Singing from the Same Song Sheet
Young people need to feel able to face their difficulties in order to learn how to understand them, work through them and move forward in their lives. Such problems are no doubt worrying, but not completely destructive if they can tap into their skills and available support to manage them, and move beyond them. This theme involves giving young patients information in a clear, relevant and manageable (too much can feel paralysing) way, and supporting them to manage their symptoms and treatment. For this to happen, involved professionals and family members also need to gain understanding. Primarily, young people need to understand themselves and be able to make the choices that are most compatible with their self-knowledge, in order to maximise their potential, their future happiness and see themselves as worthwhile and valuable.
‘Shared decision making’ is the phrase which is often used today. It’s the exchange that takes place between young people and dedicated ward staff which aims to reach a joint choice. This conversation involves all parties understanding what’s important to each other when making plans, with the young person always at the heart of things.
Your support provides a caring space for young people to process the things that are troubling them. With warmth, you can help keep their feelings, scope of options and behaviour malleable, as you nurture fruitful emotional ground around them with the compassion of your mindfulness and thoughtfulness. This can emotionally regulate the young person, even if they’ve experienced the most gruelling of traumas. They can heal from past trauma by facing it in the here-and-now, reconnecting with a place in themselves that was never traumatised - their own internal compass, which is always at hand however obscured by their troubles.
Your support provides a caring space for young people to process the things that are troubling them. With warmth, you can help keep their feelings, scope of options and behaviour malleable, as you nurture fruitful emotional ground around them with the compassion of your mindfulness and thoughtfulness. This can emotionally regulate the young person, even if they’ve experienced the most gruelling of traumas. They can heal from past trauma by facing it in the here-and-now, reconnecting with a place in themselves that was never traumatised - their own internal compass, which is always at hand however obscured by their troubles.
Young people, especially adolescents, often have a desperate, intense sense about them which can sometimes cause adults to act in restricting and restraining ways. It can all feel starkly bewildering. 11 to 14 year olds can seem rebellious and occasionally express moody and defiant behaviour which parents (or carers) can struggle to make sense of. Indeed, the young person themselves probably won’t fully fathom why they think, feel and act in certain ways either. They may seem intolerant and find it hard to compromise. Boys who were previously gentle and even-tempered may become much more aggressive. And, as if all that wasn’t enough to deal with, there are also the dreaded acne outbreaks!
While they are generally more chilled out and tolerant, and begin to develop greater ability to compromise, 15 and 16 year olds have their own share of woes - even without additional emotional difficulties. There’s loads of pressure from mates (and maybe genuine curiosity) to experiment with cigarettes and alcohol and to try drugs. They start to explore and (hopefully) accept their own sexuality too, and maybe form sexual relationships that involve strong feelings they may never have had to deal with before. It’s a fraught time; loads of choices and directions are presented and it can be hard to work it all out.
On top of all this, the adolescent's intense self-consciousness about being different, ‘mad’, ‘bad’ or ‘weird’ may make it difficult for them or their parents to seek help. Unfortunately, the young person responds to their parent’s anxiety with even more acute anxiety, and then their anxieties intensify each other. While we can appreciate this angst, a parent's most important task is to get an understanding of their child’s experience and what it means to them, and connect with them in ways they can be of most support.
It’s at this time a friendly helper is needed, someone who can help promote and maintain the family’s individuality, qualities and skills; remaining focused on positives rather than on deficiencies, while paving the way forward. A CAMHS ward is an ideal opportunity to get this special care. This theme is all about the young person (and involved family members) making the most of their time on the ward, by getting a good understanding of their current situation, what led to it and the choices available to them. Young people feel more secure, and are more able to accept help; if they sense that everyone is acting authentically and are tuned in to their world.
Young people's behaviour has meaning and purpose – it's rarely random. Putting understanding into action involves having interactions with young people that genuinely reflect your understanding of them - not merely the clinical ‘facts’ or knowledge about them, but their inherent uniqueness which unfolds organically in the here-and-now. This takes empathic imagination.
