case study mental health example

Patient Case #1: 27-Year-Old Woman With Bipolar Disorder

• Theresa Cerulli, MD
• Tina Matthews-Hayes, DNP, FNP, PMHNP

Custom Around the Practice Video Series

Experts in psychiatry review the case of a 27-year-old woman who presents for evaluation of a complex depressive disorder.

EP: 1 . Patient Case #1: 27-Year-Old Woman With Bipolar Disorder

Ep: 2 . clinical significance of bipolar disorder, ep: 3 . clinical impressions from patient case #1, ep: 4 . diagnosis of bipolar disorder, ep: 5 . treatment options for bipolar disorder, ep: 6 . patient case #2: 47-year-old man with treatment resistant depression (trd), ep: 7 . patient case #2 continued: novel second-generation antipsychotics, ep: 8 . role of telemedicine in bipolar disorder.

Michael E. Thase, MD : Hello and welcome to this Psychiatric Times™ Around the Practice , “Identification and Management of Bipolar Disorder. ”I’m Michael Thase, professor of psychiatry at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia, Pennsylvania.

Joining me today are: Dr Gustavo Alva, the medical director of ATP Clinical Research in Costa Mesa, California; Dr Theresa Cerulli, the medical director of Cerulli and Associates in North Andover, Massachusetts; and Dr Tina Matthew-Hayes, a dual-certified nurse practitioner at Western PA Behavioral Health Resources in West Mifflin, Pennsylvania.

Today we are going to highlight challenges with identifying bipolar disorder, discuss strategies for optimizing treatment, comment on telehealth utilization, and walk through 2 interesting patient cases. We’ll also involve our audience by using several polling questions, and these results will be shared after the program.

Without further ado, welcome and let’s begin. Here’s our first polling question. What percentage of your patients with bipolar disorder have 1 or more co-occurring psychiatric condition? a. 10%, b. 10%-30%, c. 30%-50%, d. 50%-70%, or e. more than 70%.

Now, here’s our second polling question. What percentage of your referred patients with bipolar disorder were initially misdiagnosed? Would you say a. less than 10%, b. 10%-30%, c. 30%-50%, d. more than 50%, up to 70%, or e. greater than 70%.

We’re going to go ahead to patient case No. 1. This is a 27-year-old woman who’s presented for evaluation of a complex depressive syndrome. She has not benefitted from 2 recent trials of antidepressants—sertraline and escitalopram. This is her third lifetime depressive episode. It began back in the fall, and she described the episode as occurring right “out of the blue.” Further discussion revealed, however, that she had talked with several confidantes about her problems and that she realized she had been disappointed and frustrated for being passed over unfairly for a promotion at work. She had also been saddened by the unusually early death of her favorite aunt.

Now, our patient has a past history of ADHD [attention-deficit/hyperactivity disorder], which was recognized when she was in middle school and for which she took methylphenidate for adolescence and much of her young adult life. As she was wrapping up with college, she decided that this medication sometimes disrupted her sleep and gave her an irritable edge, and decided that she might be better off not taking it. Her medical history was unremarkable. She is taking escitalopram at the time of our initial evaluation, and the dose was just reduced by her PCP [primary care physician]from 20 mg to 10 mg because she subjectively thought the medicine might actually be making her worse.

On the day of her first visit, we get a PHQ-9 [9-item Patient Health Questionnaire]. The score is 16, which is in the moderate depression range. She filled out the MDQ [Mood Disorder Questionnaire] and scored a whopping 10, which is not the highest possible score but it is higher than 95% of people who take this inventory.

At the time of our interview, our patient tells us that her No. 1 symptom is her low mood and her ease to tears. In fact, she was tearful during the interview. She also reports that her normal trouble concentrating, attributable to the ADHD, is actually substantially worse. Additionally, in contrast to her usual diet, she has a tendency to overeat and may have gained as much as 5 kg over the last 4 months. She reports an irregular sleep cycle and tends to have periods of hypersomnolence, especially on the weekends, and then days on end where she might sleep only 4 hours a night despite feeling tired.

Upon examination, her mood is positively reactive, and by that I mean she can lift her spirits in conversation, show some preserved sense of humor, and does not appear as severely depressed as she subjectively describes. Furthermore, she would say that in contrast to other times in her life when she’s been depressed, that she’s actually had no loss of libido, and in fact her libido might even be somewhat increased. Over the last month or so, she’s had several uncharacteristic casual hook-ups.

So the differential diagnosis for this patient included major depressive disorder, recurrent unipolar with mixed features, versus bipolar II disorder, with an antecedent history of ADHD. I think the high MDQ score and recurrent threshold level of mixed symptoms within a diagnosable depressive episode certainly increase the chances that this patient’s illness should be thought of on the bipolar spectrum. Of course, this formulation is strengthened by the fact that she has an early age of onset of recurrent depression, that her current episode, despite having mixed features, has reverse vegetative features as well. We also have the observation that antidepressant therapy has seemed to make her condition worse, not better.

Transcript Edited for Clarity

Dr. Thase is a professor of psychiatry at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia, Pennsylvania.

Dr. Alva is the medical director of ATP Clinical Research in Costa Mesa, California.

Dr. Cerulli is the medical director of Cerulli and Associates in Andover, Massachusetts.

Dr. Tina Matthew-Hayes is a dual certified nurse practitioner at Western PA Behavioral Health Resources in West Mifflin, Pennsylvania.

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138 Case Studies: Real Stories Of People Overcoming Struggles of Mental Health

At Tracking Happiness, we’re dedicated to helping others around the world overcome struggles of mental health.

In 2022, we published a survey of 5,521 respondents and found:

• 88% of our respondents experienced mental health issues in the past year.
• 25% of people don’t feel comfortable sharing their struggles with anyone, not even their closest friends.

In order to break the stigma that surrounds mental health struggles, we’re looking to share your stories.

Overcoming struggles

They say that everyone you meet is engaged in a great struggle. No matter how well someone manages to hide it, there’s always something to overcome, a struggle to deal with, an obstacle to climb.

And when someone is engaged in a struggle, that person is looking for others to join him. Because we, as human beings, don’t thrive when we feel alone in facing a struggle.

Let’s throw rocks together

Overcoming your struggles is like defeating an angry giant. You try to throw rocks at it, but how much damage is one little rock gonna do?

Tracking Happiness can become your partner in facing this giant. We are on a mission to share all your stories of overcoming mental health struggles. By doing so, we want to help inspire you to overcome the things that you’re struggling with, while also breaking the stigma of mental health.

Which explains the phrase: “Let’s throw rocks together”.

Let’s throw rocks together, and become better at overcoming our struggles collectively. If you’re interested in becoming a part of this and sharing your story, click this link!

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What Is a Case Study?

Weighing the pros and cons of this method of research

Kendra Cherry, MS, is a psychosocial rehabilitation specialist, psychology educator, and author of the "Everything Psychology Book."

Cara Lustik is a fact-checker and copywriter.

Verywell / Colleen Tighe

• Pros and Cons

What Types of Case Studies Are Out There?

Where do you find data for a case study, how do i write a psychology case study.

A case study is an in-depth study of one person, group, or event. In a case study, nearly every aspect of the subject's life and history is analyzed to seek patterns and causes of behavior. Case studies can be used in many different fields, including psychology, medicine, education, anthropology, political science, and social work.

The point of a case study is to learn as much as possible about an individual or group so that the information can be generalized to many others. Unfortunately, case studies tend to be highly subjective, and it is sometimes difficult to generalize results to a larger population.

While case studies focus on a single individual or group, they follow a format similar to other types of psychology writing. If you are writing a case study, we got you—here are some rules of APA format to reference.  

At a Glance

A case study, or an in-depth study of a person, group, or event, can be a useful research tool when used wisely. In many cases, case studies are best used in situations where it would be difficult or impossible for you to conduct an experiment. They are helpful for looking at unique situations and allow researchers to gather a lot of˜ information about a specific individual or group of people. However, it's important to be cautious of any bias we draw from them as they are highly subjective.

What Are the Benefits and Limitations of Case Studies?

A case study can have its strengths and weaknesses. Researchers must consider these pros and cons before deciding if this type of study is appropriate for their needs.

One of the greatest advantages of a case study is that it allows researchers to investigate things that are often difficult or impossible to replicate in a lab. Some other benefits of a case study:

• Allows researchers to capture information on the 'how,' 'what,' and 'why,' of something that's implemented
• Gives researchers the chance to collect information on why one strategy might be chosen over another
• Permits researchers to develop hypotheses that can be explored in experimental research

On the other hand, a case study can have some drawbacks:

• It cannot necessarily be generalized to the larger population
• Cannot demonstrate cause and effect
• It may not be scientifically rigorous
• It can lead to bias

Researchers may choose to perform a case study if they want to explore a unique or recently discovered phenomenon. Through their insights, researchers develop additional ideas and study questions that might be explored in future studies.

It's important to remember that the insights from case studies cannot be used to determine cause-and-effect relationships between variables. However, case studies may be used to develop hypotheses that can then be addressed in experimental research.

Case Study Examples

There have been a number of notable case studies in the history of psychology. Much of  Freud's work and theories were developed through individual case studies. Some great examples of case studies in psychology include:

• Anna O : Anna O. was a pseudonym of a woman named Bertha Pappenheim, a patient of a physician named Josef Breuer. While she was never a patient of Freud's, Freud and Breuer discussed her case extensively. The woman was experiencing symptoms of a condition that was then known as hysteria and found that talking about her problems helped relieve her symptoms. Her case played an important part in the development of talk therapy as an approach to mental health treatment.
• Phineas Gage : Phineas Gage was a railroad employee who experienced a terrible accident in which an explosion sent a metal rod through his skull, damaging important portions of his brain. Gage recovered from his accident but was left with serious changes in both personality and behavior.
• Genie : Genie was a young girl subjected to horrific abuse and isolation. The case study of Genie allowed researchers to study whether language learning was possible, even after missing critical periods for language development. Her case also served as an example of how scientific research may interfere with treatment and lead to further abuse of vulnerable individuals.

Such cases demonstrate how case research can be used to study things that researchers could not replicate in experimental settings. In Genie's case, her horrific abuse denied her the opportunity to learn a language at critical points in her development.

This is clearly not something researchers could ethically replicate, but conducting a case study on Genie allowed researchers to study phenomena that are otherwise impossible to reproduce.

There are a few different types of case studies that psychologists and other researchers might use:

• Collective case studies : These involve studying a group of individuals. Researchers might study a group of people in a certain setting or look at an entire community. For example, psychologists might explore how access to resources in a community has affected the collective mental well-being of those who live there.
• Descriptive case studies : These involve starting with a descriptive theory. The subjects are then observed, and the information gathered is compared to the pre-existing theory.
• Explanatory case studies : These   are often used to do causal investigations. In other words, researchers are interested in looking at factors that may have caused certain things to occur.
• Exploratory case studies : These are sometimes used as a prelude to further, more in-depth research. This allows researchers to gather more information before developing their research questions and hypotheses .
• Instrumental case studies : These occur when the individual or group allows researchers to understand more than what is initially obvious to observers.
• Intrinsic case studies : This type of case study is when the researcher has a personal interest in the case. Jean Piaget's observations of his own children are good examples of how an intrinsic case study can contribute to the development of a psychological theory.

The three main case study types often used are intrinsic, instrumental, and collective. Intrinsic case studies are useful for learning about unique cases. Instrumental case studies help look at an individual to learn more about a broader issue. A collective case study can be useful for looking at several cases simultaneously.

The type of case study that psychology researchers use depends on the unique characteristics of the situation and the case itself.

There are a number of different sources and methods that researchers can use to gather information about an individual or group. Six major sources that have been identified by researchers are:

• Archival records : Census records, survey records, and name lists are examples of archival records.
• Direct observation : This strategy involves observing the subject, often in a natural setting . While an individual observer is sometimes used, it is more common to utilize a group of observers.
• Documents : Letters, newspaper articles, administrative records, etc., are the types of documents often used as sources.
• Interviews : Interviews are one of the most important methods for gathering information in case studies. An interview can involve structured survey questions or more open-ended questions.
• Participant observation : When the researcher serves as a participant in events and observes the actions and outcomes, it is called participant observation.
• Physical artifacts : Tools, objects, instruments, and other artifacts are often observed during a direct observation of the subject.

If you have been directed to write a case study for a psychology course, be sure to check with your instructor for any specific guidelines you need to follow. If you are writing your case study for a professional publication, check with the publisher for their specific guidelines for submitting a case study.

Here is a general outline of what should be included in a case study.

Section 1: A Case History

This section will have the following structure and content:

Background information : The first section of your paper will present your client's background. Include factors such as age, gender, work, health status, family mental health history, family and social relationships, drug and alcohol history, life difficulties, goals, and coping skills and weaknesses.

Description of the presenting problem : In the next section of your case study, you will describe the problem or symptoms that the client presented with.

Describe any physical, emotional, or sensory symptoms reported by the client. Thoughts, feelings, and perceptions related to the symptoms should also be noted. Any screening or diagnostic assessments that are used should also be described in detail and all scores reported.

Your diagnosis : Provide your diagnosis and give the appropriate Diagnostic and Statistical Manual code. Explain how you reached your diagnosis, how the client's symptoms fit the diagnostic criteria for the disorder(s), or any possible difficulties in reaching a diagnosis.

Section 2: Treatment Plan

This portion of the paper will address the chosen treatment for the condition. This might also include the theoretical basis for the chosen treatment or any other evidence that might exist to support why this approach was chosen.

• Cognitive behavioral approach : Explain how a cognitive behavioral therapist would approach treatment. Offer background information on cognitive behavioral therapy and describe the treatment sessions, client response, and outcome of this type of treatment. Make note of any difficulties or successes encountered by your client during treatment.
• Humanistic approach : Describe a humanistic approach that could be used to treat your client, such as client-centered therapy . Provide information on the type of treatment you chose, the client's reaction to the treatment, and the end result of this approach. Explain why the treatment was successful or unsuccessful.
• Psychoanalytic approach : Describe how a psychoanalytic therapist would view the client's problem. Provide some background on the psychoanalytic approach and cite relevant references. Explain how psychoanalytic therapy would be used to treat the client, how the client would respond to therapy, and the effectiveness of this treatment approach.
• Pharmacological approach : If treatment primarily involves the use of medications, explain which medications were used and why. Provide background on the effectiveness of these medications and how monotherapy may compare with an approach that combines medications with therapy or other treatments.

This section of a case study should also include information about the treatment goals, process, and outcomes.

When you are writing a case study, you should also include a section where you discuss the case study itself, including the strengths and limitiations of the study. You should note how the findings of your case study might support previous research. 

In your discussion section, you should also describe some of the implications of your case study. What ideas or findings might require further exploration? How might researchers go about exploring some of these questions in additional studies?

Need More Tips?

Here are a few additional pointers to keep in mind when formatting your case study:

• Never refer to the subject of your case study as "the client." Instead, use their name or a pseudonym.
• Read examples of case studies to gain an idea about the style and format.
• Remember to use APA format when citing references .

Crowe S, Cresswell K, Robertson A, Huby G, Avery A, Sheikh A. The case study approach .  BMC Med Res Methodol . 2011;11:100.

Crowe S, Cresswell K, Robertson A, Huby G, Avery A, Sheikh A. The case study approach . BMC Med Res Methodol . 2011 Jun 27;11:100. doi:10.1186/1471-2288-11-100

Gagnon, Yves-Chantal.  The Case Study as Research Method: A Practical Handbook . Canada, Chicago Review Press Incorporated DBA Independent Pub Group, 2010.

Yin, Robert K. Case Study Research and Applications: Design and Methods . United States, SAGE Publications, 2017.

By Kendra Cherry, MSEd Kendra Cherry, MS, is a psychosocial rehabilitation specialist, psychology educator, and author of the "Everything Psychology Book."

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Pryjmachuk S, Elvey R, Kirk S, et al. Developing a model of mental health self-care support for children and young people through an integrated evaluation of available types of provision involving systematic review, meta-analysis and case study. Southampton (UK): NIHR Journals Library; 2014 Jun. (Health Services and Delivery Research, No. 2.18.)

Developing a model of mental health self-care support for children and young people through an integrated evaluation of available types of provision involving systematic review, meta-analysis and case study.

Chapter 5 the case study.

This chapter focuses on Stage 2, the empirical – or ‘primary research’ – aspect of the study, which we conducted using the case study method. We start with an outline of the specific research methods used, after which we provide a descriptive overview of the individual case study sites; we then present our findings, organised according to a number of analytical themes.

This stage of the project was designed to inform research objectives 3 and 4, which were concerned with, respectively, the factors influencing the acceptability of mental health self-care support services for CYP and the barriers affecting the implementation of such services. In addition, as with the mapping exercise (see Chapter 4 ), this stage of the study also helps realise objective 5, which was concerned with the interface between the NHS and other service providers in the provision of mental health self-care support services for CYP.

Stage 2 was conducted as a collective case study . A case study is an empirical enquiry that focuses on a single phenomenon in its real-life context, especially useful (as in our circumstances) when description or explanation is required. 181 Collective case studies are those in which multiple cases are studied simultaneously or sequentially in an attempt to generate a broad appreciation of a particular issue. 182 Yin 181 (p. 6) defines a ‘case’ as a ‘bounded entity’, a broad and flexible definition that allows the case to be as varied as an event, an individual, a service or a policy. In this project we have defined the case as a ‘mental health self-care support service for CYP in England and Wales’.

Sampling and recruitment

A purposive sampling strategy was employed to ensure that the various dimensions of the self-care support typology we derived from the mapping exercise and systematic reviews (see Chapter 4 , Table 19 ) were reflected in our sample. Accordingly, sites were recruited to include a variety of theoretical bases (e.g. cognitive–behavioural, social learning, recovery) and platforms (e.g. face-to-face or remote, group or individual). We also recruited on the basis of organisational characteristics, such as the sector the site operated in (e.g. NHS vs. local authority vs. voluntary sector) and the site leaders (e.g. health professionals vs. other trained workers vs. volunteers). It was also important to include key characteristics of the study population; thus, the sample included sites offering condition-specific and more generic support, CYP from different age groups, and different types of location (urban, rural) across England and Wales. Using the typology and these characteristics, six potential sites were selected from our sampling frame of 33 services (delivered by 27 providers), and these were approached to participate in the study. One site declined to participate so an alternative, similar in terms of typology dimensions and characteristics to the site that declined, was invited to participate and agreed.

