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.
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.
Once the team starts to think about noticing their own thoughts and emotions, they can then develop their ability to be more reflective practitioners.
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.
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.”
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.
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).
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.
It’s all about strengthening an open, honest and on-going dialogue.
Experiment with using the principles of Nonviolent Communication (described below).
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 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).”
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.”
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.”
Of course, recovery is about them taking back control over their life.
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.
“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