As we say in Wardipedia: "Imagination is the invisible but powerful engine of ward staff’s empathy, creativity and effectiveness. Ward staff continuously use their imagination to see things from each patient’s unique perspective and to create skilfully-tailored responses to help them recover."
As we say in Wardipedia: "Imagination is the invisible but powerful engine of ward staff’s empathy, creativity and effectiveness. Ward staff continuously use their imagination to see things from each patient’s unique perspective and to create skilfully-tailored responses to help them recover."
“Children find out who they are and what’s meaningful to them in part when adults are able, without an agenda, to listen in a relaxed way and to reflect back their understandings and share their knowledge of the world.”
Source: Weissbourd, 2010
Source: Weissbourd, 2010
A Good Grasp of What’s Happening
Understanding and trust in the ward setting are dynamic; everyone involved in the young person’s care needs a good grasp of what’s happening and what the best way forward is – including the young person of course. From the start of a young person’s admission, staff aim to gain understanding around their current emotional world, which leads on to the individual tailoring of treatments and interventions. Every young person on the ward has individual needs, and each requires different responses from staff.
Being understood feels great and young people thrive when they're shown real understanding and acknowledgement.
Research into attachment has compellingly evidenced that there’s so much more to young people than their behaviours, and that to truly relate to and appreciate them we can’t just depend on an assessment of their behaviour. What’s vital to ask yourself is: ‘What’s at the heart of this young person beyond their words or behaviours?’ Plus, it helps to remember that a lot of so-called ‘misbehaviour’ stems from strong emotion/s the young person is feeling. Sometimes, what’s required is a willingness to look beyond surface behaviour. The bottom line is that young people who are in need of treatment should never ever be dealt with punitively, or locked up due to a lack of compassionate understanding, or a shortage of beds, for example.
Young people not only want to be seen and heard; they want to be understood, and to understand themselves as well. Before coming to the ward they may have spent time searching the web for information and advice on their thoughts, feelings and behaviour, with varying results. In fact, one survey of youngsters suggests 62% have done a general internet search on issues such as depression. Young people are turning to the internet for advice on mental health instead of talking to their school nurse or GP, it is claimed (source).
Young people love it when staff really notice them, and pay attention in a warm and curious way to what they’re doing.
What’s required is to build a relationship with each young person and create a sense of tangible belonging, and understanding is the impetus for this. Being caring means being mindful of a young person’s needs and trying to see their world through their eyes, and appreciating how holistic it is, their mental health needs are part of them, not the sum of their life. Strong collaborations with young people are what achieves this. The therapeutic relationship “…should be based upon seeing a real human being and all the potential within, not just what they are doing at that precise moment,” says Sarah Newton, a fabulous author and speaker on how to connect, engage and motivate young people. “We should see the qualities in them and not just the behaviour in front of us. These relationships must be based on trust, understanding and equality. We have no right to control another person through rewards, punishment, blaming or shaming. These practices will not produce long term success” (Newton, 2012
). If the young person is going to feel able to have trust and feel understood, they need to see staff as being robust enough to cope with the entirety of their current experience.
What’s required is to build a relationship with each young person and create a sense of tangible belonging, and understanding is the impetus for this. Being caring means being mindful of a young person’s needs and trying to see their world through their eyes, and appreciating how holistic it is, their mental health needs are part of them, not the sum of their life. Strong collaborations with young people are what achieves this. The therapeutic relationship “…should be based upon seeing a real human being and all the potential within, not just what they are doing at that precise moment,” says Sarah Newton, a fabulous author and speaker on how to connect, engage and motivate young people. “We should see the qualities in them and not just the behaviour in front of us. These relationships must be based on trust, understanding and equality. We have no right to control another person through rewards, punishment, blaming or shaming. These practices will not produce long term success” (Newton, 2012
). If the young person is going to feel able to have trust and feel understood, they need to see staff as being robust enough to cope with the entirety of their current experience.