The six sites which agreed to participate were:

• a psychotherapy group for young people aged 14–17 years who self-harm and their families, provided by the NHS in an urban area of England
• a group intervention (Dina School) for children aged 5–6 years with emotional and behavioural difficulties (EBD), based on The Incredible Years 183 programme and provided in rural Wales by the voluntary sector
• a parenting group for parents of children with EBD, based on The Incredible Years 183 programme and operating in rural Wales as a joint NHS/local authority initiative
• a resilience-focused family support service for families of children aged 5–14 years with emerging EBD, provided by the voluntary sector (but local authority funded) and operating in an urban area of England
• a national, recovery-focused online support group for young people aged up to 25 years with eating disorders
• a supported online cognitive–behavioural intervention (Beating the Blues 184 ) provided to young people aged 14–30 years with depression and/or anxiety by the voluntary sector in an urban area of England.

Recruitment of participants at the case study sites was also purposive in that it was driven by the characteristics of the particular self-care model employed. Additionally, to ensure a range of relevant perspectives, the views of younger, as well as older, children, and those of parents and staff with differing roles providing the services were sought.

Regarding the recruitment of service user participants (i.e. CYP and their parents), we received valuable advice from the SAG on engaging these participants in the study. Recruitment documentation (the covering letter, participant information sheets, contact form and consent/assent forms; see Research ethics and governance below) was developed with guidance and feedback from CYP. At five of the sites, staff provided the recruitment documentation to current and ex-service users (or to their parents if they were aged 14 years or below), via the post or by handing the documentation to users when they attended the self-care support service. Participants provided their contact details using the contact form and the researcher (Elvey) telephoned them to arrange the interview. For the eating disorders online support site, the study was publicised, including contact details for the research team, on a web page listing details of current research projects wanting to recruit participants, via an e-mail distribution list of service users who were willing to be contacted about research projects, and via the site’s Twitter feed. CYP participants were eligible to participate only if they were aged between 5 and 17 years. Although two of the sites (sites 5 and 6) did not offer services specifically tailored for CYP, they were eligible for this study because they did offer services to those under the age of 18 years. Non-professional participants (i.e. CYP and parents) were offered £10 in gift vouchers as a token of thanks for their participation.

Recruitment of staff at each site was facilitated via a key contact, usually a service manager, who not only took part in the research, but also identified additional relevant staff to invite as participants. At five of the six sites, staff were provided with the recruitment documentation, either through the post or in person by the researcher; at the eating disorders site, documentation was supplied via e-mail.

Research ethics and governance

Like all empirical research conducted within a university setting, the case study was subject to ethical approval by the host institution, the University of Manchester. Moreover, because the research involved potential access to NHS sites and NHS patients, the ethical aspects of the study required consideration by the NHS National Research Ethics Service (NRES) prior to any consideration by the university. Regulations introduced by NRES in 2011 185 allowed an expedited proportionate ethical review in circumstances where a project had no material ethical issues . NRES provides a tool 186 to help researchers identify whether there are material ethical issues or not, and use of this tool suggested that our project might be eligible for such an expedited review. This turned out to be the case and a favourable ethical opinion was obtained through proportionate review in March 2012. As is the standard procedure, this favourable opinion was accepted by the University of Manchester Research Ethics Office shortly afterwards. While conducting the case study research, it was necessary, on two occasions (in September 2012 and October 2012), to inform NRES of a ‘substantial amendment’ to the ethics-approved protocol. One amendment was required because one site requested that the wording on the covering letter be modified to remove the term ‘mental health’. The other arose because another site worked predominantly with children aged 5 years, so we asked that our original lower age limit for CYP participants be reduced from 6 to 5 years. Both of these amendments NRES subsequently approved.

Ethical research is underpinned by three inter-related factors: (1) informed consent; (2) the safety of participants and researchers; and (3) the safeguarding of any data obtained during the course of the research.

Regarding informed consent, all identifiable participants received an age-appropriate participant information sheet informing them of the study’s nature and purpose. The participant information sheets and associated consent/assent forms were designed according to NRES guidance. 187 The versions specific to CYP, furthermore, were piloted with colleagues’ children, students at a local secondary school and young people with experience of mental health services, and were subsequently amended as a result of their feedback. Written consent was obtained from all adult participants. In line with NRES guidance, 187 all CYP participants aged 15–17 years provided their own written consent; parents provided written consent for children under 15 years old, although, in line with good practice, written assent was also obtained from these children. We needed to take a slightly different approach to consent for the online eating disorders support group (site 5). We were interested in postings on the site’s discussion boards – postings that were both anonymous and publicly available. As the postings were anonymous, it would have been very difficult to obtain individual consent for the use of these postings, so we obtained ‘proxy’ consent to access and use these postings from the eating disorders organisation providing the service.

Regarding the safety of participants and researchers, the principal risks identified for participants were that they might get upset during the interview or disclose information (e.g. in relation to child protection) that would require action by the researcher. Written protocols were prepared for both of these situations. Risks to researcher safety were minimised by adherence to the University of Manchester’s guidance on lone working.

Data safeguarding requires that confidentiality and anonymity issues be addressed, not only in the conduct of the research but also in the reporting and storage of any data associated with the research. To preserve anonymity, the data generated by the research were, wherever possible, stored with identifying features removed. In any case, the data were stored securely, with due regard to confidentiality and in accordance with the University of Manchester’s information governance regulations. When the data were circulated around the study team or SAG, analysed or (as is the case here) reported, we ensured that any identifying features were removed.

At each case study site, we complied with any specific research governance requirements. This included complying with NHS Research and Development requirements at the NHS sites selected.

Data collection and management

Case study research requires data from a variety of sources and, once collected, the data should be managed systematically. 181 Data were obtained through semistructured interviews, documentary review and virtual non-participant observation and, wherever possible, from all three participant categories: CYP, parents and staff.

Semistructured interviews

Semistructured interviews were used as the main data collection technique. They were conducted with staff at all six sites and with CYP and/or parents at all sites except the eating disorders online support site. Pragmatism largely dictated the way in which participants were interviewed in that they were given choices as to which approach they preferred (e.g. telephone vs. face to face; individual vs. group). Forty-two interviews involving 52 participants were conducted; 37 were conducted in person, either at the site’s premises or at the service user’s home, and five were conducted via the telephone. The majority of interviews (35/42) were individual, five were joint interviews with a child or young person plus parent, one was a group interview with a child, parent and sibling and one was a focus group of four young people. The interviews ranged in length from 10 minutes (for some of the youngest children, aged 5 and 6 years) to 1 hour and 20 minutes. Interviews were facilitated by the use of topic guides, copies of which can be found in Appendix 12 . All of the interviews were digitally audio recorded with the permission of participants and the recordings were subsequently transcribed verbatim by a professional company.

Documentary review

Where available, relevant documentary evidence was collected from each site. For sites 5 and 6, documentary evidence was obtained simply from the relevant websites of the services. More comprehensive data were obtained from the other four sites, including a referrer’s leaflet for site 1 as well as a printed self-injury ‘toolkit’ used in providing the self-care support service there; a Microsoft PowerPoint general presentation about the Incredible Years services at sites 2 and 3, and one about the funder’s strategic plan regarding these services; an information leaflet about Dina School training for teachers at site 2; and information leaflets about the site 4 service for referrers, parents and CYP. The documentary evidence largely served to provide a contextual background to, and additional understanding of, the six sites.

Virtual non-participant observation

For the eating disorders online support site (site 5), we collected the data via ‘netnographic’ non-participation observation, adopting the principles of a method designed specifically for health-care research. 188 , 189 Netnography is a form of ethnography used in the study of online behaviour, and as ethnography concerns everyday routine behaviours in a natural setting, 190 netnography was an entirely appropriate method of observing a service that operated entirely online. The service centred around discussion threads that were organised by the providers into nine boards, following themes such as ‘recovery’, ‘caring about someone’, ‘introductions’ and ‘poetry’. Two boards were excluded from the study as the content merely described how to use the boards. All postings over a 4-month period (August to November 2012) were collected from the remaining seven boards. These comprised 114 discussion threads with more than 500 individual messages, each of which was screened for relevance. The postings were copied from the website and pasted into Microsoft Word 2010 documents (Microsoft Corporation, Redmond, WA, USA) prior to analysis.

Regarding management and coding of the data, the three data sets – interview transcripts, background information about the sites (documentary evidence) and the online group postings – were imported into NVivo 10 (QSR International, Warrington, UK), computer software designed to assist in the collection, organisation and analysis of qualitative and mixed-methods data.

Data analysis

The data were analysed using the framework method, 191 , 192 which has five stages: (1) familiarisation; (2) identifying a thematic framework; (3) indexing; (4) charting; and (5) mapping and interpretation. For the interview data, familiarisation was achieved by all of the transcripts being read by the team member who conducted the interviews (Elvey; Kendal also facilitated one group interview), and through other members of the research team (Kirk; Kendal; Pryjmachuk; Catchpole) each reading a sample of transcripts. For the virtual non-participation observation data (site 5’s online postings), Elvey and Kendal undertook an analogous process in that they treated the Word documents into which the postings had been pasted as ‘transcripts’. Following familiarisation, the study’s research questions and the topic guides (see Appendix 12 ) were used to devise an initial thematic framework. Using this initial framework, data from the transcripts (including the online postings) and the background documents obtained from each site were then indexed by Elvey in order to produce an initial chart for each of the six sites. An example of such a chart is provided in Appendix 13 . These six charts were then circulated around team members and a final thematic framework was developed through an iterative process, whereby we met as a team several times to discuss the data and any emerging salient themes. As the final thematic framework emerged, the data from the six initial charts were assimilated into a single chart which was used to guide our analysis and interpretation of the case study findings. The final thematic framework is outlined in Table 22 in the Findings section of this chapter, and Appendix 14 illustrates (using one of the themes, ‘facilitating self-care support’, as an example) how data from each of the initial charts were subsequently assimilated into a single chart.

Themes and subthemes emerging from the case study data

• Characteristics of the case study sites

Details of the six case study sites are summarised in Table 20 and described in detail below.

Details of the six case study sites

Site 1: self-harm psychotherapy group

This NHS service was designed for young people aged 14–17 years who self-harm; it also offered some support for the families of these young people via family support groups, and families could telephone the service and talk to staff between sessions. The service was run from an outpatient setting at an NHS mental health hospital. The service operated within a recovery-focused philosophy and was eclectic in its approach, in that the group intervention employed elements of group psychotherapy, CBT, Linehan’s dialectical behaviour therapy 193 and supportive counselling. Groups ran on a weekly basis (weekday mornings), lasted 2 hours and were led by nurses and support workers. Although the service was manualised – in that there was a specific protocol in place for how the service should be delivered – there was no limit, other than reaching the age of 18 years, to the number of weekly sessions a young person could attend. Young people were referred to the service via community or inpatient services.

Site 2: Dina School

The incredible years.

The group for children with emotional and behavioural problems (site 2) and the parenting group (site 3) were interconnected, but separate, services. Both operated as part of Webster-Stratton’s The Incredible Years programme 183 that had been adopted region-wide (across the local authority area) by the commissioning bodies in the region. The Incredible Years is an evidence-based programme, influenced heavily by social learning theory. It emphasises attachment, relationship building and emotional coaching, with a focus on children learning through play and parents and teachers spending time with children, listening to them and giving them positive feedback. The overall Incredible Years programme comprises universal and targeted (indicated) interventions, both of which were available in the region. At the time of data collection, around half of the region’s schools were Incredible Years schools. In these schools, all staff members were trained in the approach and were thus able to implement the programme universally (in a regular classroom setting, for example) or in a more targeted way.

Dina School

Site 2 was an example of a targeted intervention operating in one of the Incredible Years schools. Known as Dina School, it involved children taking part in 18 weekly, small group sessions, which took place in a room at the children’s school. The groups were facilitated by two classroom assistants, who delivered the programme as set out in the Dina School manual. The programme makes use of a dinosaur puppet called ‘Dina’ (which was also used universally in the main classroom setting) as well as two additional character puppets, ‘Wally’ and ‘Molly’. These puppets were used in role plays, demonstrations of behaviours and communication techniques and in video vignettes. Each session followed a similar format, with a review of the ‘homework’ tasks that were set at the previous session, followed by activities and games and the setting of a further homework task at the end. Parents came to collect their children at the end of the session which coincided with the end of the school day.

Site 3: parenting group

Like site 2, site 3 was a targeted programme. It was one of more than 20 Incredible Years group parenting programmes that operated in the same region as site 2, offering parent training to parents of children aged from 0 years upwards, grouped according to the children’s age. The parenting group participating in this study was for parents of preschool children, aged 2–4 years, who wanted support with their child’s behaviour or communication (e.g. being withdrawn or having tantrums that the parent found difficult to deal with). Parents could self-refer or be referred to the service. The service was provided by a voluntary sector organisation and operated from its premises, although it was commissioned and funded jointly by the NHS and local authority. Parents attended 15 weekly group sessions which were facilitated by two members of staff with backgrounds in family and youth work, and in accordance with the programme manual.

Site 4: resilience-focused family support

Site 4 was a voluntary sector family support service provided to families of children aged 5–12 years with complex emotional and behavioural needs who did not require Tier 3 CAMHS care. Some children were referred to the service because their needs were not seen to warrant CAMHS input; others had attended CAMHS and were subsequently referred to this service for the more generalised support with coping and resilience that it offered. The service is based on the Daniel-Wassell model of resilience, 194 a model with six domains – secure base, friendships, talents and interests, education, positive values and social competences – that have some affinity with the principles of recovery. Staff members work through these domains with families to identify the family’s needs and then focus on those domains where the most support is needed. The family support was delivered by a member of staff from the voluntary organisation operating the service. The staff, who had a variety of professional backgrounds including youth work, social work, psychology and nursing, met with the child and his or her parent(s) individually (sometimes together) at home and at school. As with The Incredible Years, this service was manualised with a prescribed number of sessions.

Site 5: online eating disorders discussion board

This site, operated by an eating disorders charity, consisted of online message boards for young people concerned about, or experiencing, eating disorders. The message boards were established around 6 years ago to improve access to support. Although the online eating disorders service was a ‘virtual’ service, operating entirely over the internet, the charity operating the service offered some other services for young people including a telephone helpline and a live online chat service which some message board users had also participated in. Like the self-harm service, this service operated within a recovery-focused philosophy. To post messages, users had to register on the internet site (supplying their name and e-mail address). Although the posts were moderated, they were freely available on the internet for anyone to read. The boards were organised into themes, and users posted messages that mostly described their worries about food or eating, or their experiences of living with eating disorders, as well as messages that sought support from others or offered emotional support and practical tips to others. The boards were moderated by volunteers, many of whom had experienced eating disorders themselves and some of whom had trained in relevant fields such as counselling. Although the service was open to young people up to the age of 25 years, it was eligible as a case study site because those under 18 years of age were represented in the postings. Unlike the other five sites (which were manualised to one degree or another), this service was inherently spontaneous and adaptable.

Site 6: supported online cognitive–behavioural therapy intervention

Site 6 was a charity-operated, supported online CBT service for young people with anxiety or depression aged between 14 and 30 years. Although the service was open to people up to the age of 30 years, it was, like site 5, eligible as a case study site because those under 18 years of age used the service. The service had been established by staff at the site who had had prior experience of anxiety and depression themselves. It was set up in response to a perceived gap in suitable service provision for young people and young adults and aimed to appeal to this group by being accessible and flexible. The site operated as a drop-in centre, whereby people could come without an appointment and access information and advice. Service users came to the charity’s base and worked through a specific online CBT course – Beating the Blues 184 – with a volunteer from the charity facilitating the young person through each CBT session. Like most CBT interventions, this service was manualised with a prescribed number of sessions.

• Participant characteristics

Table 21 summarises the interviews conducted at each case study site. In total, 52 participants were interviewed between July 2012 and March 2013. The CYP ( n  = 17) who took part ranged in age from 5 to 17 years. Of these 17 CYP, four were interviewed as a focus group (at the self-harm group psychotherapy site), and six were interviewed along with a parent, five at the family support site and one at the self-harm site. Of the 15 parents who took part, nine were interviewed individually and six along with their child. Two of the individual parent interviews at the parenting site were conducted via the telephone. The service provider staff interviewed ( n  = 19) included nurses, psychologists, classroom assistants, social workers, youth workers, counsellors and lay volunteers. Three members of staff at the family support, group parenting and eating disorder sites were interviewed over the telephone. The majority of staff and family members were female; two male staff members and three fathers were interviewed. Of the six young people interviewed at the self-harm and anxiety/depression sites, half were male and half female; at the sites where younger children were interviewed, most (8/11) were male.

Participants by site and category

Although the overall quantity of data is sufficient for a case study, 195 a few observations need to be made about the relative success of our recruitment strategy across the six sites. Recruitment was relatively successful for all three participant categories across sites 1, 2 and 4, though only having one parental interview at site 1 was disappointing. Site 3’s recruitment was also reasonably successful given that parents were the target of the service and that, as they were under 5 years of age, we did not have ethical permission to interview the children. We did not attempt to recruit parents at sites 5 and 6 because the very nature of the services at these sites meant that it would be difficult to identify parents. The low numbers of staff participants at these two sites was also understandable because these services – both provided by the voluntary sector – had limited resources to employ significant numbers of staff. With site 5, we did not manage to recruit any CYP participants for interview despite advertising on the service provider’s website and through other online networks. Though disappointing, this is not an especially serious recruitment limitation as any interview data obtained would have merely augmented the CYP’s perspectives on self-care support which we obtained via the netnographic non-participation observation data.

Site 6 perhaps created the most significant recruitment issue in that we only managed to recruit one CYP participant at this site. This site was a relatively newly established service which was operated by a small organisation with one full-time member of staff. We recruited via the service manager who asked that we involve only ex-, not current, users of the service. The service manager searched the contact database and telephoned or sent information to all ex-users inviting them to participate in an interview. During the 7 months that we were in contact with the site, only eight people aged 17 years and below accessed the service. Two agreed to be contacted by the research team and subsequently participated in interviews, one of whom has since taken on a role as a volunteer providing the service.

