An adolescent mental health team set up an outreach role as a way of engaging vulnerable young people with mental health services and interventions
Maxine Shepherd, PGDip Cognitive Behavioural Therapy, DipAddictions, RMN, is adolescent mental health practitioner, Barnes Unit, Adolescent Mental Health Team, Northumberland, Tyne and Wear NHS Trust.
Shepherd, M. (2009) Developing an outreach service in adolescent mental health to improve engagement. Nursing Times; 105: 31, early online publication
An adolescent mental health team developed an outreach service to improve access to services for vulnerable young people, many of whom do not normally access treatment.
This article explores ways of engaging with this group, combining an outreach approach and other styles of work such as the cycle of change and motivational work.
Keywords: Mental health, Engagement, Cycle of change
- This article has been double-blind peer reviewed
- Developing the outreach role has improved access to services for young people who would otherwise be unlikely to approach mental health services.
- The process of engagement and the encouraging participation in service development is a way of working in a meaningful way with excluded young people.
- Engagement is a useful tool to encourage clients to move through the cycle of change.
The Barnes Unit in Sunderland is a tier 3 adolescent mental health team that provides a community-based treatment service for 16–18-year-olds with complex mental health difficulties.
It follows the recommendations in Together We Stand (Health Advisory Service, 1995), which recommended a four-tiered approach in child and adolescent mental health services (CAMHS).
Our aim is to identify, assess and treat young people with complex mental health problems and provide a consultancy and training resource for professionals working with young people.
Therapeutic interventions available include family therapy, cognitive behavioural therapy (CBT) and eye movement desensitisation and reprocessing (EMDR).
Part of my role as a mental health practitioner is to provide outreach services to the adolescent population to improve access to tier 3 mental health provision.
There is a huge amount of discussion about ensuring that people receive the appropriate therapeutic intervention (Project Match Research Group, 1997).
However, there is also a wealth of research showing that engagement and the therapeutic relationship can create change in clients (example, Ritter et al, 2002).
Within the adolescent mental health outreach role, I also considered the cycle of change (see Prochaska and DiClemente, 1982). Assessment and conversations with young people showed that some were not ready to enter services. It therefore seems appropriate to consider what interventions could be implemented to help straight away and move clients to the stage of considering service involvement.
In Sunderland, there are a number of accommodation services for young people including for the following groups: young women aged 16–18 who have experienced domestic violence; 16–25-year-olds who are homeless; and single parents. All offer supportive key-worker packages.
Apart from accommodation services, areas supporting young people include education, training, drug and alcohol services, non-statutory mental health services, housing agencies and young parent groups.
All these services have one thing in common – that is, young people attend them – so they provide a setting where interventions can potentially be offered. They also provide a way of improving information-sharing with young people and access to services while addressing inequalities (DH, 1999).
I believed that engagement with young people and staff needed to be the foundation of anything that was to follow.
First, I introduced myself to unit managers and key workers, asking what they would like from my role. This allowed me to attend previously arranged drop-ins to meet young people.
The aim was to support staff and ensure accessibility to a service for young people offering evidence-based interventions, as recommended in the CAMHS Review (Department for Children, Schools and Families, 2009).
However, mental health intervention was not the agenda with the young people concerned; being accepted into their community was my main aim initially.
I gave young people advice and information on benefits, harm minimisation, drug use, sexual practices and physical health problems, allowing them to set their own agenda. This approach helped me to become accepted and to begin to introduce mental health messages in a non-imposing manner.
After some time, informal conversations arose on young people’s concerns about their mental health. This led to setting up appointments to see me at the drop-in venues.
I carried out informal assessments and made suggestions about the best way to help them deal with their concerns. Since clients were at different stages of change, making referrals was appropriate and helpful for some, while, for others, continuing with drop-in appointments when they wanted them was as much as they would accept.
One issue was how we could meet the needs of those young people who would not accept any support from me.
One way forward appeared to be to support staff at these venues as much as possible. Increasing their awareness and understanding of mental health issues would further improve the service for young people, while I waited for clients to take the next step to talk to me.
Training was provided to increase staff understanding of various mental health conditions.
I was able to identify where regular drop-ins would be needed and occasional ‘pop-ins’ would be helpful, while always providing brief intervention appointments for those requesting them.
All of the agencies I worked with were aware of the Barnes Unit’s flexible approach to meeting individual needs. They would contact me at any time to request an appointment for an assessment outside of drop-in and pop-in times.