Helping Young People Discover Their Recovery Compass
Recovery is about a young person’s whole life, not just their symptoms and behaviour. Conversely, trying to modify their behaviour with anger, criticism and commands can cause heightened rage and/or fear reactions. The human brain has primitive emotional alarm mechanisms in the lower parts. Without emotionally responsive and consistent interaction, a young person’s higher brain can rapidly be overtaken by these mechanisms. As you will know all too well, they’re working out the limits, and so clearly and reasonably setting boundaries is essential. One example where conveying clear boundaries and expectations is critical is when caring for the hurting child who has come from a family where nearly everything was ambiguous and jumbled. Saying exactly what you mean, and meaning what you say as much as you can, is another way to bring some clarity and avoid mixed messages.
While we’re on the subject of the brain, more specifically the growth of the teen brain, the magic of Magnetic Resonance Imaging (MRI) has given neuroscientists a much better understanding of what really goes on at this important time in human development. It turns out the idea that the brain is fully formed by late childhood is a huge myth. Instead, MRI technology has shown that different parts of the brain mature at different rates. In the early teenage years, the brain goes through another dramatic growth spurt. This explains the similarity between ‘terrible twos’ and the ‘traumatic teens’! But we can have loads of empathy for adolescents, because basically, their brains aren’t yet able to fully regulate emotions. One of the last parts of the brain to develop is the pre-frontal cortex, which is often described as ‘the brain’s policeman’ or ‘moral compass’, and is still under construction beyond the age of twenty. It’s an important aspect of the brain, because it gives us the ability to control emotions and make sound judgements.
As the above quote emphasises, experts agree that adolescents feel safest when they know what the limits are. They actually don’t expect total freedom to do exactly what they want. However incongruous it may seem, deep down they actually want you to set out the appropriate parameters despite the fact that they may challenge you. Shared rules don’t have to mean unquestioned control. In fact, they’re most effective, not when made as definitive statements, but when explored together, with questions.
For young people who’ve experienced negative control by others, control issues sadly endure. They come to associate any sense of control with pain, and therefore, are internally inclined to resist all perceived control. Of course, modelling a shared agreement works a lot better than dictating universal institutional rules. Plus of course, the best time to reason with teenagers is when they’re not in an emotional state.
For young people who’ve experienced negative control by others, control issues sadly endure. They come to associate any sense of control with pain, and therefore, are internally inclined to resist all perceived control. Of course, modelling a shared agreement works a lot better than dictating universal institutional rules. Plus of course, the best time to reason with teenagers is when they’re not in an emotional state.
Everyone needs to follow the boundaries that are established, not just the young person. Indeed, following boundaries and rules yourself is one of the best ways to teach them!, If young people see you as basically reasonable; they will be more inclined to keep within the boundaries you’ve set. Whereas no discussion and no negotiation is likely to accumulate resentment.
When they feel understood, young people are more able to take on board other people’s perspectives.
Young people like to know where they stand and having clear boundaries and rules gives them security and helps them understand what is acceptable. This involves explaining why certain rules are in place, and being clear about what’s expected of them. Doing so builds respect and understanding, and staff act as good role models. By following and accepting your boundaries, they can develop a sense of independence and self-control, which are essential skills. Guiding and supporting young people in ways that support their dignity is a wonderful gift, helping their emerging wellbeing and their emotional and social intelligence.
Young people like to know where they stand and having clear boundaries and rules gives them security and helps them understand what is acceptable. This involves explaining why certain rules are in place, and being clear about what’s expected of them. Doing so builds respect and understanding, and staff act as good role models. By following and accepting your boundaries, they can develop a sense of independence and self-control, which are essential skills. Guiding and supporting young people in ways that support their dignity is a wonderful gift, helping their emerging wellbeing and their emotional and social intelligence.