From the analysis of the case study data, four principal themes emerged, each containing a number of subthemes. These themes and subthemes are summarised in Table 22 and discussed in more detail in the ensuing sections. At this point, however, it can be noted that the first two themes mostly provide contextual detail about, respectively, the users and providers of mental health self-care support services for CYP, whereas the remaining two focus largely on the factors contributing to the acceptability of such services.

Having a mental health problem

This theme provides some contextual detail about CYP’s and their families’ understanding of the mental health problems experienced prior to using the services at the case study sites, their understanding of self-care in the context of these problems and their experiences of any self-care support received.

Understanding the mental health problem

The conceptualisation of CYP’s difficulties specifically as mental health problems appeared to be connected to the CYP’s age. The youngest children interviewed, aged 5 and 6 years, did not describe having any mental health problems or difficulties themselves. School staff and parents tended to think that these children mainly lacked confidence or had difficulties expressing or managing their emotions. Some parents described emotional outbursts and tantrums and two described their children as being ‘unhappy’.

I had concerns about his behaviour; he would break down into quite severe tantrums that would last for 20 minutes . . . he would spit all over the seats . . . strip naked and hit and lash and kick; hurt himself, hurt me. And generally I just felt that I had this unhappy child on my hands … I couldn’t go out with him . . . So I was kind of feeling trapped in my own home because of his behaviour. Parent of younger child

Older, primary school-age children and their parents described various emotional and behavioural problems: being unsettled or disruptive at school; having emotional outbursts at home; having problems with family members or in making friends; lacking confidence; and having communication problems, especially in expressing emotions.

Me and my mum didn’t really use to get along, and not able to cope, like, and with my brother and sister, I didn’t know how to be responsible and stuff. Child

Young people – that is, older children – who had used the self-harm (site 1), eating disorders online support (site 5) and depression/anxiety (site 6) services had a wide range of experiences, from severe mental health problems and diagnosed conditions, to milder symptoms and difficulties. Some attendees at the self-harm site had been diagnosed with depression and others described feelings of low mood, anxiety and intense feelings. Staff at the self-harm group mentioned a variety of self-harm that users presented with, including cutting and burning. Some CYP attending the self-harm (site 1) and family support (site 4) services had experienced more than one type of difficulty or problem, including being bullied at school, not attending school, displaying signs/symptoms of autism, family relationship problems and misuse of alcohol and/or drugs.

Self-care and self-care support

Just as participants described a wide range of mental health problems and difficulties, their experiences of self-care and support for their problems and difficulties prior to accessing the services were also mixed. Obtaining support was sometimes related to their understanding of the specific mental health problem, as in the case of one young person who had struggled with depression over an extended period:

Interviewer: So had you had any help with your depression before you went to the centre?

Young person: No, none, not at all. I had little understanding as well, it wasn’t something that had been spoken about.

Participants generally described undertaking little self-care before coming into contact with the services. Nonetheless, some parents whose children had attended the Dina School groups (site 2) had also previously attended an Incredible Years parenting course and had used some of the approaches at home. A few parents mentioned using techniques from books or television programmes such as Supernanny . Across most of the sites, the situation for many participants was that they came into contact with the services at a point when their problems had emerged, but they had rarely engaged in self-care themselves or received support they were happy with.

With some of the older children (young people), there was some evidence that they could make rational choices regarding self-management, especially when it came to medication:

Young person: I usually forget to take it, or I intentionally go out my way not to take it, because I feel as if I don’t need it and it makes me feel different . . . I was on Sertraline, but it kept me awake and then I was on Mirtazapine and then some other things . . . I didn’t like them . . . I don’t feel as if meds help me.

Another young person: I’m on medication at the moment, because my depression has peaked at the moment . . . so it [the medication] does work.

However, these choices were not always adaptive, as in these examples of young people ‘self-medicating’ with alcohol:

Young person, interviewed in a group: I used to drink and hide in a tree to drink, because my mum wouldn’t allow it, so I used to hide and had to go in a hole and fall out of a tree regularly drinking, that’s how I coped.

Second young person in the group: Yeah. I used to think alcohol helped me, but it used to just make me worse.

Regarding the support received, there were participants at all of the case study sites with experience of accessing some form of health care or support prior to attending the self-care support service; CAMHS, social services, GPs, psychiatrists, paediatricians, school counselling services and social services were all mentioned. For example, some families had a history of contact with social services due to family situations and some parents had sought help because they were concerned that their child might have an autistic spectrum disorder. There were some reports of positive experiences, such as helpful school counsellors, health visitors and other workers:

My outreach worker who works with me to integrate into the community, because I’m, kind of, agoraphobic, I don’t like people, crowds, so he works with me to try and get me into the community. Young person

However, many negative experiences were recounted where families had felt dismissed when they raised concerns, for example, about their children’s behaviour or social understanding and had found support hard to access. The mother of one child who had previously been referred to community-based mental health services had found the care provided inadequate:

It didn’t help much, she used to just enjoy going there because I was doing all the talking, they would watch her play, so it wasn’t . . . [helping her with] expressing her feelings . . . and then it just kind of stopped, they were thinking she didn’t need it, but she’d got so much anger at the time, she wanted to leave the house . . . I was worried for her. Parent

Two settings in particular were singled out for criticism by young people: mainstream schools and inpatient hospital care. Young people had experienced bullying at school, including being bullied about their mental health problems by other students. Some had stopped attending mainstream school and were at school units and felt that staff at mainstream schools often struggled to help students who self-harmed:

They’re not trained in mental health and are only really equipped to do with stuff, like, things to do with education and . . . bullying and peer pressure . . . they’re not equipped . . . they really don’t have a clue when it comes to stuff like mental health and things like self-harm . . . I had a really bad experience with my mentor. Young person

In terms of hospitals, participants described how support for self-harm in inpatient settings focused mainly on preventing physical harm. For example, two participants reported being restrained and put into seclusion (actions which could both be seen as punitive) when staff found that they were in possession of objects which the staff thought the young people would use to self-harm. Participants had found that they could access either group ‘talking therapies’ or an individual to talk to in the units, but had found this problematic because the therapy was not suitable for them at that stage, or because staff did not spend enough time with them:

Young person, interviewed in a group: There’s people there all the time that you can talk to, [but] I think the therapy puts quite a lot more stress on you at the very beginning . . . you’re taken out of your house . . . kind of throw you in with a bunch of new people, that’s hard to deal with . . . it’s a lot harder to then feel comfortable . . . I think, I had therapy twice, it didn’t work, so they basically just left me.

Second young person in the group: [My named nurse] was on nights and then when she was on days, she didn’t speak to me anyway, that was so unhelpful. She came to my room at like half past 10 and I’d be talking about stuff and getting upset and minutes later I had to try and sleep.

Young person: Yeah I had some nights when mine was . . . on nights and the head of [name of department], so he really didn’t have time [for me].

Running throughout the narratives of the young people was a recurring sense of anxiety around accessing support. Feeling alone, not knowing where to turn for help, discomfort and worry about discussing their problems with family or friends were mentioned repeatedly. The following data extract was taken from one of the site 5 message boards:

When you realise youve got some kind of (eating disorder) what was the first thing you all did? It’s just im stuck and going nowhere, the idea of food and excercise is going round and round in my mind, having crazy thoughts in my head all the time- but i cant tell anyone or even talk about it to anyone because i could shy when it comes to spilling out information about myself . . . any help? Pleasepleaseplease . . . ALSO, if you call the youthline what do they ask you and stuff? because I really wanna call them but im scared of the reponse and over the phone (procedure). Young person, verbatim message board posting

Providing self-care support

This section explores the findings relating to staff views about providing self-care support services, their reasons for involvement, training and supervision, and the extent to which their service is integrated with other services.

Service development

Staff at the sites became involved in the services for a variety of reasons: a desire to change things or innovate on the basis of personal, often negative, experiences of mental health services; wanting to improve the evidence base for practice; and often just sheer enthusiasm to help CYP. For example, the manager of one site had been motivated to found an independent alternative to traditional ‘clinical’ approaches on the basis of personal negative experiences elsewhere:

I started to experience the onset of depression and anxiety and looked at what sort of support or help was available to me and there was nothing that I felt I would have been likely to access or appealed . . . so I . . . basically came up with a service that I would have liked to see when I was in that situation and applied for funding and got it. Service lead

At another site, the service lead had been influenced by observations from her own practice, at a time when there was a perceived ‘epidemic’ of self-harm among young people and generally insufficient support available, and when anxiety about the risk of serious harm, including suicide, was high among staff who worked with young people. The rationale behind setting up a group therapy service was that a group approach could be appropriate for young people because of the influence and importance of peer groups to this age group. Moreover, improvements in peers would be clearly visible in a group setting and so serve as a vehicle for hope and optimism in other group members.

The Incredible Years programme, on the other hand, had been adopted at two sites because of its perceived strong evidence base:

I felt really strongly that I knew that the programmes were blueprint [evidence-based] programmes . . . that met the high standards for replicability and for research . . . I really, really like the Incredible Years model. Staff member

Moreover, service development seemed to be coupled with service leads who were enthusiastic and highly motivated, even to the point of being ‘on a mission’:

So it kind of became my mission and it’s grown into the mission for the Authority to develop all of those programmes. Service lead

Across all six case study sites, the attributes of the service leads in particular were suggestive of a high level of leadership skills, in that there was evidence of innovation, planning, empathy (for CYP, parents and colleagues), motivation and communication.

Training and supervision

All of the sites except the online eating disorders site (site 5) were manualised, that is there was a specific written manual in place for how the service should be delivered. The Incredible Years sites (sites 2 and 3) and the anxiety/depression site (site 6) were guided by manuals that prescribed the topics to be covered in each session; the self-harm (site 1) and family support (site 4) services had manuals that were less prescriptive.

At the self-harm site (site 1), all staff running the groups were provided with the service manual and, as part of their training, they also observed groups prior to becoming a group leader. Staff running the groups met monthly for group supervision with the service lead. On its initial formation, staff at the family support service (site 4) had been trained in the resilience approach by its architects. New staff members were first introduced to the model and subsequently trained by the service’s current staff, as well as receiving clinical supervision from a psychologist. At the anxiety/depression site (site 6), training was provided by the company supplying the CBT programme and all volunteers had to work through the course before working as a volunteer; there was no formal clinical supervision in place at this site, however.

The two Incredible Years services (sites 2 and 3) were different in that, of all the sites, they had the most structured and formal arrangements for training and supervision. To deliver a programme, staff members were required to undergo formal training. Staff members were regularly supervised by local colleagues and there was ongoing monitoring from the programme base in the USA. The service lead explained why she thought the training and ongoing supervision and support were important:

We’re using an evidence-based programme and actually unless you really are delivering with fidelity we know that you can’t guarantee that you’re going to get the same results as [the] research . . . everybody who delivers the group in [area name] can be sure they’re either going to be able to work with [or get] supervision from someone who’s accredited either as a peer coach or as a mentor . . . I think that is really important in making it effective. These are hard groups to run, so it’s important ensuring that people do get the support. Service lead

Fidelity was not emphasised as strongly at any of the other sites. This is perhaps because fidelity can be in opposition to flexibility, a characteristic seen by many as a key factor in a service’s accessibility, as will become apparent when the next theme, Accessing self-care support , is discussed.

Integration with other services

As outlined earlier in the site descriptions, the two Incredible Years sites (sites 2 and 3) had been widely adopted by local commissioning bodies. These services were closely integrated with local planning and commissioning structures and with the local education, health and social services sectors. The Incredible Years services were an exception, however. None of the other services had this level of integration with health, education and social care. The family support service (site 4) was integrated in as much as it was run by a voluntary sector organisation but funded by a local authority, with clinical supervision provided by an NHS psychologist. It also had close links with special educational needs co-ordinators (SENCOs) in schools and could form part of an action plan arising from national ‘Common Assessment Framework’ 196 assessments. Staff at the family support service, however, perceived that there were overlaps between their work and that of the NHS and social services, and that they fitted into a niche between the two.

The self-harm group (site 1) was run from a NHS mental health trust, at a CAMH day service. The service is attached to an inpatient unit with residential and non-residential care and education provision. Self-harm groups using the same principles are run at other NHS locations in the region, and although these groups are integrated with other services to the extent that GPs and consultants can refer CYP to them, they are usually run as ‘standalone’ services with little integration with the NHS CAMHS provider delivering them. The eating disorders (site 5) and depression/anxiety (site 6) services were provided by charities dedicated to helping people with particular difficulties in these areas. The depression/anxiety service was run by a small, relatively new organisation which provided some other activities as well as the supported online CBT, and to some extent could be seen as an alternative, rather than a complement to, statutory services. Regarding the eating disorders charity operating at site 5, integration tended to be limited to ‘signposting’ in that message board posters often offered advice to other board users about how to access statutory services, encouraging users to overcome their anxieties in accessing such services and offering opinions about those services.

Where integration was most evident was in the referral processes at the various sites. This is discussed further in the next section.

Accessing self-care support

This theme, and the next, will present findings on the acceptability of the self-care support services, both in terms of their general accessibility (this theme) and the perceived attributes that services and their staff possess that facilitate CYP and their parents to care for themselves (the next theme). Regarding general accessibility, two key subthemes emerged from the data: one pertaining to referral and one focusing on engagement.

Referral to services

Children, young people and their families had accessed the services via a range of routes, including self-referral, signposting and referral by professionals. The self-harm (site 1), family support (site 4) and parenting group (site 3) services were well integrated into referral pathways and several CYP and parents at these sites had been referred in this way. Several postings on the eating disorders message boards (site 5) mentioned being ‘signposted’ to the board by health professionals, including psychologists and doctors. The parenting group (site 3) and anxiety/depression (site 6) sites encouraged self-referral and publicised their services; some parents had found out about the service through leaflets in their child’s school bag, or through a friend. The anxiety/depression site was advertised through posters and leaflets in shops and bars as well as through presentations at schools and Sure Start centres. At Dina School (site 2), staff at the school had approached the parents of children who they thought would benefit from the service and asked these parents for consent to include their children in the group. Schools were a common source of referrals for the family support service (site 4) and two children who participated in the study had been referred by school staff, one by a SENCO and one by a school nurse. The young person interviewed at the anxiety/depression site (site 6) had self-referred to this service following a presentation at school; in interview, the service manager expressed disappointment that no school nurses had made referrals to the service.

One family who had attended the family support service recalled a long wait (around 2 years) from becoming aware of the programme to the time when they started receiving the support. Waiting times were not cited as a problem, however, by other study participants.

Building and maintaining engagement

In building engagement with health-care services, one of the first barriers to overcome can be the physical access to services. The participants at all of the case study sites seemed to encounter few physical barriers to access, though it should be added that we did not recruit those with probably the best information about barriers to access – ‘dropouts’ from the services – to our sample. For the physically provided services, none of the CYP or parents reported particular problems with travel to the sites. The virtual eating disorders support site could be accessed via the internet at any time, although messages were only uploaded when staff members were available at the service to moderate them (until 20.30 on weekdays and until the afternoon on Saturdays). The Incredible Years services (sites 2 and 3) covered a large rural area and were provided in convenient venues across the region. The young people at the self-harm group site (site 1) were all at school or college and often had to miss school or college to attend the service, though none of the young people interviewed raised this as an issue. These young people were mostly brought by car to the service by their parents. There were several examples of staff working to make services convenient to attend, or taking the service to the families. For example, staff at the family support service (site 4) worked with families in their homes and with children at school. The parenting group (site 3) was generally provided in a group setting but could be run by staff on an individual basis at people’s homes if necessary:

Staff member: It’s very different to a traditional service where you might send out an invitation and if the parents don’t come then . . . they might say that you might not be able to access the service. With Incredible Years it’s more about going out and getting the parents really. So it’s about awareness raising, training lots of agencies who know about the programme . . . but [also] offering really nice coffee and biscuits. If parents miss a session, [it’s] really important that they have the hand-outs. So, if it’s possible, the leader goes and visits them at home.

Another staff member: Recently we’ve had a case [where] mum . . . is not ever there physically when we turn up for our appointment . . . so our worker . . . she’ll go to the child’s nursery . . . to try and catch mum at a drop-off, just to have that initial face-to-face engagement because we were mindful that this is a mum who is surrounded at the moment by professionals who are all breathing down her neck, and we wanted to make sure that mum had a fair view of where we were in that process, what our role is and that we’re not scary monsters who are trying to trip her up.

Flexibility in service provision seemed to be a key in not only building, but also maintaining, engagement with CYP and their families. As a member of staff at the family support service (site 4) outlines:

It’s looking at each case on an individual basis and thinking about what are the reasons for disengagement, why haven’t they engaged, is this a language issue, did they not understand when the appointment was, is it that the intervention isn’t working for them . . . It’s quite involved; but we don’t just do a kind of, if you don’t pitch up we send you a letter and then if you don’t pitch up again we bin you off to be picked up by some other agency – we will attempt always to get an answer. And then if it’s just that it’s not working, well, then we’ll have a conversation about that and let’s work it out. Staff member

Another example of the flexible nature of the services was the between-session support that the sites offered. At the self-harm (site 1), family support (site 4) and parenting group (site 3) sites, support in addition to the scheduled sessions was available, including staff being available to parents over the telephone if they wanted to make contact. Staff at these sites emphasised that they worked hard to engage people in the services and to maintain engagement once a supporting relationship had been established. However, a participant who provided clinical supervision at one of the sites provided an alternative perspective on this, suggesting that it was possible to be overly flexible in that, for example, always bringing the service to a family’s home could potentially discourage independence:

I think, the fact that they [the organisation] go out and work with families in their local area, either at home, or in schools . . . that’s really important . . . something that families will like [but] if you’re going to visit somebody at home then . . . how do you evaluate their motivation to change? Because . . . if you’re at home and somebody comes to see you then actually you don’t necessarily need to do anything to engage, other than sit and nod and make the right noises . . . but if you’ve actually got to physically leave the house and go somewhere, then that suggests that your motivation might be greater to engage . . . it’s trying to get the match between that initial buy in to the service [and maintaining engagement]. Staff member (from outside the organisation)

Some staff expressed an awareness of working with parents who were used to being highly monitored by statutory services and said this could sometimes be a challenge when working to engage parents initially. A school-based member of staff, for example, who had referred several children to the service observed:

You do have the odd family who you refer who don’t engage. And it’s very sad really . . . it’s usually . . . parents who have already got to the point of social services . . . [people think] oh, don’t get social services involved, they’ll take my children from me. And once social services are involved . . . they’re breathing down your neck all the time then, aren’t they? I mean, they’re popping in and out of your house all the time, they’re watching your every move, very intrusive. Staff member

Facilitating self-care support

This theme explores the perceived attributes that services and their staff possess that facilitate CYP and their parents to care for themselves. Key facilitators of mental health self-care support for CYP appear to be organisations and staff that are welcoming; a skills focus whereby CYP and parents are taught relevant self-care skills and then given the chance to practise these skills; opportunities for peer support; and the provision of time and attention.