The hope is that, if the right interventions can be given at the appropriate time, it may prevent young people presenting in crisis and needing hospital admission. 11 Million (2008) discussed the need to avoid inappropriate admission of young people to hospital, especially onto adult wards.
In many respects, the outreach service could appear to be an autonomous role. However, clinical supervision is essential to ensure that clients receive the best service and non-statutory services are supported.
Individual and group supervision are in place. The individual form provides support, education and the opportunity to explore issues, to ensure the outreach role does not become isolated or unfocused.
I believe that useful interventions have taken place, whether in the form of structured therapeutic sessions or brief intervention and engagement.
The brief format was a maximum of six sessions offering a therapeutic intervention influenced by a cognitive approach and supported by other styles of work such as narrative techniques, advice and education.
This created the opportunity for clients to make sense of and ‘normalise’ some of the unpleasant thoughts and feelings they were experiencing. This helped them to understand that mental health services were not frightening and can be accessible.
For some young people considering treatment, this engaging process has facilitated a move to the action stage of change (see Prochaska and DiClemente, 1982), resulting in them requesting a referral to our service.
I feel I have built up good relationships with clients and staff, resulting in improved access to services and availability of advice and support. They have also accepted my visits into their community and lives.
During the first 12 months of the outreach work, 126 face-to-face brief interventions were given, of which 15 were for males aged 16–18, 91 were for females aged 16–18 and 20 were for people over 19.
Those over 19 were assessed and referred to appropriate agencies. The conditions/diagnoses presented in the 126 face-to-face contacts are shown in Fig 1.
Throughout this process, young people have been encouraged to express their opinion on the service we offer, influence training packages and any resources developed.
When recently designing the new service leaflet, we sought advice from clients about content, wording and graphics. All draft copies were taken back to them to comment on and changes were made.
Recently, interviews were held for a community nurse post. Questions from clients were incorporated into the process and a representative from our client group was part of the interview panel.
All of these activities will continue and, hopefully, new ones will be developed, to ensure clients’ voices are integral to service development.
There have been some obstacles and difficulties in developing the outreach role. There were times when I felt my presence in the venues was being questioned and I often felt like an unwanted student.
However, after expressing my feelings in supervision, I realised that I could not expect everyone to see me automatically as a resource. It was up to me to prove that I could be of value to them.
This was validated through anonymous evaluation questionnaires which clients completed.
Some comments included:
‘It’s good people think I’m hard but I need someone to talk to.’
‘It’s good ’cause it comes to where we are.’
‘Two people should come so you don’t have to wait to see somebody.’
I will continue with this process by listening to young people, taking their views back to the team and sharing their opinions on what they would like to be different.
I intend to engage with any new services opening in our area, constantly reflecting on the questions of engagement or therapeutic intervention.
Data shows that a number of people over 18 have also accessed the outreach services and it appears there is a gap in service provision for this client group. We need to discuss how to meet their needs with adult services.
- The Department for Communities and Local Government (2008) discussed the prevalence of mental health problems among young homeless people.
- Over half of all respondents in the DCLG survey (52%) had experienced depression, anxiety or other mental health problems, and 33% had current mental health difficulties (a rate of around three times higher than that of young people in the general population).
- Current mental health problems were more common among young women (40%) than men (24%) (DCLG, 2008).
Department for Children, Schools and Families (2009) Children and Young People in Mind: the Final Reportof the National CAMHS Review. London: DFCS.
Department for Communities and Local Government (2008) Statutory Homelessness in England: theExperiences of Families and 16–17 Year Olds. London: DCLG.
Department of Health (1999) National Service Framework for Mental Health: Modern Standards and ServiceModels. London: DH.
11 Million (2008) Out of the Shadows? A Review of the Responses to Recommendations Made in Pushed intothe Shadows: Young People’s Experience of Adult Mental Health Facilities. London: 11 Million.
Health Advisory Service (1995) Together We Stand: the Commissioning, Role and Management of the Childand Adolescent Mental Health Services. London: HAS.
Prochaska, J.O., DiClemente, C.C. (1982) Transtheoretical therapy towards a more integrated model of change. Psychotherapy Theory, Research and Practice; 19: 276-288.
Project Match Research Group (1997) Matching alcoholism treatments to client heterogeneity: Project MatchPosttreatment drinking outcomes. Journal of Studies on Alcohol; 58: 1, 7-29.
Ritter, A. et al (2002) The influence of the therapeutic relationship in treatment for alcohol dependency. Drug andAlcohol Review; 21: 3, 261-268.