Understanding the Young
Person’s World
Knowledge of child, adolescent and family development is fundamental to assessment and intervention, as it guides the team’s understanding of a young person’s needs, behaviour and attachment relationships. We strongly support the government’s suggestion that everyone working with children, young people and families should have a common set of skills and knowledge. CAMHS staff should be supported and encouraged to enrich their specialist skills, with a broader understanding of child development, mental health and psychological wellbeing.
“Caring's also about remembering how it feels to be a child and putting yourself in your kids' shoes sometimes. It means lightening up, being playful, and having a laugh.”
Sue Atkins, parenting expert
, 2007
Sue Atkins, parenting expert
, 2007
As you’ll know, if assessment, intervention and treatment approaches are going to be of real help, it’s crucial to try to understand the young person’s own world. For example, all young people have an inherent spirituality (which isn’t necessarily experienced in relation to a particular religion or faith - see Wardipedia) which should be thoughtfully appreciated and included to achieve a truly holistic picture of their needs (Aldgate 2006). Young people’s current language, views and cultures need to be integrated into the training and development of staff. Likewise, professionals sometimes find it hard not to use mental health or medical jargon, or language that isn’t age-appropriate. The team might like to discuss how to turn medical words into young people’s language. Learn to speak their language, and they’ll be more receptive. Co-operation and mutual respect come from knowing how to read the messages young people communicate, and responding to them with kindness and inspiration.
“As teens are figuring out who they are, they want to have control over, not just their personal lives, but also over how and when to disclose personal information. They want to control both the type of information they reveal and when and how they reveal that information. In fact, a 2004 study published in Communication Reports found that teenagers are especially sensitive when adults request information in a direct manner, so the key to getting the information you want is to be subtle and use conversation openers... When using conversation openers, keep in mind that the goal is to keep your questions gentle and non-judgmental. Always go for a soft and interested tone in your voice; loud voices beget screaming teenagers.”
Greenberg & Powell-Lunder, 2010
Greenberg & Powell-Lunder, 2010
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. The team can seek to interpret their countless distinct, sometimes baffling expressions and to trust their adeptness to come up with ways to respond appropriately. Focus, curiosity, and compassion are vital to this work.
Working with Misunderstandings
“Communication is the best way to avoid misunderstandings”, says Sue Palmer in her groundbreaking book Toxic Childhood, “Encouraging children to talk things through helps them solve their problems, understand other people's point of view, avoid conflicts and prevent disagreements escalating into fights.”
These lists might help as you endeavour to meet your patients where they are:
Certain experiences are virtually guaranteed to provoke adverse reactions in young people. These include:
Adapted from Downshire & Grew 2014
Teenagers Translated: How to Raise Happy Teens
- Criticism
- Condescension
- Lack of gratitude
- Unfairness
- Being ignored
- Unrealistic goals / deadlines
Adapted from Downshire & Grew 2014
Teenagers Translated: How to Raise Happy Teens
Normal pre-teen and teenage behaviour
Lee N and Lee S. 2009
- Shutting the door and shutting parents out.
- Being monosyllabic.
- Being slow to react and being oblivious to others' feelings.
- Needing to sleep a lot.
- Feeling embarrassed to be seen with a parent in public.
- Rejecting guidance and doing the opposite.
- Oblivious of time and deadlines.
- Winding up parents and siblings - sometimes deliberately.
- Being angry and sarcastic.
- Being forgetful.
- Hogging the computer or TV, oblivious to anyone else wanting them.