Welcoming staff; welcoming organisations

Positive staff attitudes appeared to be particularly important. At every site (apart from the online eating disorders service), service users spoke spontaneously and positively about the staff running the service, using adjectives such as ‘nice’, ‘lovely’, ‘good’ and ‘thoughtful’ to describe them. Listening to CYP, allowing them to tell their own story and treating them with empathy and compassion, was also important. This was mentioned particularly by parents at the family support service (site 4) and the young people at the self-harm service (site 1), who liked the manner of the staff and contrasted this with previous, negative experiences at other services. Young people using the self-harm (site 1) and anxiety/depression (site 6) services in particular emphasised the importance of being able to trust staff in order to talk to them openly:

You have to feel comfortable talking to that person, if you don’t like them, then you’re not going to feel comfortable, so you’re not going to engage with them at the level that’s needed to help [you] recover. Young person

At several sites, CYP and parents perceived staff as wanting to understand and help them and felt that they were treated with care and compassion:

The service worker talked to me as if he’d been there before . . . went out of his way for me. Young person

It wasn’t just a job to her. Parent of a younger child

Knowing that the service would accept people for who they were and be open to hearing about their problems was an important attribute of the case study sites operated by voluntary sector organisations. Being non-judgemental or offering non-judgemental support was a particularly positive aspect:

You could be honest and say, ‘This is what my child has done’, and you weren’t judged. Parent of a younger child

Indeed, contrasts were sometimes drawn with other statutory or conventional health and social care services perceived (unfairly or not) as being judgemental. A worker who referred into the family support service noted:

You’ve got to the point where this has become . . . crisis time: ‘We’ve got a plan here in front of us, you will do this, you will do this, you will do this’ . . . whereas with [site name] it’s not, ‘you will do . . .’ it’s ’these are the suggestions that we can make, that will make things better for you’. So it’s not as judgemental, well, social services aren’t judgemental, I suppose, but it might feel like they are . . . I hear in lots of groups that I go to . . . ‘you’re all judging me, that I’m this, you’re judging me on that’. Staff member

A similar feeling was expressed in an interview with a young person at another site:

Young person: [With the general practitioner (GP) and] even with CAMHS sometimes . . . it seems a bit like I’m being judged, or it doesn’t seem like they’re there for me in the way that I’d like, but it was different with [site name], like, it definitely felt a lot more welcoming.

Interviewer: Okay. Is it the people at the GP and CAMHS? Or is it more general?

Young person: I think, it’s more the method, like, I mean, it’s just all about a feeling, it feels like if I’m at the doctors . . . it becomes a thing that I’m ill, or there’s something wrong with me . . . you still sit there and you feel like you’re being judged . . . it definitely affects your confidence when you’re trying to answer, like, the questions, like, confidently and with, like, full honesty . . . I don’t know, like, when I saw my GP I didn’t tell him the whole truth, just because I didn’t feel that comfortable.

Organisational features of the sites were also important in determining how welcoming a service was. In the earlier Service development and Building and maintaining engagement subthemes, we discussed how the service leads appeared to have a high level of leadership skills, and described how staff often worked hard to make services convenient to attend, or took the service directly to the families. There were also some comments about the premises that the services were delivered from. At two of the voluntary sector sites, staff explained that particular efforts had been made to ensure that the physical surroundings were attractive to young people, featuring, for example, bright colours and soft furnishings or having music playing. On the other hand, CYP at one site commented that the rooms in which the groups were held were somewhat small. The physical features of the premises, however, were overshadowed by spontaneous references that CYP and parents made to the welcoming ambience. Indeed, there was often blurring between organisational and individual staff attributes: ‘welcoming’, ‘friendly’ and ‘non-judgemental’ were used by CYP and parents to describe both the staff and the general atmosphere or ambience of the service, often in contrast to other services they had experienced.

Activities to build skills for self-care

The use of skill-building techniques and opportunities to practise such skills in their daily lives was considered an important feature of all six services. Children, young people and parents outlined a variety of practical activities and techniques, including games and exercises, which they had used in formal sessions (in vitro) as well as at home and in school (in vivo). Fittingly, given the nature of this study, most of these activities and techniques were designed to assist the participants in managing (self-managing) the CYP’s condition or problems. For example, in the self-harm group (site 1), young people were supported in devising coping strategies other than self-harming; in site 2, children practised communication skills at home that they had learnt at Dina School; and in the family support group (site 4), families were encouraged to action plan and set goals. For younger children in particular, a large proportion of their narratives consisted of their recollections of the various games and activities in which they had taken part. The youngest children stated that they had gone to Dina School to learn things and that they got ‘prizes’ (plastic chips) for doing well at the activities there:

Interviewer: And what did you get a chip for?

Child: When I’m doing stuff nice.

Many of these activities focused on identifying thoughts and emotions or on learning techniques to relieve anxiety or calm anger. These had been introduced by staff at the sites and also practised by children outside the sessions. The older primary school-aged children seemed to have more insight into the purpose of the activities and techniques:

We used to do these words about temper and then after that to calm me down we used to play a few games. Child

The parents who were interviewed also seemed to appreciate practical techniques and talked at length about implementing these at home. Reward systems including sticker charts were mentioned frequently, along with techniques designed to help children manage tasks and express their feelings:

I think it is important to have a task and try and complete it and stuff. Young person

I think she is responding well to positive rewards . . . she loves the reward charts . . . I give her a sticker just on her T-shirt if she’s done something really nice. Parent of younger child

And from an interview with another parent:

Interviewer: Are there any things in particular that you find helpful?

Parent of younger child: Well there was the words on the fridge . . . the fridge magnets spelling out, ‘I’m not happy’, ‘I’m . . .’

Child: ‘. . . sorry’.

Parent: ‘Sad’, ‘I’m sorry’ and . . .

Child: ‘I love you’.

Parent: ‘I love you’, yeah. We did that for a while. We lost all the pieces, like, we did it for a while.

Some games and techniques were ‘prescribed’ as part of the manual or workbook for the course. However, most of the activities allowed some personalisation such as tailoring rewards to the individual child. For example, staff at the family support service (site 4) found out what children were interested in or enjoyed and then looked for local activities or clubs they could join, such as football or the Boys’ Brigade. At the self-harm site (site 1), young people put together their own ‘tool boxes’ of distraction techniques, memorabilia and keepsakes that helped them reduce urges to self-harm. The service also provided support for caring for wounds that arose from cutting, and advice on ways to camouflage scars, with an organisation specialising in this visiting the group.

I’ve got this thing called a tool box in my room that I put all my different distraction techniques inside so, like, if I’m having a bad day, even if I’m not having a bad day . . . I could use the different things. And different things work at different times, so one time, like, writing out your feelings might be enough, or drawing might be enough, but sometimes you have to use a range of things to minimise that urge and sometimes nothing works, but . . . at least I’ve tried. Young person, interviewed with parent

The programmes delivered at sites 2 and 3 (the Incredible Years sites) and site 6 (the anxiety/depression support service) were supplemented by videos for participants to watch that contained vignettes or examples of role plays to augment the situations or techniques that the programmes considered. These were criticised repeatedly by staff and service users for being outdated and participants disliked that they had been filmed in the USA as they would have preferred British accents. One service user found them ‘idealised’ in that the actors looked too ‘perfect’ and suggested that videos featuring real people, not actors, would be more helpful.

Sharing experiences and peer support

Although a key aspect of all of the services at the case study sites was introducing CYP and their families to stock tools and techniques to help them care for themselves, an important aspect of skills building was supporting CYP and parents to discover self-care techniques for themselves. Often, this happened with the support of their peers, especially in the sites operating group-based approaches where other group members could play a key role in generating ideas or giving feedback. For example, children in the Dina School groups (site 2) took part in role plays and other interactions that helped them to think through how they could handle things that children might find difficult, such as sharing:

[Using a puppet to act out] snatching a book, [then discussing], is that kind?, is that unkind? . . . then after a while you’d get them to bring their problems in, you know, if you have a problem on the yard [playground], you know, if someone’s not listening to you, or doesn’t want to play, well, eventually they would come up [and talk about it with the group]. Staff member

Similarly, users of the online support service (site 5) frequently exchanged tips and techniques. Postings on the message boards often included users sharing self-care tips and suggestions with each other, and describing various relaxation or distraction techniques and activities such as reading, knitting, writing, drawing and exercising:

Listening to music is a huge relaxation thing for me, also drawing/writing – either a story, poetry or in a journal. Do you enjoy reading? To begin with i didnt have much concentration for reading, but now I am really enjoying reading again, and i find if i start reading after a meal when i am anxious that I can get lost in the book, and before i know it half an hour has passed. I’ve also tried knitting, but i’m a bit of a perfectionist so that didnt go so well. Hope you are ok, and that some of these tips may help you. Verbatim message board posting

The following were taken from two other sites:

They discuss coping strategies, like, they’ll say, like, if you get the urge to self-harm, what do you do? And they, sort of, come up with, ‘well, I’ll go and do this, I’ll go and put my favourite music on, my film, go for a walk, walk the dog, talk to my mum’ . . . and I do think it’s very beneficial. Staff member

I enjoyed the discussion. And what was nice is the feedback we gave each other . . . Because I think, that does you good, to have other people sometimes go, no, you’re good at that or why don’t you try this or why don’t you try that? . . . because you put it into practice with other people, it works better than you just reading books. Parent

Although the sharing of practical tips and techniques was an important element of peer support, the sharing of the experiences among CYP and parents was perhaps more beneficial. As discussed in the first theme, Having a mental health problem , some participants had not talked about their difficulties with other people prior to coming into the services and had felt alone with their problems. Staff members and attendees at several sites talked about the emotional benefit of being in a group with people who had had similar experiences, in that people who had previously felt isolated with their problems, or uncomfortable about seeking help for them, felt less alone:

It was actually amazing really; firstly because you realise that what your child was doing was normal and that all the other children were doing the same things. Parent of younger child

I think they listen more to their peers, their peers is pivotal, isn’t it, in adolescence, so I think the peer groups are very important, and that sense of belonging is good. And often . . . I’ve found that every single youngster who attends a group, is excluded from some aspect of their life, either from their family or from a peer group, because they’re bullied or they bully or, you know, they don’t fit somehow . . . So I guess being together with other young people helps you feel, you know, you’re not on your own with this. Staff member, another site

As well as receiving support from others, satisfaction gained from feeling that they had helped others was also important to some participants:

It was good for [my daughter] to see that she had helped other people, she liked that; that helped her as well. Parent of older child

As well as perceiving that the sharing of experiences was helpful, staff and parents felt that having a mixture of experiences and people at different stages of illness or recovery within a group provided additional benefits. The self-harm and parenting groups brought together people from different social groups who would normally not socialise together, but who had experienced similar problems, and this seemed to be helpful in terms of giving people a wider perspective on their problems, or perhaps developing empathy:

[They] have a good understanding of each other’s needs . . . it runs well because it’s a mixture . . . they’re all at different stages of their recovery . . . we’ve got young people who have been established for a long time and . . . have almost recovered, others are at the stage of contemplating, sort of, change and in the process of recovery and some that are not ready to change. And that’s, as I say, a very supportive group . . . those that are almost recovered, they do get and understand where [those who are less recovered] are coming from. Staff member

Very heterogeneous . . . you’d have youngsters in local authority care, and then you’d have very upper middle class young people, who were anxious about exams and stuff like that. And that actually works as well, because kind of sometimes it’s good to see people in other situations . . . you thought your situation was really bad, but actually, there’s people who are worse off, and something about that kind of gratitude about what you have got. Another staff member, same site

The participant quoted below, who described herself as ‘middle class and educated’ seemed to agree that this could be a benefit:

It sounds awful, but people that you might not necessarily have mixed with before, because you wouldn’t have had the chance, and got to know them . . . different social spheres . . . all of that’s broken down . . . [there can be perceptions that] . . . some backgrounds are better, supposedly, than others. And actually, you know, one of the mums in particular, who hadn’t got any further education . . . was just a fantastic mum. Whenever we’d . . . learn a new principle, when we’d feed back the next week, her and her partner had discussed it, and had both tried it . . . And it was nice to hear about other people, and there is a range of us, you know, people with partners, people without. Parent of younger child

The ‘sharing experiences’ aspect of peer support was complemented by others including the social aspect and what might be termed an ‘empowerment’ aspect. Regarding the social aspect, service users at the self-harm (site 1) and parenting (site 3) sites enjoyed attending the groups and especially liked the social aspect of getting to know others in the group. The parenting course (site 3) had an arranged ‘buddy system’ where parents were paired up and encouraged to telephone each other between sessions to talk about how they were getting on with their tasks or exercises, and some of these parents also reported forming friendships and continuing to meet socially after the programme had finished. From the focus group:

Young person 1: I prefer group talks, like, talking in groups, instead of taking medication . . . [at first] I was an inpatient so I was really struggling and . . . just having the support off people in the group was what I needed.

Young person 2: We’re good for each other!

Young person 3: We just, like, support people with what’s been going on in their week, and stuff, and it’s nice, because we’re like a little family.

Young person 4: We are like a family aren’t we?

The social benefit of groups was also reported by the staff member at the eating disorders message board service (site 5):

[T]he message board is a really good place to start forging links with other people in a very safe and supported way and it helps to build their confidence . . . when they suggest something to somebody [and they] come back and say, ‘that was really good, I did that and it really worked for me’ [they] make very strong bonds with each other. Staff member

Some of the group activities also appeared to help empower the CYP. For example, the self-harm groups (site 1) helped participants develop empathy by encouraging the young people to take it in turns to chair the group. Each group began with each member giving an update on how his or her week had been, and a role of the chair was to ensure that each person contributed. Staff observed that some young people in the group seemed unhappy or annoyed when they would have preferred not to contribute but the chairperson still asked them to share their experiences with the group. The staff member who described this thought that this could help young people to appreciate the difficult task that staff sometimes faced in encouraging young people to engage in ‘talking therapies’, and that sometimes encouraging someone to contribute in a group, even if they seemed not to want to, could help develop empathy and leadership skills in the young person.

Although our data demonstrate that peer support is beneficial, the risk of ‘contagion’, or triggering self-harm or problems with eating, was perceived as a key challenge by staff at the self-harm (site 1) and eating disorders (site 5) sites. Staff at both of these services saw risks in group work and worked actively to manage such risks. Unlike the parenting site (site 3), where parents were ‘buddied’ with another parent and encouraged to support each other between sessions, young people at other sites were discouraged from having contact outside of the service. At the self-harm site, young people were actively discouraged from meeting outside the group and, at the online site, interaction was controlled through moderation of the message board postings. This involved screening and editing posts to ensure that they did not contain contact information.

Some people who had attended the self-harm groups (site 1) and parenting courses (site 3) remembered feeling nervous about attending their first session. As it was the first time they had attended anything of that nature, they were unsure what to expect and were nervous about having to talk about their difficulties in front of other people. They felt that groups were only helpful for people who were at a stage of their illness or recovery where they were ready to attend a group. Our interviewees had all settled into the groups and had positive experiences, but they thought that the group setting would not be suitable for everyone; some people simply would not want or choose to discuss their problems in a group setting. Staff at the self-harm group identified managing dominant personalities as a further challenge that they had to be aware of, in order to make sure that all group members had a chance to participate during each session.

Time and attention

Giving CYP time and attention appeared to be a valued characteristic of the services. At four of the six sites, participants valued simply spending time with children, especially when this involved enjoyable activities. A key principle of Dina School (site 2) and the parenting course (site 3) was giving children positive attention. The Dina School groups allowed for each child to receive more attention than would be possible in a regular class. Parents felt that their children enjoyed being in the group and that the environment was more realistic than the regular classroom for them to learn about talking about their feelings. Parents who attended the parenting course found that setting time aside for their children was helpful, including scheduling time to play with them and also having activities together as a reward for good behaviour, and reported that their children were calmer. At the family support service (site 4), a worker described how during school holidays, instead of having appointments with children at their school, she had collected them from home and brought them to the centre, and had been surprised by how much they enjoyed this:

Often I’ll go and pick the children up and bring them here, which they just think is the best thing in the world . . . it’s not that exciting, but it’s just something different . . . that’s what some of them say. Staff member

Participants of different ages seemed to enjoy positive attention, perhaps away from a school or the clinical or home environment:

Another thing as well that sticks in my mind about the group is when [staff member] actually took us out once into town . . . as a group . . . just to do something nice, instead of being stuck in a small room that’s quite clinical . . . it was good. Young person

At one site, young people recalled their experiences of being inpatients, when some staff would come to talk to them, but often at inappropriate times or not for long enough. At another, family members of younger children appreciated project workers talking to the children themselves.

I think that young people often really have appreciated the fact that someone has taken the time to listen to them and hear their side of the story. Staff member

An older sibling of one of the children at the same service singled out the way that the project worker had helped her brother to understand his behaviours and the emotions attached to them, and what might affect these:

When [child’s name] used to get angry we used to talk to him and try and calm him down . . . but we never used to speak to him about why he got angry . . . I think because [project worker’s name] spoke to him and broke it down into steps that he could understand . . . and then she used to ask him stuff about his friends and his family. Sibling

Although CYP and parents appreciated the time and attention that staff at the sites gave them, staff mentioned that operational constraints sometimes prevented them from providing as much time as they would have liked. The manuals for the Incredible Years services (sites 2 and 3, Dina School and parenting groups) were prescriptive, with themes and associated activities being set out for each session. However, although staff at these sites liked the fact that all the materials for the sessions, and also the letters to send home to parents, were provided (as this made the course easy to deliver), they felt that there was too great a volume of material, and that they had often had to leave out certain aspects in order to complete the sessions on time.

