are associated with improved recovery from illness, and reductions in premature mortality.”

Public Health England, 2015 - Read more here
"...any attempt to build children and young people’s social and emotional skills/character capabilities (or whatever else we call them), needs measurement attached...so that we can find out if our efforts are making a difference."

Source: Jean Gross CBE, Early Intervention Foundation Trustee. Read more here

Easing mental health problems is more effective if the young person’s strengths, self-efficacy and resilience are boosted.

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“Hope is important because it can make the present moment less difficult to bear. If we believe that tomorrow will be better, we can bear a hardship today.”

Thich Nhat Hanh

Growing and Finding Hope



For a lot of young people, recovery means a sense of worth, and to leave the ward having had a safe and nurturing period in which to prepare for their next step in life. Recovery is about growing and finding hope. It’s about our whole lives and is possible for everyone.

Recovery in a young person’s words:
“As a creative and visual person I find that physical tools to help aid recovery and prevent crisis are key… I have a box with key things I use if I am having difficulties. It has positive quotes, mindfulness and meditation aids, a 'comfort' scarf, a letter I wrote to myself when I was having a good day and things like a mood scale to help identify just where I am. It also includes a list of things that I can do so I don't have to try and think of something, so going for a walk, playing the flute, calling a friend etc. I have found that other service users I have met have found this useful too.

A weekly challenge is a good way of setting yourself small goals using baby steps. You can do this as a group and all write down your challenge in a 'challenge book' so you can help keep each other motivated. Start with easy and manageable goals and as each week passes you can set more challenging goals, but do keep them manageable. This is useful in any area of life. For example, you could set goals around schoolwork, about going to a new place, or leaving an old one, around connecting with friends and family again. Just keep them manageable and remember that baby steps are okay!”
CAMHS staff are brilliant at building therapeutic relationships based on helping young people find their own path. In a sense, staff use a consultative approach, to look with the young person at what they would like to change, and come to positive, shared outcomes. Young people can sometimes feel really muddled and have a mind full of questions. Whether you have the answers, or can refer them to other resources for answers, it’s important to support their questioning nature. See this as part of their journey of gathering information, to make a plan on how to move forward.

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A massive part of recovery is for young patients to learn to make choices for themselves. They're encouraged to have a level of control within the boundaries of the ward. When they prepare for leaving hospital they should continue to be encouraged to get involved in decision making. One strategy is discussing goals and involving them in setting their own, so that goals are not imposed on them without them having a say.

The setting up and achieving of goals are the flowers of the therapeutic relationship, but staff know that the relationship has to be rooted in honesty, respect and consistency. Recovery goals can be moulded by staff, but only from the raw material provided by the young person. Staff know that stepping in excessively, undermines the young person’s sense of control in their own lives. It is at this time in their lives, perhaps more than any other, that young people need a helper who can support them to nourish and maintain their uniqueness and their vast qualities, talents and attributes. Inpatient intervention and treatment varies according to the individual and the presenting problem, but what’s overarching is that young people need to be equipped with a bespoke emotional toolbox, and to learn how to choose the right tool at the right time. In other words, they need emotional resourcefulness and self-understanding.
"What we really want is kids who can handle and move along through the many feelings that life brings...Joy is the goal, but being comfortable and experiencing all the emotions life brings is the way to get there most often."

Steve Biddulph, 1999 - read more here
"The message is clear, we need to make sure that the right support is in place for all young people, that all parents, carers and teachers understand about suicide risk and that young people are equipped to look after their emotional well-being before life's pressures become overwhelming."

Jacqui Morrissey, Samaritans' Head of External Affairs

Recovery is about growing and finding hope. It’s about our whole lives and is possible for everyone.

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“I believe there are five qualities that help youngsters move toward adulthood with the resources needed to find their passion, manage the obstacles that may get in their way, and persevere to making their dreams come true. These five qualities are resilience, self-respect, problem-solving, visioning, and gratitude.”