Lee N and Lee S. 2009
Nurture by Nature
Here's a useful list of personality types and qualities which you might spot in your patients and therefore help you be more adaptive in your interactions:
EXTROVERT
INTROVERT
SENSORS
INTUITIVES
- Jump into new situations
- Like variety and action
- Energised by interaction
INTROVERT
- Wait and watch before getting involved
- Are life’s specialists
- Energised by introspection
SENSORS
- Realistic and practical
- Like games with rules
- Work at a steady pace
- Accept things as they are
INTUITIVES
- Imaginative and creative
- Like make—believe and fantasy
- Work with bursts of energy
- Interested in how things could be
These types are based on the Murphy-Meisgeier system which is the children's strand of the Myers-Briggs Type Indicator assessment. The tests are shorter and more child-friendly than the adult ones. A professional qualified in the system can carry out an assessment. Parents, teachers and others can request a report to better support the child; a career report outlining jobs that play to the child’s strengths; and a ‘know yourself’ report for the child.
'Nurture by Nature' by Paul Tieger et al looks at each type, and gives tips throughout childhood; about how to understand the child, and also support them in areas that don't come naturally.
Source: Paul Ackerley in Psychologies Magazine, Nov 2015
'Nurture by Nature' by Paul Tieger et al looks at each type, and gives tips throughout childhood; about how to understand the child, and also support them in areas that don't come naturally.
Source: Paul Ackerley in Psychologies Magazine, Nov 2015
While some young people are organised and have some ownership of their issues, others will feel chaotic, confused and overwhelmed. They may fluctuate a great deal in the way they behave, feel and relate to others. They may sometimes be cooperative and communicative, and at other times, express themselves through anger. What really helps is a commitment to tolerating the massive anxieties and raw panic that stimulates young people into sometimes attempting to reject and disrupt the help they need. They should be helped to recognise that it’s normal to experience all sorts of different feelings, including anger.
When we understand a young person’s anger process, we’re able to deescalate rather than inadvertently provoke the situation. “We’re also able to support them in learning how to handle the situation themselves.” says Sarah Newton, a leading authority on how to connect, engage and motivate young people. “It’s always a really good idea to talk through volatile situations after asking… what they thought they could have done, how perhaps they could have got their anger out in a constructive way that doesn't hurt anyone (or their feelings) and what you can do to help them.” (Newton 2012).
When we understand a young person’s anger process, we’re able to deescalate rather than inadvertently provoke the situation. “We’re also able to support them in learning how to handle the situation themselves.” says Sarah Newton, a leading authority on how to connect, engage and motivate young people. “It’s always a really good idea to talk through volatile situations after asking… what they thought they could have done, how perhaps they could have got their anger out in a constructive way that doesn't hurt anyone (or their feelings) and what you can do to help them.” (Newton 2012).
The care approach is tailored to each person’s needs. It bears in mind the basic notion that everyone works together to try to make sense of the young person’s past and present experiences and formulates suitable goals. This empowers the young person to attain some congruence and control.
When staff are fully present, fully in the ‘now’, it allows young people to understand that their needs are being met in the present, and that staff are focusing on them, not on other things that are happening. This helps young people to feel a special connection to you and the ward environment.
You’ve probably realised by now that what underlies all of the COLOURFUL themes is mindful, caring relationships. Positive therapeutic connections thrive when we begin to make sense of the ways in which a young person and their carers understand themselves and the world around them.
You’ve probably realised by now that what underlies all of the COLOURFUL themes is mindful, caring relationships. Positive therapeutic connections thrive when we begin to make sense of the ways in which a young person and their carers understand themselves and the world around them.
Coming, Staying and Moving Forward
The following are some helpful views from young people, parents and staff about what is needed before, during and after an admission. They come from YoungMinds’ ‘Where Next? New directions in inpatient mental health services for young people Report 2’ (View it here)
During Stay (cont.)
- Education to be available and well supported, including access to further education options for young people over 16.
- A comfortable, welcoming environment, ideally with gender segregated areas, single bedrooms, and enough space to have visitors and spend time with them privately. The environment must address both privacy and safety needs, e.g. by providing somewhere to make private phone calls and lockable cupboards for personal belongings.
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