Sometimes it was hard to keep their attention, because we’ve got a programme to deliver and it’s quite a lot to fit into those 2 hours, so sometimes [we] would look at it before and think we’re never going to fit all that in so we’d think, right, we won’t do that activity today, we’ll do that next week and try to fit in an activity where they’d be moving a bit more and try to adapt it a little bit. Staff member

Both CYP and parent participants at several sites mentioned that they would have preferred more sessions or time with the service – a statement also echoed by staff at some sites – but financial constraints prevented this from occurring. In particular, staff at one of the voluntary sector sites outlined how a scheduled 15-week programme had to be reduced to 12 weeks because of financial and resource restraints.

Now we have this 12-week programme and it used to be a bit more like 15 weeks and we used to be able to be a bit more flexible with what each different family needed . . . I feel I used to do a lot more . . . therapeutic work with the young people and creative work, and some of that has had to be cut because we’re having to be a bit more focused on where we need to get to, which is a bit of a shame . . . I used to do a lot more kind of crafty things . . . than I feel that I’ve got the time to really do now. Staff member

• Summary of the case study findings

This chapter has presented the findings derived from 52 interviews with children, young people, parents and staff, some documentary evidence and over 500 message board postings at six case study sites.

The aim of this stage of the project was to investigate the acceptability of mental health self-care support services for CYP and the interface between mental health self-care support providers, the NHS and other service providers in the statutory, private and voluntary sectors.

A common feature across all the case study sites was the perceived accessibility of the services provided. The self-care support services appeared to offer convenient locations and appointment times, maintained engagement with between-session support, and were staffed by people who were caring and compassionate. Given that self-care support necessarily requires an agent – a professional or lay person to provide that support – it was reassuring to witness passionate, motivated, welcoming, non-judgemental and child-centred staff at all six sites. Where barriers were mentioned, they tended to be discussed in the context of other, sometimes competing, services (including standard NHS and local authority services) rather than with reference to the services at the six sites. These barriers could be seen as criticisms of the other sites and were broadly related to inflexibility: applying (stigmatising) diagnoses and labels, rather than seeing the child or young person as a person needing help and support; being dismissive of, or failing to appreciate, the concerns that CYP and their families might have about having a ‘mental health problem’ or accessing services; adhering rigidly to manualised interventions without questioning the readiness of CYP and their families to self-care or the intervention’s suitability to the CYP; and affording them little choice in their (self-)care.

Taking all of the participants’ perspectives – CYP, parents and staff – into account, we can speculate on some of the key elements of effective mental health self-care support for CYP. From the case study data it seems that, in addition to flexibility, effective mental health self-care support services for CYP seem to be built on straightforward access; positive staff and organisational attributes that are non-judgemental and welcoming; the provision of time and attention; the chance to learn and practise skills relevant to self-care; and systems of peer support which include opportunities to share experiences and practical tips.

If there is an overall constraint, it is regarding the interface with other services. The case study sites cut across the NHS, other statutory providers and the voluntary sector, yet there was no clear pattern of how well these providers worked together, if at all. In the two Incredible Years sites, there was a seamless integration of the health, social care and education sectors; yet in another site (the family support group), even though there was ‘nominal’ integration between health, social care and education, the service preferred to see itself as a ‘niche’ not quite fitting into any of these domains. In the other sites, there was either no visible integration or somewhat erratic integration or, as in the case of one site, an almost defiant refusal to integrate demonstrated by the setting up of an alternative, rather than complementary, service. Where the interface between the sectors worked best was in relation to referral: though only a few services had extremely well-integrated referral pathways, all had some degree of interface, even if it was as simple as merely signposting into, or out of, the self-care support service, or using networks among the sectors to promote self-referral to the service.

Included under terms of UK Non-commercial Government License .

• Cite this Page Pryjmachuk S, Elvey R, Kirk S, et al. Developing a model of mental health self-care support for children and young people through an integrated evaluation of available types of provision involving systematic review, meta-analysis and case study. Southampton (UK): NIHR Journals Library; 2014 Jun. (Health Services and Delivery Research, No. 2.18.) Chapter 5, The case study.
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• Published: 01 April 2021

Three case studies of community behavioral health support from the US Department of Veterans Affairs after disasters

• Tamar Wyte-Lake   ORCID: orcid.org/0000-0001-8449-7701 1 , 2 ,
• Susan Schmitz 1 ,
• Reginald J. Kornegay 3 ,
• Felix Acevedo 4 &
• Aram Dobalian 1 , 5  

BMC Public Health volume  21 , Article number:  639 ( 2021 ) Cite this article

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Metrics details

Community disaster resilience is comprised of a multitude of factors, including the capacity of citizens to psychologically recover. There is growing recognition of the need for public health departments to prioritize a communitywide mental health response strategy to facilitate access to behavioral health services and reduce potential psychological impacts. Due to the US Department of Veterans Affairs’ (VA) extensive experience providing trauma-informed behavioral healthcare to its Veterans, and the fact that VA Medical Centers (VAMCs) are located throughout the United States, the VA is well situated to be a key partner in local communities’ response plans. In this study we examined the role the VA can play in a community’s behavioral health response using case studies from three disasters.

This study investigated experiences of VA employees in critical emergency response positions ( N  = 17) in communities where disasters occurred between 2017 and 2019. All respondents were interviewed March–July 2019. Data were collected via semi-structured interviews exploring participants’ experiences and knowledge about VA activities provided to communities following the regional disasters. Data were analyzed using thematic and grounded theory coding methods.

Respondents underscored VA’s primary mission after a disaster was to maintain continuity of care to Veterans. The majority also described the VA supporting community recovery. Specifically, three recent events provided key examples of VA’s involvement in disaster behavioral health response. Each event showed VA’s integration into local response structures was facilitated by pre-existing emergency management and clinical relationships as well as prioritization from VA leadership to engage in humanitarian missions. The behavioral health interventions were provided by behavioral health teams integrated into disaster assistance centers and non-VA hospitals, VA mobile units deployed into the community, and VA telehealth services.

Conclusions

Recent disasters have revealed that coordinated efforts between multidisciplinary agencies can strengthen communities’ capacity to respond to mental health needs, thereby fostering resilience. Building relationships with local VAMCs can help expedite how VA can be incorporated into emergency management strategies. In considering the strengths community partners can bring to bear, a coordinated disaster mental health response would benefit from involving VA as a partner during planning.

Peer Review reports

Disaster behavioral health

The current COVID-19 pandemic, while still underway, has already demonstrated the need for psychological interventions to manage the isolation, stress, and trauma stemming from the ongoing disaster [ 1 , 2 , 3 , 4 , 5 ]. While the scale of the event is unprecedented, interest in understanding the psychological consequences of disasters is not unique to the pandemic [ 6 , 7 , 8 , 9 , 10 ]. Generally, studies exploring the impacts of disasters on behavioral health have found increases in psychological distress in the short term, with the potential for some individuals to experience long-term psychiatric disorders such as posttraumatic stress disorder, depression, and anxiety [ 6 , 7 , 8 , 9 , 10 ].

To ameliorate the potential negative health effects to impacted populations, numerous early interventions have been explored [ 7 , 11 , 12 , 13 , 14 ]. Some countries such as the Netherlands and Iceland use federally structured plans to implement disaster behavioral health interventions [ 12 , 15 ]. And countries like New Zealand have invested heavily in developing extensive mental health programs in response to large scale disaster events [ 16 , 17 ]. In the United States, federal entities strive to create resources and guidance on implementing behavioral health services after disaster, however, interventions are generally managed and delivered by state, territory, and local agencies [ 14 , 18 , 19 ]. Often, after federally declared disasters, the US Federal Government additionally provides funding through the Crisis Counseling Assistance and Training Program (CCP) to community behavioral health programs [ 8 , 13 , 20 ]. Yet the structure and content of interventions are left to the discretion of the implementing agency.

Regardless of the services provided, having a plan in place prior to a disaster can facilitate implementation [ 8 , 11 , 12 , 13 , 19 , 21 , 22 ]. Few publications detail the creation of a local disaster behavioral health response plans [ 15 , 18 , 20 ] or describe the process in which interventions were deployed following an incident [ 7 , 10 , 15 , 20 , 23 , 24 ]. Common themes arising in studies exploring disaster behavioral health plans or interventions are the need for interdisciplinary teams and interagency collaboration [ 8 , 12 , 18 , 19 , 20 ] and strong community response [ 16 ].

The United States Department of Veterans Affairs

One interagency partner often overlooked in the United States is the U.S. Department of Veterans Affairs (VA) Veterans Health Administration (VHA). Previous publications on VHA’s participation in collaborative disaster planning and preparedness efforts with local communities identified barriers to its involvement [ 25 , 26 ]. One such barrier is that the community, and sometime even VHA employees, are unaware that VHA is tasked with planning for and acting to support “national, state, and local emergency management, public health, safety and homeland security efforts” [ 9 , 27 ]. This responsibility to contribute to community efforts is called the VA’s Fourth Mission and is in addition to VHA’s duty to ensure continuity of services to veterans after a disaster.

The expertise of VHA’s 322,030 healthcare professionals and support staff who provide a range of services at its 1255 healthcare facilities spread throughout the U.S. and its territories makes VHA a valuable potential partner in disaster response [ 28 ]. In addition to inpatient and ambulatory medical care, VHA provides a variety of reintegration programs including trauma recovery and behavioral health services for Veterans and their families at its facilities and through community-based care at Vet Centers, Mobile Vet Centers, and college and university campuses [ 29 ]. How these services are applied in community response efforts has been detailed in the grey literature [ 28 , 30 , 31 , 32 ].

This study highlights the potential role of local VA facilities in supporting local behavioral health activities after a disaster, and specifically, presents three exemplars of VHA integrating into communities’ disaster behavioral health response and providing behavioral health support to non-Veterans. The three VA facilities and the events they responded to are: (1) VA Pacific Island Healthcare System (VAPIHC), which is based in Honolulu, Hawaii but provides care to Veterans throughout numerous Pacific Islands. On October 24th, 2018, Super Typhoon Yutu made direct landfall on the Mariana Islands, a US Commonwealth with a nascent established VA tele-mental health clinic on the island of Tinian. This was the strongest typhoon ever recorded to strike the area, severely damaging or destroying many buildings and much of the critical infrastructure of Tinian [ 33 ]; (2) Orlando VA Healthcare System, which serves east central Florida, and encompasses 7 counties. On June 12, 2016, a domestic terrorist attack [ 34 ], targeted hate crime, and one of the deadliest mass shootings in the U.S. occurred at a local establishment, Pulse Nightclub. In a matter of hours, 49 people were killed and 53 were wounded before law enforcement breached the building and ended the violence [ 35 ]; and (3) VA Southern Nevada HCS (VASNHCS), located in and providing care throughout Las Vegas, Nevada. On October 1, 2017, the worst mass shooting in modern history took place at the Route 91 Harvest Music Festival on the downtown Las Vegas Strip. A gunman opened fire on a crowd of more than 22,000, killing 58 people and wounding 413 [ 36 ]. These cases provide examples of interagency partnerships and the implementation of collaborative responses for communities developing their own plans to address the behavioral health needs of their citizens during disasters, including the ongoing COVID-19 pandemic.

Study design

The results presented in this paper stem from a larger study broadly examining the role of local VA facilities in responding to regional large-scale disasters. This study used qualitative interview methods to elicit study participants’ experiences during disasters impacting the U.S. between 2016 and 2018 (see Table  1 for the full list of the disasters covered in the study, the impacted US states and territories, and VA entities affiliated with the impacted areas). Findings on disaster behavioral health functions were pulled as a subset of data and analyzed. The VA Greater Los Angeles Healthcare System Institutional Review Board (Los Angeles, California USA) approved this study.

Setting and sample

The full study sample was purposively chosen to represent individuals with emergency response roles critical to coordinating VA’s local response to disasters. Emergency management personnel at various levels of the VA were the first point of contact and, when applicable, identified additional individuals with critical response roles to interview. Additional respondents were recruited independently by the project team These facilities made up the broad recruitment sample. Due to some respondents covering multiple disasters or being deployed to disasters outside their normal service region, not all entities were included in the final sample.

Data collection methods

Data were collected through semi-structured, 60-min telephone interviews between March–August 2019, using an interview guide developed for this study (see Additional file  1 ). Interviews were conducted individually with each respondent and led jointly by at least two of the authors. Interviews explored participants’ experiences and knowledge about VA activities in the community, specifically focusing on how VA networked and coordinated with non-VA community agencies. Interviews were audio-recorded, although one respondent declined to be recorded.

Analysis plan

A total of 17 individuals were interviewed. However, five interviews did not indicate collaborating with non-VA entities and were therefore not included in the analysis. Due to their involvement in multiple disasters, two respondents were interviewed twice. At completion of the interviews, this resulted in 13 interview recordings being transcribed, and one set of interview notes (due to interviewee declining to be recorded), resulting in a total of 14 interviews that were analyzed with Atlas.ti (v.7) using a grounded theory approach. In phase one of analysis, one author reviewed all 14 interviews, using inductive coding to identify emergent themes in the data, and informed by extensive conversations about project findings held by the project team at the conclusion of each interview [ 37 ]. As a product of this process, a significant emergent theme [ 37 ] was the presence of interagency partnerships implementing collaborative responses to address the behavioral health needs of local citizens during disasters. A decision was made by the project team to narrow the focused coding analyses [ 37 ] to the way local VA facilities engaged in a behavioral response within their local community, in response to their respective large-scale disaster events.

In phase two of the analysis, the initial codes identified by SS were reviewed by TWL for consistency and agreement. Codes not deemed consistent to the focus topic were dropped. Additional grounded themes were confirmed by the team and applied to the data set [ 37 ]. Consensus on final codes was achieved, and one code list was finalized. In phase three of the analysis, the final code list was applied across all relevant interviews. The final code list had a focus on behavioral health response, including behavioral health activities, method of delivery, reactions of staff, and types of impacted community populations, but also included an identification of high level themes across all disasters, including VA expertise, integrating into local, established response activities, identification of local needs, and logistical challenges. Authors TWL and SS then independently coded each interview and resolved discrepancies by consensus.

All respondents played a substantial role in VA’s activities following the respective disasters. However, only 12 participants indicated the VAMC they supported collaborated with non-VA partners during the event in question. Included disasters ranged from widespread to geographically contained; weather-related to acts of violence; and direct impact on VA facilities ranged from none to significant. Though not all respondents described intensive engagement with the community following the event, all respondents described the importance of integrating into local, established response activities. This translated into involvement in community-wide drills and planning committees and following the lead of local incident command. Respondents indicated one of the areas where the VA could provide support to the community was in disaster behavioral health relief operations.

Activities described by respondents were often centered around tasks where the VA could reduce the caseload of other community agencies by identifying Veterans obtaining services in the community and meeting their needs regardless if they were previously enrolled in VA benefits. One key activity described by several respondents included outreach into local shelters. As one respondent explained, VA staff at shelters “[distribute] fliers [that] outline that our counselors are experts in trauma, loss, and in readjustment. They also provide referrals to Veterans for a variety of services, including housing and employment. We also offered free counseling for all community members impacted .”

Identifying where shelters were established and receiving authorization to deploy VA assets to those locations required coordination with local authorities. Multiple respondents mentioned connecting with emergency management running relief efforts to describe available VA resources and detail the services available to both Veterans and the community at large. In some of the events explored in this study, the non-VA authorities were unaware of what the VA could offer while others had pre-existing relationships that allowed for more transparent understanding of how the VA could support response efforts. One respondent went on to describe how the disaster that impacted their VAMC led to additional outreach to local jurisdictions and shelter coordinating agencies (e.g., the American Red Cross) to build relationships and understanding specifically of the behavioral health services the VA could deploy, if needed and approved.

Respondents noted there were specific benefits to conducting outreach in locations where other agencies provided services to the people impacted such as shelters and Local Assistance Centers. They noted that VA staff could more easily reach Veterans to enroll them, if eligible, into VA services and offer care to those who usually used non-VA health and mental health facilities, thereby supporting local agencies by reducing potential patient loads elsewhere. Additionally, by positioning resources at a central location, VA could more readily offer community members services as an extension of their work with Veterans. One specific resource identified as useful for Veteran and community support was Mobile Vet Centers, which have the primary goal of providing social work and mental health services to Veterans. In cases where respondents mentioned this resource, they underscored that non-Veteran community members who requested services in the first days after the disaster were never turned away.

Three community profiles

Three disaster events described by respondents distinctly highlighted cases where the VA was deeply involved in the local community’s disaster behavioral health response. Each event showed VA’s integration into local response structures was facilitated by pre-existing emergency management and clinical relationships, as well as prioritization from VA leadership to engage in humanitarian missions to support the community.

Telehealth in Tinian, Mariana Islands

Prior to Super Typhoon Yutu impacting the Mariana Islands, the VA Pacific Island Healthcare System (VAPIHC) established tele-mental health services on the island of Tinian. These services were located at a non-VA owned healthcare clinic using pre-positioned VA telemedicine equipment and coordinated with the clinic director and staff. Typhoon Yutu devastated the island and led to many Tinian healthcare clinic employees losing their homes. The clinic with VA tele-mental health equipment became a temporary housing site for staff as it was undamaged by the storm. The clinic director realized that in addition to sheltering needs, employees also experienced significant trauma. However, there were limited mental health resources on the island. Once VA became aware of the need, it worked with other federal agencies to manage the logistics of implementing services that took advantage of pre-positioned VA resources.

“… it was a relationship that we had with [the US Department of Health and Human Services] (HHS) and a relationship that we had with the folks on Guam and Saipan … we have a lot of relationships going on. So, we knew that we had that telehealth equipment. We also knew that Tinian was … hit pretty hard. And that there was a lot of grief. And so I can’t say how it totally emerged, but there’s so many relationships and there’s so much communication during an emergency.”