Susan Stiffelman, family therapist


Confidence for Recovery



Confidence plays a massive part in mental health recovery. It’s not merely a personality trait some people have and other people lack, it’s a skill everyone can learn. ‘Self-efficacy’ is a good way to think about this. As defined above, self-efficacy is the conviction that one can master a situation in order to produce a positive result. This not only applies to the young person, but also the member of staff.
Self-confidence generally follows, rather than precedes, success, so young people on the ward can safely be exposed to mini problems that are challenging but achievable, to help them test things out and experience the joy of achievement. This is based on the idea that the best time to give young people choices is when things are going well, instead of waiting until things are feeling muddled.
Confidence is important for:

  • The choices young people make.

  • Their level of effort and motivation.

  • How they feel about themselves, others or the task at hand.

  • How long they persist when they confront obstacles.

  • The quality of functioning.

  • Resilience to adversity.

  • Vulnerability to depression or stress.

  • Adoption and success of healthy behaviour changes.


Adapted from Boniwell 2015 - read more
Through mindful and sensitive work, the team, always working at the young person’s pace, forms a relationship with them where the young person can begin to explore their thoughts, feelings and behaviours, and gradually work through their difficulties.

Confidence plays a massive part in mental health recovery. It’s not merely a personality trait some people have and other people lack, it’s a skill everyone can learn.

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"It has long been recognised that far too many young people who rely on mental health services are ‘lost’ to the system when they reach adulthood. From a point where they receive regular, focused support for their mental health needs, they find themselves on their own, unprepared for the abrupt cultural shift from a child-centred developmental approach to an adult care model. They may disengage, in many cases dropping through the care gap between the two services and losing much needed continuity of care...

For so many reasons, this “cliff-edge” situation must end."

Source: Closing the gap: priorities for essential change in mental health - view it here

Transitions



Transition from adolescent to adult services is consistently experienced by young people as a major hurdle. Regardless of which service a young person may be moving to, staff involved should get to know them before the transition, and plans should be in place to ensure that the transition is as smooth and as seamless as possible (McDougall, 2013).

YoungMinds (who are doing sterling work in this and many other areas) define transitions as “the movements, passages or changes from one position, state, stage, subject or concept to another. These changes can be gradual or sudden, and last for differing periods of time.” They have a brilliant section on their website which explores how the transitions experienced by your patients can be supported and enhanced. Read more here.
“It’s not like moving to the adult service is seamless. It might look that way from the outside, but for patients it can feel like a massive step. You know people where you’ve been and you trust them and they know you well. You know who to contact and where to go. And moving to the next place can be really scary and confusing because you have to kind of start again. But if a worker comes in from the very start of your problems and gets to know you, they can be there in the background all the time so something is familiar. That way the gaps don’t feel so big and frightening.”

Young person
Supporting transitions

  • Work to ensure positive relationships during periods of transition.

  • Be sensitive to patients’ needs and think about how the transition may be affecting them.

  • Ensure patients are given opportunities to talk about and discuss what will be happening and to ask any questions.

  • Give patients the opportunity to visit new ward / service / hospital.

  • Liaise with staff based at the new ward / service to help build relationships and encourage questions from the patients who are moving on.


(Source: inspired by a school best practice list by Burnham & Baker, 2011)
Groups needing particularly robust transition processes (of course, everyone's transitions should be as smooth and as well-managed as possible) include:

  • Looked after children

  • Care leavers moving to independent living

  • Young people entering or leaving inpatient care

  • Young people entering or leaving prison
  • Young offenders

  • Children and young people with learning disabilities

  • Unaccompanied asylum-seeking minors

  • Children and young people with caring responsibilities

  • Those not in education, employment or training


  • Source: see NHS England, 2014
    “In addition to improving health outcomes, there is a need to develop interventions that build skills in youth and young adults and support adjustment across home, work and community settings. The more we support young people during a period of key life transitions, there is much evidence to indicate there will be a path to become a well-adjusted adult.”

    Leo Glavine, provincial health minister in Canada

    Transition from adolescent to adult services is consistently experienced by young people as a major hurdle.

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    Featured Tools and Ideas



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

    Transition support

    Transition support and outreach teams support links between Tier 3 and 4 services

    In order to facilitate clear pathways of care, some organisations have developed transition support and outreach teams to strengthen links between Tier 3 and 4 services, and facilitate the process of admission and discharge from hospital. Outreach and transition support services have been successful in reducing patients’ length of stay and preventing their readmission to hospital.

