Every moment matters: therapeutic relationships within inpatient CAMHS

The last six years of my career almost didn’t happen. A memory I’ve shared with many colleagues in our service is how I started in inpatient CAMHS as my final year training placement as a clinical psychologist. Although I had never worked on a ward before, I had enjoyed community working with adolescents and asked my supervisor, Jamie, if he knew of somewhere I could work with a similar cohort for my elective placement. He suggested getting in touch with Gordon at the Hope and Horizon Units at Pennine Care in Bury, which I duly did and I was then allocated the placement for a year. During my first few weeks, I used to walk to my car crying most days at the end of a shift. I felt de-skilled, under confident, distressed and out of my depth. The level of emotional pain in the system, the restriction, the seemingly chaotic nature of some of the processes, the unfamiliar guise of the psychologist role there all felt really destabilising. I confided in my course mates and said I was planning to ask to move placements to something that felt more contained and straightforward. A good friend encouraged me to share this in supervision, seek support and try and stick it out another couple of weeks. I did, and after a few months, and as I grew in confidence I also grew to love working in inpatient CAMHS. Why is also the reason why I have chosen to do the work I have done.

In inpatient CAMHS, every moment matters. Every hello on the corridor, every response to a shouted question or a tearful or frustrated gaze, every wondering with the team, every lean towards compassion, every shared laugh and confided pain matters. Because, it’s the therapeutic milieu, and the relationships that contribute to and are cultivated by it that matter.  Even as a naïve trainee, I was under no illusions that 30 or 60 minutes a week with me was what made the difference. It was all the time spent with the whole team – and nursing staff in particular - that mattered. Time in empathy, in play, in conflict and resolution, in listening, in connection. In delivering staff reflective groups, team formulation meetings and in listening to young people in ward round, in the corridor and in sessions, what I heard was that this is what matters and yet this is also the hardest thing. Staff, young people and family members told me that this part of the work was make or break in terms of outcomes, and yet it also pushed them all to the limits.

So, when I found out about the HEE/NIHR ICA funding scheme, I knew what I wanted to focus on – therapeutic relationships. I had never wanted to work solely in academia but had retained a passion for research and innovation from my earlier research assistant roles and PhD. The ICA allowed me to retain my role as a clinician while doing post-doctoral, independent research alongside it, which was truly informed by and directly impacted practice. I built a team of mentors and explored the literature and possible research designs. Securing the funding meant I could boost my research and clinical skills too- in qualitative methods and Cognitive Analytic Therapy, which would align well with the relational research focus.

Combining my clinical and research roles has afforded a balance and a variety that has been invigorating and grounding. It allowed me to facilitate our young people and carers’ Council, Moving Forward, to consult on both service developments and research ideas. This input has been so valuable and energising and I’ve also learnt a lot about participation and involvement. I was able to bring my clinical experiences to bear on the research plans, every step of the way focusing on the real world impact rather than solely the research outputs.

I started with a systematic review of possible interventions to improve the therapeutic alliance for nursing staff, who are so core to the therapeutic milieu. I discovered that, despite agreement on its necessity, there was very limited evidence for how to support staff effectively. Following this, I undertook an in-depth qualitative exploration of how young people, nursing staff and family members actually experienced therapeutic relationships in inpatient settings, alongside their reflection on what facilitated and impeded them. This provided a rich dataset that elucidates the complexities and impact of therapeutic relationships in this setting. Working with John from MindWick and alongside input from young people and carers, we were able to produce an animated video summary, which really showcases the testimony of the participants. Incorporating input from young people, clinical staff and academics, I was able to put together an outline of a training and support package for staff, drawing on both my inpatient experience, the data emerging from the qualitative work, systematic review and my developing relational skills.

Covid, the end of my research funding and a related change in job role have meant that putting the training package into practice as a formal research trial has stalled. However, the benefit of being a clinician in this setting has meant that this hasn’t needed to be a block to the work influencing practice. The findings have informed the new inpatient competency framework for staff, e-learning package for health care assistants and workforce planning. Talking with the authors of the recent NIHR themed review revealed lots of overlaps and confirmed the need to direct our attention and energy to effective therapeutic relationships. Joining forces with the children and young people's inpatient taskforce means that we hope to implement an online interactive session to share the understanding with staff. Through the magic of Twitter, the research is also making its way to various professional education programmes across the country. Locally, I have a training package ready to roll out to our staff teams and nationally, there are many avenues to embedding the ideas into CYP IAPT whole team training.

I’d love to hear about anyone doing similar work and I’m more than happy to share my passion for both clinical research and therapeutic relationships. It’s great to see inpatient CAMHS receiving the support and input it has needed for so long. The work we do is so important, so necessary and so complicated; it’s crucial we find ways to bring compassion to this and focus on what matters to young people and their families.