Respondents reported it was initially challenging to identify whether VA could provide mental health services in the community and how the services would be funded. Staff at all levels of the VA worked with the Federal Emergency Management Agency (FEMA) and HHS to get official authorization as well as receive federal funding for VAPIHC to provide time limited tele-mental health interventions to clinic staff on Tinian. VAPIHC Tele-mental Health Hub coordinated with the local clinic director to inform employees about available services and utilized technology onsite to provide weekly support groups for 13 health center employees.

Director’s 50 in Orlando, Florida and the pulse nightclub shooting

The Orlando VA Healthcare System (OVAHCS) houses a unique emergency response team “The Director’s 50.” Made up of multi-disciplinary VA healthcare workers, including mental health professionals (i.e. psychologists, psychiatrists, mental health nurses), the Director’s 50 can deploy a team of up to 50 volunteers within 2 hours to areas throughout the region when authorized by the Orlando VAMC Director. As described by one respondent, the mission of the team is,

“to provide an immediate gap fill to an emergency before VA can get its assets organized and into a formal support and response role. So the team is multi-disciplinary and multi-functional with its capabilities, so that it can immediately address the needs of the emergency response until VA can formalize how it’s going to provide their support to the community.”

The Director’s 50 includes interdisciplinary clinical and service support training for all members such as triage and treatment services, mental health intervention, peer counseling, and psychological support to trauma. Through participation in community-wide exercises and drills, the Director’s 50 has built versatile capabilities and strong relationships with local emergency management agencies and area hospitals.

In response to the Pulse Nightclub Shooting, VA Central Office requested OVAHCS to deploy the Director’s 50 to provide VA resources and support the community’s response. The team activated their mass notification system to alert their nearly 100 volunteer members and quickly assembled an initial response team of about 15 clinical, mental health, and support professionals within 1 hour. Respondents noted having internal approval can speed up the process of deploying teams. In general, to distribute VA resources into the community, a federal disaster declaration is required to initiate the Robert T. Stafford Disaster Relief and Emergency Assistance Act or where the HHS Secretary has activated the National Disaster Medical System, both of which grant VA the ability to provide assistance. Therefore, respondents noted a need to balance expectations of leadership to help quickly, while also ensuring VA resources were legally allowed to be used in the response.

One thing that facilitated OVAHCS’s integration into the local response system was a pre-existing relationship with the City of Orlando’s Office of Emergency Management and the Central Florida Medical Disaster Coalition, which facilitated the Director’s 50 integration into the city’s response and allowed them to report to the victim reunification center. The team was tasked.

“to be the initial communication to the family members for those victims that actually passed away. So, 49 victims, our team was assigned to go ahead and be the initial contact to let them know that their loved ones had passed, and to begin the coordination for services, grief counseling and victim advocacy, you know, to help them prepare the initial points of piecing together their lives after being notified of such tragic events.”

Accordingly, the initial multi-disciplinary team narrowed its focus to mainly members with mental health expertise. Over the next 2 weeks, the team worked with the community, helping to manage vigils and gatherings for the public, and continuing grief counseling and mental health support for the whole community, including providing peer behavioral health support to municipal first responders. Since this act of violence targeted people who were Lesbian Gay Bisexual Transgender Queer (LGBTQ) frequenting Pulse Nightclub, not only were relatives of victims or survivors from inside the building affected, but the entire LGBTQ community felt the traumatic impact of the shooting. One respondent described the importance of providing mental health support from multiple community agencies when a disaster of this magnitude occurs,

“And they [the people who were at the shooting] truly needed a place, and this is why we were there for greater than just the 24-48 hours of initially identifying the people who was killed during the shooting, you had everyone that was inside of the club who were seeking a place where they could go and receive the care and support that they needed as well. And obviously, you know, this is something that is an endemic issue with healthcare as a whole, is the access to mental health counseling and services. So VA, as well as some other partnering mental health organizations were able to supply that need right there at the site where they were doing victim notification or victim reunification and family support. We were able to do that.”

One respondent noted a key point to remember about the Director’s 50, “they are all volunteers...And these people will go—you know, 24 hours a day, day in and day out, to execute that mission. And we have to think about team resiliency.” This included caring for team member’s well-being by rotating staff and providing and attending to the mental heath of one another. As described by one respondent,

“Because when it was all said and done, the team was very affected by what they had to do. You know, just imagine hearing—you know, overwhelming grief for every one of the 49 victims’ families that would show up. And the team took that burden on … and I will tell you, to this day, it still affects the people who went and supported that mission. And they really—those who supported that mission have a greater reverence for what we do now, as a team. So you’d never have to ask them to—whether they are going to support anything related to the Director’s 50. That comradery that’s there, they won’t let their own kind of—go into the bowels of despair like that, alone.”

Integrating into community response in Las Vegas, Nevada after the route 91 harvest festival shooting

As a large city with many national and international visitors, respondents described Las Vegas as having a very centralized emergency response structure. Relationships between VA Southern Nevada HCS (VASNHCS) and local response agencies and area hospitals were described as “tightknit” with great working relationships where organizations plan and prepare for disasters together. As one respondent put it,

“what I do know is my community. I know my community partners. I know what they have, what they don’t have, they know what I have, what I don’t have. And that’s what makes us so resilient. That’s community.”

Although located too far away from the Las Vegas Strip to actively receive injured victims when the shooting occurred at the Route 91 Harvest Music Festival, VASNHCS activated its Hospital Incident Command System so it could actively participate in the community’s response and organize efforts. A Multi-Agency Coordination Center (MACC) organized the response activities, and respondents underscored the value of both pre-existing relationships and an understanding of the county’s emergency response structure. As explained by a respondent,

“You can’t wait for your community to ask you. You have to be on the forefront and know what they need. And you only do that by knowing your community. You know, I spent probably as much time in my community as I do in my medical center. A lot of the time, it’s my own time, but again, it builds that relationship that when they’re updating their mass casualty plan, one of the people they’re calling is [me].”

This previous collaboration, as well as being present at the MACC, allowed VASNHCS to identify community needs that it could address.

As news of the shooting spread, VA leadership tasked VASNHCS with deploying staff into the community. However, it was challenging to balance the push from VA to deploy with continuing to respect established local coordination structures. VASNHCS maintained a presence within the Medical Area Surge Command of the MACC to offer resources and expertise, waiting for requests, instead of directly deploying assets outside of the established system.

In the immediate response, VASNHCS assisted with managing fatalities. It offered morgue space to the county and initiated the mass fatality plan to increase morgue capacity. This provided the county and partner hospitals space for victims until they could be processed, and families could claim them. Additionally, VASNHC offered a Psychological First Aid (PFA) team.

Initially, VASNHCS deployed their PFA team to the community’s family reunification center. The team was composed of social workers, psychologists, psychiatrists, administrators (as support staff), canteen services (for water and snacks to sustain clients and staff), and the medical center’s Chief of Staff. As the situation evolved, the MACC received requests from local agencies for psychological assistance and VASNHCS transitioned to directly integrating into area hospitals.

Three Las Vegas hospitals received the bulk of the injured or dead and recognized the need for psychological interventions with their staff. Due to their close relationships with other hospitals, one respondent explained that they were familiar with the Employee Assistance Program (EAP) at these hospitals. The respondent knew it would take time for the EAP to arrive onsite and they would most likely focus on clinical staff involved in directly treating the injured. Therefore, VASNHCS developed a three-pronged approach to complement EAP services at the receiving hospitals. Firstly, the PFA team provided what one respondent called “ trauma therapy ” to hospital staff, regardless whether they worked the night of the shooting. The assistance extended beyond clinical staff to non-clinical departments, such as environmental services/housekeeping, whose staff were also impacted through their response roles.

Respondents reported one of the reasons their response in the hospitals was so successful was that the team was multidisciplinary, allowing staff from different departments to talk to people in similar positions, which was valued by the recipients.

“So for example, we have a nurse that’s trained in trauma, psychological first aid. So they want the nurses at [the hospital with a patient surge], they want to talk to our team. They were still processing. But when we brought our nurse into the ward, they were more than willing to open up to her, because she was one of them. She was part of their tribe. So we try to match our tribe to their tribe, and that’s why we were successful.”

Secondly, the VASNHCS team worked with victims of the shooting, providing PFA and social work services. Thirdly, they integrated with family members of patients at the hospitals and provided them items that they did not otherwise have because they were visitors to Las Vegas. Examples included coordinating free transportation to and from hospitals and hotels, connecting them to local mortuary services, and providing information about how to access services when they returned home.

The PFA team ran for 24 h a day, for 7 days in those three impacted hospitals. To balance VA patient care with the community response mission, VASNHCS staff volunteered shifts outside of their normal work hours. One respondent described the overwhelming desire of VA staff to help their community.

“And while it didn’t impact our staff or our clinics, or our patients, it impacted our community. I think another thing that still amazes me to this day, was the outpour of our staff and what I mean by that is they were coming out of the woodwork to support. We had more volunteers working an eight-hour shift and then coming in [to volunteer] at five o’clock or four o’clock and working to midnight to two in the morning and not go home until four or five in the morning, and then go to work the next day, because we didn’t want to impact our patient care. And they were doing this out of their—you know, because they care. They care about the community, they care about the event, they care about the people. And then at the end of the day, you know, we had more volunteers than we had placements, because we did not want to overwhelm the health systems with all of these VA personnel.”

However, with new volunteers each shift, a key lesson learned was to have a daily team debrief. As people changed daily, a debrief provided key information and a running tally of support being provided to save time and avoid reinventing the wheel identifying contacts or systems already developed.

Another lesson was that preparedness requires ongoing maintenance. The importance of ongoing preparedness was underscored when VASNHCS realized that leading up to the shooting, they had reduced their focus on PFA training. As described by one respondent, “ We noticed that we need that continuous [psychological first aid] training, that we need continuous exercising, and it’s not an easy fit, to send a bunch of people to someone else’s hospital or an area to do that kind of service .” They also realized the first wave of personnel went into community hospitals without basic supplies they needed to provide services, including basic items such as pens, PFA guides, and informational brochures.

Three months following the shooting, the VASNHCS Emergency Manager, working with the Chief of Social Work hosted a lunch for staff who volunteered to thank them for their involvement. During that event, they realized volunteers were not only impacted by the event itself, but also by their time providing support in the community. They therefore created a forum to again gather staff who had deployed at the 6 month and 9 month marks to eat and talk about the impact of the event on the healthcare system and themselves. On the 1 year anniversary, management had a special event for the volunteers,

“we actually had people from the community that we supported coming in and they broke bread with our team and what they did was, they talked about what the impact of the VA Southern Nevada Healthcare System was going into that event, and how we helped them bridge the gap [of mental health support] that was crucial at that time, and how appreciative they were to our cause and our Clark County Office of Emergency Management gave all our staff that responded T-shirts that said Vegas Strong, because they wanted them to know that we—they appreciated the work that we did for them to support our community.”

The need for attention to the psychological well-being of individuals during and after a disaster has been well proven as disasters have been found to be associated with both short and long-term symptoms and disorders [ 6 , 7 , 8 , 9 , 10 , 38 ]. Although in some parts of the world there are federally structured plans to implement disaster behavioral health interventions, in the United States there is a patchwork system that often relies on support and resource allocation from a multitude of agencies [ 8 , 13 , 14 , 18 , 19 , 20 ]. In this study we examined the role the VA can play in a community’s disaster relief effort and highlighted the opportunity for VA to support behavioral health response focusing specifically on case studies from three disasters.

Essential to effective emergency management is an understanding of, and engagement with, available resources in a local community. This is of particular importance when considering complex individual and group needs such as behavioral health support. VA Medical Centers can be seen as challenging partners to work with because they are both a federal entity and a local healthcare facility [ 26 ]. However, in the case of Super Typhoon Yutu, the federal positioning of the VA and its connection with HHS and FEMA facilitated the deployment of VAPIHC virtual resources. The regional respondents who supported the VA disaster mission in Tinian described how preexisting relationships with federal partners facilitated authorization and funding.

Another potential challenge to incorporating the VA into response efforts is that prior to offering services, VA leadership must balance the mission of the agency with community needs, without contradicting the restrictions of the Stafford Act. In all three presented cases, VA’s behavioral health support was not formally included in a city or county response plan, and yet pre-existing relationships between key stakeholders facilitated the provision of VA behavioral health services to support identified community needs. Respondents also described participating in interagency coordinating groups, response trainings, and exercises before the disaster. These activities aided in a deeper understanding of the response structures each partner operated under and encouraged strong rapport between agencies.

Relationships between VA emergency management and local emergency management proved invaluable as VA staff understood that services should not be provided without first engaging local response coordinators. All VA facility leadership and emergency managers are required to be trained in the Incident Command System (ICS) and National Incident Management System (NIMS), which are the coordinating structures all U.S. response agencies work within [ 39 ]. As a health care provider at a national level, VHA falls within the operations section Essential Support Function (ESF) 8: Public Health and Medical Services to support the Department of Health and Human Services [ 40 ]. Local jurisdictions may also connect with VAMCs through ESF 8 representation. For example, the VA has provided significant support to communities impacted by COVID-19. As of July 8, 2020, VA provided more than 330,000 pieces of Personal Protective Equipment (PPE) in support of the Fourth Mission, as well as hand sanitizer, laundry support, test kits and testing support, and webcams for use with existing equipment to state and local facilities. In addition, VA has admitted 279 non-Veterans to VA Medical Centers because of the pandemic [ 27 ]. Much of this coordination was done through ESF 8 coordination at a local or national level.

While respondents did not go into detail about their participation in the emergency management structure, some participants described their VA’s roles within emergency operations as liaisons. Groups such as this could report to either the planning, operations, or command sections within the ICS. Group supervisors would most commonly report to the operations section chief, likely through branch directors, given that the focus of the work would be more on specialized functions as needed for tactical operations. Regardless of where they fit, their presence at emergency operations centers and command posts facilitated communication to allow for VA’s integration into incident action plans. Particularly during the response to mass casualty events in Orlando and Las Vegas, understanding the local response network and then proffering available services was essential to avoid confusion or duplication of activities. By working within the established coordination centers, VA’s efforts were effectively integrated into the greater community behavioral health response and were deployed to points of greatest need. Although a detailed understanding of the integration of VA activities into ICS structures fell outside of the scope of this work, future assessment of the integration of VA representatives into local, state, and/or regional ICS structures could help clarify roles and identify which section liaisons best support (e.g., operations, planning, logistics) [ 40 ].

VA is increasingly strengthening partnerships with agencies that provide behavioral health services to Veterans and their families who use non-VA community-based care [ 41 ]. In each case example, the primary support provided by VA to the community was the provision of behavioral health services in response to an identified need. Respondents described this as being due, in large part, to the recognition of VA’s expertise in trauma and post-trauma treatment, thereby allowing these resources to come to the forefront. While not mentioned by the respondents, an additional value that VA providers add to disaster behavioral health responses is their exposure to and understanding of the unique needs of various populations throughout their communities. In addition to ensuring care is culturally competent to the unique identity of being a Veteran, VA staff must respect the diversity of Veterans themselves. Just like the U.S. population at large, Veterans represent a range of ages, races, genders, sexual orientations, socioeconomic statuses, etc. and mental health services must be considerate of this diversity. The VA recognizes this and offers training to providers to understand and respect their patients’ unique needs [ 42 ]. Working with a variety of populations preposition VA staff to have a deeper understanding of the post-disaster needs of the wider community.

Two of the case examples described in this study especially bring to the forefront the importance of disaster behavioral health response planning and implementation teams understanding unique experiences of community members. Super Typhoon Yutu directly impacted an archipelago housing a majority Asian and/or Pacific Island population. The Pulse Nightclub shooting, while a terrorist event, was a targeted hate crime intended to inflict violence on the LGBTQ community. Disaster behavioral health interventions for these affected groups not only need to take into consideration the importance of cultural competency but also the potential of re-traumatization and distinct population mental health needs.

In the Northern Mariana Islands, while there is a mix of ethnic groups (Filipino, Chamorro, Chinese, Carolinian, Korean, Palauan, etc.), many either identify as or are categorized more broadly as Asian and/or Pacific Islanders. Although there are more than 1.4 million people who are considered Pacific Islanders living the in the U.S., there is a dearth of information on the mental health of this population [ 43 ]. Similarly, the prevalence and incidence rates of mental illness in the Mariana Islands is not well studied [ 44 ]. Some sources attribute this lack of understanding to a disproportionate underuse of mental health services [ 43 ]. However, Asian and Pacific Islanders within the U.S. and those territories affiliated with it often experience transgenerational trauma, discrimination, continued loss from colonization, historical trauma, and mental health stigma which can impact psychological wellbeing and help seeking behavior. Additionally, cultural elements (collectivism, reverence for the past, hierarchical social order, etc.) of this population are important to understand when providing behavioral health services [ 43 , 45 ]. One of the reasons respondents indicated that the VA was asked to provide assistance following Typhoon Yutu was the lack of availability of mental health services in Tinian. The established VA telehealth technology increased accessibility to behavioral practitioners from VAPIHC who most likely were experienced working with Asian and Pacific Island populations since more than 55,000 Veterans who identify as this ethnicity live in Island Areas or Hawaii [ 46 , 47 ].

The Pulse Nightclub Shooting was a terrorist driven hate crime targeting individuals who identified as LGBTQ. Members of this group often experience discrimination, stigma, and trauma throughout their lives. Discrimination and heterocentric health and mental health practices can marginalize this population and impact help seeking behavior [ 48 , 49 ]. This is of particular concern as individuals who are LGBTQ face numerous mental health disparities with a higher likelihood of experiencing depression, anxiety, substance misuse, and suicide attempts. The shooting not only targeted LGBTQ people but it also took place during Latin Pride Night meaning many of the victims and casualties were LGBTQ Latinx. The resulting psychological impacts of the Pulse Nightclub shooting on those directly impacted, people who are LGBTQ Latinx, and individuals in the wider LGBTQ community have been investigated and show experiences of trauma and impacts on perceived safety [ 50 ]. At the time of the shooting, the Orlando VAMC had established relationships with LGBTQ local mental health services and had staff knowledgeable in the needs of this community [ 51 ]. In fact, in the recent past, the VA has increased its efforts to ensure Veterans who are LGBTQ receive the highest quality patient-centered care possible [ 52 ]. Mental health services in particular have bolstered recognition of the complex needs of these Veterans [ 52 ].