    Source: see McDougall and Cotgrove, 2013


    Peer support for transitions

    Helping young people move on to using adult mental health services with peer support

    A peer support scheme has been launched to help young people move on to using adult mental health services. The scheme provides peer support workers to enhance the transition process for young people, when they move from CAMHS to adult mental health services.

    Clinical Lead/Senior CAMHS Practitioner, Sharon Jeffreys said: “We’re hoping that the peer support workers will not only act as positive role models for the service users, but also that, as they have had first hand experience of accessing mental health services, they will be able to empathise with and reassure young people, and promote the fact that people can and do recover from mental health problems.”

    Source: doncasterfreepress.co.uk - read more here




    A discussion kit

    Talking Wellbeing: - A discussion kit for young people

    Talking Wellbeing is a kit that supports a five-step workshop exploring wellbeing in a guided yet flexible way. It is aimed at young people aged between 14-19, can be used with a group of between three to ten participants and will be of interest to a wide range of people working with or needing to involve young people.

    Read more at ncb.org


    Free self-help tools

    Online resources: funky and free self-help tools

    The Box is the self-help section of the MyMind website. Young people will find useful activities and tools to download and use.

    StepUp

    Step up to the challenge of learning something new, or becoming even better at the things you’re already good at. An easy to use Action Plan to help you achieve your goals.

    OnTrack

    Exercise is just as important for our mind as it is for our body. Keep on track with this fun record sheet, as you steadily work physical activity into your week.

    ThinkTalk2

    Talking about our worries can really help, but it's not always easy to choose the right person to talk to. This mind map can help you to see the choices open to you.

    FunFocus

    Shrink your worries down to size by simply having fun. This activity helps you to see just how important fun can really be!

    Shine

    Step up to the challenge of learning something new, or becoming even better at the things you’re already good at. An easy to use 'Action Plan' to help you achieve your goals.

    Chillax

    Having difficulty in winding down and switching off at the end of the day? Chillax's handy tips can make a real difference in helping you to benefit from a good night's sleep. MP3 Download.


    Outcomes Orientated CAMHS

    Outcomes Orientated Child and Adolescent Mental Health Services

    ”Our initiative will involve disseminating a whole service model, Outcomes Orientated Child and Adolescent Mental Health Services (OO-CAMHS), through working in partnership with eight other UK Child and Adolescent Mental Health teams in order to enhance the effectiveness, efficiency, safety, patient-centredness and equitability of their services.”

    More here and here


    CAMHSweb

    The Very Cool CAMHSweb

    This online platform includes a number of tools to help young people and their therapist explore their strengths, feelings and relationships, and work on personal goals.

    Dr Jessica Austin, Lead Clinical Psychologist with the West Norfolk Family and Young Person’s Service, said: “This exciting project will make a huge difference to the recovery of many young people across West Norfolk, and we are delighted to be taking part in the pilot.

    “CAMHSweb is a fantastic tool which helps young people feel more in control of their mental health care.

    “It gives them the chance to personalise their treatment and express their thoughts in a variety of different ways. For example, they can doodle their goals and create avatars of the people in their lives, then, using one of the tools they can place them on a target showing how close and how supportive they are to the individual’s recovery.

    “It is a very graphical and creative way of helping young people.”

    More here


    Smooth transitions

    Young people leaving the service have an agreed and documented discharge plan that supports self-management where possible, and explains how to access help if this becomes necessary. Where a young person is moving to another service, whether to adult mental health services or to a different service, staff ensure that the agreed transition protocol is followed. As a minimum, this will involve: a joint meeting between ward staff and the new service that includes the young person and/or parent/carer, and a written discharge summary, followed up after six months to check that the transition has proceeded smoothly.

    Source: NHS England, 2-14 - read more here 

    To find out more and for tools to help with the commissioning of transition, see CHIMAT CAMHS transitions resources


    Think-Throughs

    An inpatient admission is a good opportunity for young people to do ‘think-throughs’ about the right way to handle things. They can do the think-throughs with you at neutral times, long before anything else has had a chance to go wrong. ( see Janis-Norton, 2012)


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    Education has a special role to play in promoting and sustaining positive mental health, particularly for pupils with additional educational needs and disability.





    COLOURFUL Themes Menu

    Caring Relationships
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    On and Off the Ward
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    Relational and Physical Safety
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    Unique Recovery Journeys
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