All three cases demonstrate innovative ways VA can provide behavioral health support outside of their facilities, i.e., via telehealth capabilities across an ocean and into a healthcare clinic, teams of mobile units reaching directly into the community to support victims, victims’ families, and the community at large, and finally by incorporating PFA teams directly into hospitals to support staff, patients, and patients’ families. This flexibility across sites to address different needs and populations while using varying available infrastructure support, is paramount to any local jurisdiction’s ability to meet on the ground needs following a disaster. It demonstrates the variability between VAMCs and the importance of local disaster behavioral health planning teams to pre-identify resources to assess local capacity. Plans can then be developed that access and deploy the tools/skills of interdisciplinary and interagency teams. Building processes to deploy local health and mental health practitioners can lead to more rapid implementation of interventions and help ensure the diversity of the impacted community is recognized and respected. Additional studies focused on how communities develop disaster behavioral health plans could provide insight into which agencies are involved and how they collaborate. It may also be useful to assess whether and how these plans are implemented to identify best practices.

In addition to the people directly impacted by disasters, respondents underscored the importance of offering support to responders as well. There is growing recognition that health care workers are themselves front-line response workers who may be psychologically impacted when caring for others, leading to a growing emphasis on the importance of selfcare and employee wellbeing [ 39 , 40 , 41 , 42 ]. In all three case studies, behavioral health support was, at least in part, directed toward healthcare workers. In the case of Las Vegas, a respondent highlighted the advantage of having behavioral health support come from individuals who understood the culture of the population they were helping, e.g., nurses supporting nurses. Further, respondents in Las Vegas and Orlando highlighted the importance of supporting deployed behavioral health team members. They detailed actions to maintain staff well-being by having rotating shifts, encouraging peer support, and facilitating gatherings for staff to publicly thank them for their efforts and allow them to address their experiences together as a group. Understanding the needs of healthcare and behavioral health personnel and building support networks into response frameworks can help better sustain and strengthen the overall response process.

A primary limitation of this study is that interviews were conducted up to one and a half years after the disasters described, potentially impacting recall. However, multiple interviewees corroborated the information presented for each of the case studies. Another limitation is that this study focused exclusively on the experiences of VA employees fulfilling mission requirements and their description of instances where VA acted in support of the Fourth Mission. Very few of the respondents directly provided the behavioral health interventions. These perspectives could provide deeper understanding of the interventions themselves as well as the impacts they may have on practitioners. Neither community members nor coalition partners were interviewed in this study. Future research would benefit from both interviewing non-VA participants to explore additional perspectives and gain greater insight on how local jurisdictions experienced collaborating with VA representatives and exploring alternative approaches to mental health units within and outside VA to examine whether and when different approaches may be preferable.

As the largest integrated healthcare system in the United States, VA can play an important role in disaster response across the country. As recognition of VA’s expertise in behavioral health grows, particularly around trauma and post-trauma treatment, VA should be considered a strong potential partner in behavioral health responses. Local VAMC staff are part of the community in which they live and the Veterans they serve are a microcosm of the larger population of the U.S. As the respondents in this study showed, there is a deep desire by VA staff to provide support following a disaster if they are able. Anticipating potential behavioral health concerns, and having a plan to address them, can foster community disaster resilience. While these plans may be different for each jurisdiction, they can be strengthened by identifying and incorporating a range of partners. Having preexisting relationships where VA’s capabilities are known before a disaster occurs can facilitate the rapid deployment of VA resources into identified areas of community need. The case studies presented demonstrate the flexible nature of these resources. By extending knowledge about innovative ways to share behavioral health and other resources in a disaster response, communities and healthcare coalitions can be better prepared to engage collectively and rapidly mobilize essential assets to support the wellbeing of those who need it most.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Abbreviations

Crisis Counseling Assistance and Training Program

U.S. Department of Veterans Affairs

Veterans Health Administration

VA Medical Center

VA Pacific Island Healthcare System

VA Southern Nevada HCS

Veterans Health Administration Health Care System

Veterans Integrated Service Network

Office of Emergency Management

US Department of Health and Human Services

Federal Emergency Management Agency

Lesbian Gay Bisexual Transgender Queer

Multi-Agency Coordination Center

Psychological First Aid

Employee Assistance Program

Personal Protective Equipment

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Acknowledgements

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This work was supported by the US Department of Veterans Affairs, Veterans Health Administration, Office of Emergency Management and the Office of Population Health. The views expressed in this presentation are those of the author and do not necessarily reflect the position or policy of the VA or the US government.

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TWL and SS planned the study, including instrumentation, conducted the data analysis, and wrote the paper. RJK and FA supported the qualitative analysis and contributed to revising the paper. AD helped to plan the study and contributed to revising the manuscript. All authors have read and approved the manuscript.

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2017 Disaster Qualitative Study: Collaboration Project Interview Guide. Interview guide utilized during project’s semi-structured interviews.

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Wyte-Lake, T., Schmitz, S., Kornegay, R.J. et al. Three case studies of community behavioral health support from the US Department of Veterans Affairs after disasters. BMC Public Health 21 , 639 (2021). https://doi.org/10.1186/s12889-021-10650-x

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How to Write a Case Conceptualization: 10 Examples (+ PDF)

Such understanding can be developed by reading relevant records, meeting with clients face to face, and using assessments such as a mental status examination.

As you proceed, you are forming a guiding concept of who this client is, how they became who they are, and where their personal journey might be heading.

Such a guiding concept, which will shape any needed interventions, is called a case conceptualization, and we will examine various examples in this article.

Before you continue, we thought you might like to download our three Positive CBT Exercises for free . These science-based exercises will provide you with detailed insight into positive Cognitive-Behavioral Therapy (CBT) and give you the tools to apply it in your therapy or coaching.

This Article Contains:

What is a case conceptualization or formulation, 4 things to include in your case formulation, a helpful example & model, 3 samples of case formulations, 6 templates and worksheets for counselors, relevant resources from positivepsychology.com, a take-home message.

In psychology and related fields, a case conceptualization summarizes the key facts and findings from an evaluation to provide guidance for recommendations.

This is typically the evaluation of an individual, although you can extend the concept of case conceptualization to summarizing findings about a group or organization.

Based on the case conceptualization, recommendations can be made to improve a client’s self-care , mental status, job performance, etc (Sperry & Sperry, 2020).

• Summary of the client’s identifying information, referral questions, and timeline of important events or factors in their life . A timeline can be especially helpful in understanding how the client’s strengths and limitations have evolved.
• Statement of the client’s core strengths . Identifying core strengths in the client’s life should help guide any recommendations, including how strengths might be used to offset limitations.
• Statement concerning a client’s limitations or weaknesses . This will also help guide any recommendations. If a weakness is worth mentioning in a case conceptualization, it is worth writing a recommendation about it.

Note: As with mental status examinations , observations in this context concerning weaknesses are not value judgments, about whether the client is a good person, etc. The observations are clinical judgments meant to guide recommendations.

• A summary of how the strengths, limitations, and other key information about a client inform diagnosis and prognosis .

You should briefly clarify how you arrived at a given diagnosis. For example, why do you believe a personality disorder is primary, rather than a major depressive disorder?

Many clinicians provide diagnoses in formal psychiatric terms, per the International Classification of Diseases (ICD-10) or Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Some clinicians will state a diagnosis in less formal terms that do not coincide exactly with ICD-10 or DSM-5 codes. What is arguably more important is that a diagnostic impression, formal or not, gives a clear sense of who the person is and the support they need to reach their goals.

Prognosis is a forecast about whether the client’s condition can be expected to improve, worsen, or remain stable. Prognosis can be difficult, as it often depends on unforeseeable factors. However, this should not keep you from offering a conservative opinion on a client’s expected course, provided treatment recommendations are followed.

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Based on the pointers for writing a case conceptualization above, an example for summarizing an adolescent case (in this instance, a counseling case for relieving depression and improving social skills) might read as follows.

Background and referral information

This is a 15-year-old Haitian–American youth, referred by his mother for concerns about self-isolation, depression, and poor social skills. He reportedly moved with his mother to the United States three years ago.

He reportedly misses his life and friends in Haiti. The mother states he has had difficulty adjusting socially in the United States, especially with peers. He has become increasingly self-isolating, appears sad and irritable, and has started to refuse to go to school.

His mother is very supportive and aware of his emotional–behavioral needs. The youth has been enrolled in a social skills group at school and has attended three sessions, with some reported benefit. He is agreeable to start individual counseling. He reportedly does well in school academically when he applies himself.

Limitations

Behavioral form completed by his mother shows elevated depression scale (T score = 80). There is a milder elevation on the inattention scale (T score = 60), which suggests depression is more acute than inattention and might drive it.

He is also elevated on a scale measuring social skills and involvement (T score = 65). Here too, it is reasonable to assume that depression is driving social isolation and difficulty relating to peers, especially since while living in Haiti, he was reportedly quite social with peers.

Diagnostic impressions, treatment guidance, prognosis

This youth’s history, presentation on interview, and results of emotional–behavioral forms suggest some difficulty with depression, likely contributing to social isolation. As he has no prior reported history of depression, this is most likely a reaction to missing his former home and difficulty adjusting to his new school and peers.

Treatments should include individual counseling with an evidence-based approach such as Cognitive-Behavioral Therapy (CBT). His counselor should consider emotional processing and social skills building as well.

Prognosis is favorable, with anticipated benefit apparent within 12 sessions of CBT.

How to write a case conceptualization: An outline

The following outline is necessarily general. It can be modified as needed, with points excluded or added, depending on the case.

• Client’s gender, age, level of education, vocational status, marital status
• Referred by whom, why, and for what type of service (e.g., testing, counseling, coaching)
• In the spirit of strengths-based assessment, consider listing the client’s strengths first, before any limitations.
• Consider the full range of positive factors supporting the client.
• Physical health
• Family support
• Financial resources
• Capacity to work
• Resilience or other positive personality traits
• Emotional stability
• Cognitive strengths, per history and testing
• The client’s limitations or relative weaknesses should be described in a way that highlights those most needing attention or treatment.
• Medical conditions affecting daily functioning
• Lack of family or other social support
• Limited financial resources
• Inability to find or hold suitable employment
• Substance abuse or dependence
• Proneness to interpersonal conflict
• Emotional–behavioral problems, including anxious or depressive symptoms
• Cognitive deficits, per history and testing
• Diagnoses that are warranted can be given in either DSM-5 or ICD-10 terms.
• There can be more than one diagnosis given. If that’s the case, consider describing these in terms of primary diagnosis, secondary diagnosis, etc.
• The primary diagnosis should best encompass the client’s key symptoms or traits, best explain their behavior, or most need treatment.
• Take care to avoid over-assigning multiple and potentially overlapping diagnoses.

When writing a case conceptualization, always keep in mind the timeline of significant events or factors in the examinee’s life.

• Decide which events or factors are significant enough to include in a case conceptualization.
• When these points are placed in a timeline, they help you understand how the person has evolved to become who they are now.
• A good timeline can also help you understand which factors in a person’s life might be causative for others. For example, if a person has suffered a frontal head injury in the past year, this might help explain their changeable moods, presence of depressive disorder, etc.

Sample #1: Conceptualization for CBT case

This is a 35-year-old Caucasian man referred by his physician for treatment of generalized anxiety.

Strengths/supports in his case include willingness to engage in treatment, high average intelligence per recent cognitive testing, supportive family, and regular physical exercise (running).

Limiting factors include relatively low stress coping skills, frequent migraines (likely stress related), and relative social isolation (partly due to some anxiety about social skills).

The client’s presentation on interview and review of medical/psychiatric records show a history of chronic worry, including frequent worries about his wife’s health and his finances. He meets criteria for DSM-5 generalized anxiety disorder. He has also described occasional panic-type episodes, which do not currently meet full criteria for panic disorder but could develop into such without preventive therapy.

Treatments should include CBT for generalized anxiety, including keeping a worry journal; regular assessment of anxiety levels with Penn State Worry Questionnaire and/or Beck Anxiety Inventory; cognitive restructuring around negative beliefs that reinforce anxiety; and practice of relaxation techniques, such as progressive muscle relaxation and diaphragmatic breathing .

Prognosis is good, given the evidence for efficacy of CBT for anxiety disorders generally (Hofmann, Asnaani, Vonk, Sawyer, & Fang, 2012).

Sample #2: Conceptualization for DBT case

This 51-year-old Haitian–American woman is self-referred for depressive symptoms, including reported moods of “rage,” “sadness,” and “emptiness.” She says that many of her difficulties involve family, friends, and coworkers who regularly “disrespect” her and “plot against her behind her back.”

Her current psychiatrist has diagnosed her with personality disorder with borderline features, but she doubts the accuracy of this diagnosis.

Strengths/supports include a willingness to engage in treatment, highly developed and marketable computer programming skills, and engagement in leisure activities such as playing backgammon with friends.

Limiting factors include low stress coping skills, mild difficulties with attention and recent memory (likely due in part to depressive affect), and a tendency to self-medicate with alcohol when feeling depressed.

The client’s presentation on interview, review of medical/psychiatric records, and results of MMPI-2 personality inventory corroborate her psychiatrist’s diagnosis of borderline personality disorder.

The diagnosis is supported by a longstanding history of unstable identity, volatile personal relationships with fear of being abandoned, feelings of emptiness, reactive depressive disorder with suicidal gestures, and lack of insight into interpersonal difficulties that have resulted in her often stressed and depressive state.

Treatments should emphasize a DBT group that her psychiatrist has encouraged her to attend but to which she has not yet gone. There should also be regular individual counseling emphasizing DBT skills including mindfulness or present moment focus, building interpersonal skills, emotional regulation, and distress tolerance. There should be a counseling element for limiting alcohol use. Cognitive exercises are also recommended.

Of note, DBT is the only evidence-based treatment for borderline personality disorder (May, Richardi, & Barth, 2016). Prognosis is guardedly optimistic, provided she engages in both group and individual DBT treatments on a weekly basis, and these treatments continue without interruption for at least three months, with refresher sessions as needed.

Sample #3: Conceptualization in a family therapy case

This 45-year-old African-American woman was initially referred for individual therapy for “rapid mood swings” and a tendency to become embroiled in family conflicts. Several sessions of family therapy also appear indicated, and her psychiatrist concurs.

The client’s husband (50 years old) and son (25 years old, living with parents) were interviewed separately and together. When interviewed separately, her husband and son each indicated the client’s alcohol intake was “out of control,” and that she was consuming about six alcoholic beverages throughout the day, sometimes more.

Her husband and son each said the client was often too tired for household duties by the evening and often had rapid shifts in mood from happy to angry to “crying in her room.”

On individual interview, the client stated that her husband and son were each drinking about as much as she, that neither ever offered to help her with household duties, and that her son appeared unable to keep a job, which left him home most of the day, making demands on her for meals, etc.

On interview with the three family members, each acknowledged that the instances above were occurring at home, although father and son tended to blame most of the problems, including son’s difficulty maintaining employment, on the client and her drinking.

Strengths/supports in the family include a willingness of each member to engage in family sessions, awareness of supportive resources such as assistance for son’s job search, and a willingness by all to examine and reduce alcohol use by all family members as needed.

Limiting factors in this case include apparent tendency of all household members to drink to some excess, lack of insight by one or more family members as to how alcohol consumption is contributing to communication and other problems in the household, and a tendency by husband and son to make this client the family scapegoat.

The family dynamic can be conceptualized in this case through a DBT lens.

From this perspective, problems develop within the family when the environment is experienced by one or more members as invalidating and unsupportive. DBT skills with a nonjudgmental focus, active listening to others, reflecting each other’s feelings, and tolerance of distress in the moment should help to develop an environment that supports all family members and facilitates effective communication.

It appears that all family members in this case would benefit from engaging in the above DBT skills, to support and communicate with one another.

Prognosis is guardedly optimistic if family will engage in therapy with DBT elements for at least six sessions (with refresher sessions as needed).

Introduction to case conceptualization – Thomas Field

The following worksheets can be used for case conceptualization and planning.

• Case Conceptualization Worksheet: Individual Counseling helps counselors develop a case conceptualization for individual clients.
• Case Conceptualization Worksheet: Couples Counseling helps counselors develop a case conceptualization for couples.
• Case Conceptualization Worksheet: Family Counseling helps counselors develop a case conceptualization for families.
• Case Conceptualization and Action Plan: Individual Counseling helps clients facilitate conceptualization of their own case, at approximately six weeks into counseling and thereafter at appropriate intervals.
• Case Conceptualization and Action Plan: Couples Counseling helps couples facilitate conceptualization of their own case, at approximately six weeks into counseling and thereafter at appropriate intervals.
• Case Conceptualization and Action Plan: Family Counseling helps families facilitate conceptualization of their own case, at approximately six weeks into counseling and thereafter at appropriate intervals.

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Analyzing Strengths Use in Different Life Domains can help clients understand their notable strengths and which strengths can be used to more advantage in new contexts.

Family Strength Spotting is another relevant resource. Each family member fills out a worksheet detailing notable strengths of other family members. In reviewing all worksheets, each family member can gain a greater appreciation for other members’ strengths, note common or unique strengths, and determine how best to use these combined strengths to achieve family goals.

Four Front Assessment is another resource designed to help counselors conceptualize a case based on a client’s personal and environmental strengths and weaknesses. The idea behind this tool is that environmental factors in the broad sense, such as a supportive/unsupportive family, are too often overlooked in conceptualizing a case.

If you’re looking for more science-based ways to help others through CBT, check out this collection of 17 validated positive CBT tools for practitioners. Use them to help others overcome unhelpful thoughts and feelings and develop more positive behaviors.

In helping professions, success in working with clients depends first and foremost on how well you understand them.

This understanding is crystallized in a case conceptualization.

Case conceptualization helps answer key questions. Who is this client? How did they become who they are? What supports do they need to reach their goals?

The conceptualization itself depends on gathering all pertinent data on a given case, through record review, interview, behavioral observation, questionnaires completed by the client, etc.

Once the data is assembled, the counselor, coach, or other involved professional can focus on enumerating the client’s strengths, weaknesses, and limitations.

It is also often helpful to put the client’s strengths and limitations in a timeline so you can see how they have evolved and which factors might have contributed to the emergence of others.

Based on this in-depth understanding of the client, you can then tailor specific recommendations for enhancing their strengths, overcoming their weaknesses, and reaching their particular goals.

We hope you have enjoyed this discussion of how to conceptualize cases in the helping professions and that you will find some tools for doing so useful.

We hope you enjoyed reading this article. For more information, don’t forget to download our three Positive CBT Exercises for free .

• Hofmann, S. G., Asnaani, A., Vonk, I. J., Sawyer, A. T., & Fang, A. (2012). The efficacy of cognitive behavioral therapy: A review of meta-analyses. Cognitive Therapy and Research , 36 (5), 427–440.
• May, J. M., Richardi, T. M., & Barth, K. S. (2016). Dialectical behavior therapy as treatment for borderline personality disorder. The Mental Health Clinician , 6 (2), 62–67.
• Sperry, L., & Sperry, J. (2020).  Case conceptualization: Mastering this competency with ease and confidence . Routledge.

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Perspectives

A Case Study of the Early Childhood Mental Health Therapeutic Consultation Protocol within a Specialty Multidisciplinary Pediatric Clinic for Adopted and Foster Care Children

Experiences of maltreatment, caregiver transitions, and other forms of chronic stress in early childhood have been related to an increased likelihood of health and mental health disorders. Despite having a number of well-developed and validated therapeutic options for fostered and adopted children, families are often overwhelmed by their child’s multiple health needs and have a difficult time accessing care. This case report describes a 2-year old female child in foster care who took part in a multidisciplinary program for fostered and adopted children ages 0 to 5 years old. This family’s experience highlights that patients can receive streamlined evaluations, short-term therapeutic interventions, and long-term service recommendations by providing families with a single point of contact in an integrated care setting. This approach decreases the time burden placed on parents, increases the effectiveness in understanding and addressing a child’s needs, and improves family and provider collaboration. Further, models of integrated care reduce the likelihood of misdiagnosis. Many symptoms of early childhood adversity and attachment disorders can present like other common mental (i.e., Autism Spectrum Disorder) and physical disorders (i.e., motor delays). Misdiagnosis can lead to recommendations that are ineffective or ultimately harmful to children with experiences of trauma. Given the range of general and mental health effects of multiple housing transitions, maltreatment, and/or neglect, this case underscores how a team approach is invaluable for promoting at-risk young children’s wellbeing and development.

Keywords: Foster Care; Adoption; Mental Health; Early Childhood; Integrated Care

Introduction

Over 443,000 children were involved in the foster care system in the United States during 2017 (Child Trends Databank, 2019). Children under the age of five are the largest group within foster care (~41%, N = 183,959; Child Trends Databank, 2019). Almost all children involved in these systems have experienced multiple transitions, maltreatment, and/or neglect. Many have also experienced malnourishment, pre-and post-natal substance exposure, premature birth, and exposure to infectious diseases. Environmental stress, bodily harm, and illness in early childhood can carry consequences for physical and mental health functioning across the lifespan (Cicchetti & Handley, 2019; Malionsky-Rummel & Hansen, 1993; Smith & Thornberry, 1995; Vachon, Krueger, Rogosch, & Cicchetti, 2015; Anda et al., 2006). Given the medical complexity of foster children, multi-disciplinary care models, including medical providers, mental health specialists, public health nurses, social workers, and occupational therapists (OT), are essential.

The purpose of this paper is to highlight the experience of a 2-year old female in foster care with a program that integrates early childhood mental health therapeutic consultation with a unique multidisciplinary medicine program for fostered and adopted children. We will, 1) illuminate the need for new ways for fostered and adoptive children under five to engage with health, mental health and other services, and 2) highlight an early mental health therapeutic consultation protocol within a pediatric setting. Ultimately we aim to motivate the development of this and similar programs across the United States to better serve young children facing threats to their life long trajectories of mental and physical illness due to early experiences of adversity.

Early Childhood Mental Health Evaluation in an Interdisciplinary Pediatric Team

Multiple housing transitions, maltreatment and/or neglect can be related to a range of medical, developmental, and emotional symptoms, with treatments located outside of the sphere of early childhood psychological intervention. Early childhood experiences of abuse and neglect have been linked to cardiovascular concerns, sensory processing disorders, failure to thrive, and chronic infections associate with immune system dysfunction (Anda et al., 2006; Felitti et al., 1998). Malnutrition, often associated with experiences of neglect, can have a detrimental impact on a child’s development trajectory if left unaddressed – including an increased risk for cardiovascular and metabolic disease in adulthood (Campbell et al., 2014), lower IQ scores in early adolescents (Liu et al., 2003), and micronutrient deficiencies that cause irreversible alterations to brain development (Monk et al., 2013).

While physicians in the United States are typically underprepared to address mental health ramifications of early childhood trauma, mental health providers similarly lack the training to fully conceptualize a child’s necessary medical interventions for their physical health needs. Due to this increased medical complexity for children who have faced early adverse experiences, it is invaluable to have a team approach that addresses concerns and efficiently rules out multiple etiologies for symptoms.

Further, many mental health symptoms related to trauma or attachment disorders can present like other common early childhood disorders. This may be difficult for providers without specialized training in early childhood trauma and attachment disorders to accurately determine the appropriate diagnosis. Misdiagnosis can lead to recommendations that are ineffective or ultimately harmful to children with experiences of trauma. For example, Autism Spectrum Disorder (ASD), trauma-related disorders, and attachment disorders have a similar profile of symptoms in early childhood. This includes delayed speech, delayed social cueing, difficulties with attention, and self-harm behaviors. However, for children with experiences of neglect, clinicians would recommend trauma-informed treatments focused on building attachment relationships and stability. For children with ASD, more behavioral oriented approaches would be recommended to target the growth of specific social skills. An ASD diagnosis for children with a trauma-related or attachment disorder could further disturb the child’s developmental trajectory by delaying appropriate services that focus on bolstering the child’s relational needs.

Access to Care and Therapeutic Consultation

Early childhood interventions that address parent-child attachment for children who have experienced early trauma have shown efficacy in reducing children’s negative behavioral and emotional outcomes (Reyes et al., 2017; Dozier et al., 2017; Cohen et al., 2000). However, a large number of children facing adversity do not ever receive the benefits of early interventions (Hartinger-Saunders et al., 2019). Specialty pediatric care settings that work with early mental health providers and their state’s department of human services have the unique opportunity to dramatically increase the likelihood that children who are at risk are identified and receive evidence-based interventions. However, to our knowledge, there are no standardized protocols, on how to incorporate early mental health and relationship-based evaluations into pediatric specialty care. This paper aims to highlight the benefits of a cross-systems integrated care model for addressing mental health concerns among young children in foster and adoptive care.

In the United States, foster care and adoption legislation is determined by the State. In Minnesota, children in foster care have a case review hearing 90 days after a child’s removal from parental care. After the court reviews the parent’s progress on their case plan, there may be a 6-month extension on the child’s foster care placement. Once a child has been in foster care for 12 months, the court will file a petition to decide on a permanency plan. Children in foster care can be adopted when their birth parents sign a voluntary consent, after which they have a ten-day period to change their mind. Children may also be made available for adoption through a court procedure to end parent rights. Birth parents have 20 days to appeal the court’s order.

The Adoption Medicine Clinic (AMC) at the University of Minnesota has been evaluating internationally adopted children since 1986 and in the past decade has focused on providing more services for children who have been domestically adopted or are in foster care. Funded by a grant from the Minnesota Department of Human Services the clinic has incorporated specialists into pediatrician visits, including psychology, OT, pediatric/public health nurses, and genetic counseling to address the far-reaching effects of early childhood adversity on physical and psychological functioning.

In 2019, approximately 48% (N = 188) of the population seen by AMC were children 5 years old or younger and were noted to have high rates of behavioral and emotional difficulties. Throughout 2019 and the beginning of 2020, the program spent large amounts of time doing community outreach to create partnerships and referral pathways. The program encouraged social workers across the state to refer young children and their foster families to the AMC for integrated care. All data and the case review were collected via chart review and approved by the University of Minnesota Institutional Review Board. At the onset of visits to the AMC, foster parents were provided with consents by check-in staff to choose to include their clinical information in research.

Early Childhood Mental Health Therapeutic Consultation Program Description

The over-arching goal of integrating the Early Childhood Mental Health Evaluation Protocol into AMC was to identify young children who are at high risk for long term mental health difficulties and displacement from their current foster or adoptive home. The mental health portion of the evaluation protocol consists of three components by which children are screened for (1) prenatal and postnatal experiences of trauma, (2) current behavioral, social, cognitive, and emotional concerns, as well as (3) current service access. In addition to the evaluation, the service includes referrals and a tailored psychoeducational intervention.

The first component of the evaluation consists of collecting information on pre and post-natal experiences of adversity. Prenatal risk factors can include the biological parent’s level of stress, access to prenatal care, prenatal substance use, and genetic liability for psychopathology. Postnatal risk factors for this population often include neglect, abuse, chronic mobility, food insecurity, and multiple separations or transitions from primary caregivers. We identify the duration and age of these experiences in order to integrate a developmental framework that considers how the developmental timing and duration of these experiences could affect functioning. The clinician utilizes a standardized traumatic event screening form to identify risk for post-traumatic stress disorder as well as the Disturbances of Attachment Interview (Smyke & Zeenah, 1999) which inquiries about symptoms of Reactive Attachment Disorder and Disinhibited Social Approach Disorder (DC:0-5; Klaehn, 2018).

The second component of the evaluation is collecting information on the child’s mental and behavioral health difficulties. Information is gathered via medical chart review, foster parent interview, and behavioral observations in the clinical setting. Providers review the child’s previous psychological evaluations and diagnoses. Clinicians complete a foster parent interview assessing the child’s developmental trajectory and the formation of their current attachment relationship using the Disturbances of Attachment Interview (Smyke & Zeanahm, 1999).

Mental health providers then observe child behavior in the context of a medical and occupational therapy exam. The observation protocol is designed to help mental health providers identify children’s difficulties in cueing distress elicited by the exam, using foster or adoptive parents for emotion regulation and support, as well as indiscriminate friendliness with unfamiliar medical staff. Mental health providers observe the parent-child relationship (Crowell, 2003; Cooper, Hoffman, Powell, & Marvin, 2011). The observation protocol captures a snapshot of how foster and/or adoptive parents attend to children’s distress and how, they provide structure, guidance and direction to their children. Children lacking a caregiver with these skills are the most likely to experience high levels of maladjustment related to early experiences of risk. Consistent and responsive caregiving has been shown to act as a buffer between young children and their environment, preventing the negative consequences of stress on mental and physical health (Johnson et al., 2018; Measelle & Albow, 2018; Liberman et al., 2004).

At the end of the exam, mental health providers review the foster parent and/or adoptive parents’ concerns and goals for the child’s mental health, and evaluate if there are any risks for these foster/adoptive parents requesting the child be removed from their current placements. Child placement instability has been related to a host of emotional, behavioral and developmental difficulties in children (Fisher et al., 2016). Unfortunately, many states have a high rate of foster care placement instability (U.S. Department of Health and Human Services, 2014). Foster parents who are at risk for requesting that children be moved to a different placement often have young children with high medical, behavioral, and emotional needs. Research suggests that children with more trauma symptoms are at an increased risk for foster care displacement (Clark et al., 2020). During the interview, foster/adoptive parents at risk often highlighted feeling exhausted by the child’s needs, feeling as if they do not have the skill set to help the child, and feeling like they don’t have the resources to identify those skills. Through our work, we have found it to be really important and impactful to have a candid discussion with foster parents about any of these concerns. Many foster parents were very grateful to have a space to talk through these concerns without judgement.

The third component of the evaluation consists of reviewing the child and their foster/adoptive family’s current service utilization and needs. This involves reviewing if full developmental assessments using the DC:0–5™ Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood have been completed as well as what mental health services the families may be using. In evaluating current mental health services, we review families’ satisfaction with those services as well as provide recommendations for evidence-based interventions and providers with whom those interventions can be accessed. Families then receive a brief educational therapeutic consultation, based on our conceptualization of the child’s current functioning and history. Foster/adoptive parents are provided with information on how to best emotionally and behaviorally support children’s development in the context of their early adverse experiences. Most foster/adoptive parents receive educational information based on the Circle of Security (Zanetti et al., 2011) as well as in the moment feedback during the end of the session based on the Attachment Biobehavioral Catch-Up protocol (Dozier et al., 2017). We also discuss ways young children signal distress and ways foster/adoptive can help buffer those responses.

Young children who are identified as high-risk for placement disruption or long-term mental health difficulties are referred for a full mental health evaluation (using the DC:0–5™) and trauma-informed as well as relationship-centered evidence-based treatment. Children that need immediate intervention and care because their current level of dysfunction is a risk for their wellbeing receive rapid access to a one to three session brief intervention while they wait for longer-term therapeutic options to become available.

Rationale for a Case Study

We chose to highlight Anna’s* participation in our program as a case study for multiple reasons. First, there is limited knowledge on the feasibility of integrated care consultation models for young children in foster care. We will highlight how a common point of contact can increase high-risk children’s access to appropriate and timely early intervention services. Relatedly, we hope to use this case to highlight the medical complexity of these young foster care children and hope to support program and policy development. Third, many of these children are at risk for experiencing multiple foster-care placements. Multiple placements have been related to increased maladaptive functioning (Lloyd & Barth, 2011). We hope to use this case to highlight how providing consultations services, short term emergency care, and facilitating the prioritization and referrals to community services, integrated care settings like these may decrease the likelihood of multiple placements.

Case Background

Anna is a 2-year 8-month-old Black female who presented to the AMC. Anna was accompanied by her foster mother Rachel*, who was interested in gaining a better understanding of Anna’s behaviors and wanted to learn additional techniques to help support her development. Rachel described Anna as bold, talkative, active, and loving. Rachel had an initial interest in adopting Anna, but had concerns about her ability to provide long term care due to Anna’s many medical and emotional needs.

Based on a medical record review and foster/adoptive parent interview, Anna was prenatally exposed to marijuana, cocaine, and alcohol. Anna’s biological mother experienced homelessness and engaged in sex work while pregnant. Anna’s biological mother has a history of substance use, an anxiety disorder, and depression. Anna was born at 36 weeks gestation via cesarean section due to maternal preeclampsia. At birth Anna weighed 3 lbs. and spent one week in the neo-natal intensive care unit due to her low birth weight. At birth, she had Δ9-tetrahydrocannabinol (THC) in her system and was potentially exposed to a Sexually Transmitted Disease. As a young infant, Anna was reported to have spent time with various caregivers for extended periods of time while under her biological mother’s care and experienced residential mobility. At 10 months, Anna had a documented emergency room visit after reportedly being dropped by her biological mother. At 11 months, she was removed from her biological mother’s care due to concerns for neglect and placed with her current foster family. At placement, Anna was malnourished – weighing only 11 lbs. – and was diagnosed with failure to thrive. Since being placed with her foster parent, Rachel reported multiple ear infections but otherwise noted that Anna had appeared to be medically healthy. At the time of the AMC visit Anna was living with her two foster parents, her biological sister (1-year-old), and three foster siblings (9, 5, and 2 years old). Anna did not have any contact with her biological mother or father since being in foster care.

At the initial foster care placement, Anna displayed flat affect and was socially uninhibited. At the time of evaluation, Anna displayed extreme difficulties with separating from her foster parents, often refused food, and had no independent self-soothing behaviors. Anna and Rachel had previously engaged with play therapy, but Rachel reported that it seemed to make Anna’s symptoms worse. Rachel noted high levels of intense meltdowns after play therapy sessions as well as regression in her toileting abilities. Due to these symptoms, they ceased services. Over the few months leading up to the appointment, Anna displayed high-intensity distress and anger at home and appeared inconsolable. In order to manage Anna’s emotional and behavior needs, Rachel took 6 months off of work and sent Anna’s 1-year old biological sister and foster siblings to daycare. This was a challenging experience financially and emotionally for Rachel and the other children. Additionally, there were concerns with sensory processing, speech development, and muscle reflex issues. Anna covered her ears during loud noises, displayed freezing behaviors in new or unfamiliar situations, and had a hard time with zippers and putting clothes on.

Implementing the Early Childhood Mental Health Therapeutic Consultation Protocol

Anna and her foster mother spent an hour with our multi-disciplinary team of occupational therapist, nurses, medical doctors and psychologists. All team members were present for the duration of the visit. Results of the medical exam noted generalized muscular weakness, vitamin D insufficiency, iron deficiency, and tonsillar hypertrophy. Anna was prescribed a series of vitamin supplements. The experience of traumatic stress and micro-nutritional deficit prenatally and in early childhood may cause an altered vitamin D metabolism in children (Terock et al., 2020). Further, iron deficiency – also related to micro-nutritional deficits – can worsen for children directly in proportion to the amount of rapid post-placement growth (Fugelstad et al., 2008). Both nutritional issues have been related to numerous long-lasting developmental and cognitive deficits (Doom et al. 2014; Terock et al., 2020).

Due to prenatal exposure to substances, the medical team assessed Anna for the facial features of prenatal alcohol exposure. Her facial feature measurements were not consistent with those seen in children with Fetal Alcohol Spectrum Disorder. The occupational therapy team noted a speech delay and slight sensory processing difficulties on their developmental screening. They recommended a full assessment with a speech language therapist.

In Visit Observations

The mental health team observed Anna’s interactions with her primary caregiver, Rachel, and her emotional reactivity/regulation during novel situations. During the visit, Anna started by cuddling into her foster mother and was not interested in exploring the toys in the room. Throughout the hour Anna became increasingly more interested in the toys and displayed more positive emotions. Anna looked to her foster mother for support when she was unsure of toys or new people. Her mother provided comfort as well as acknowledged and validated her emotional expressions (both positive and negative). Anna appeared to experience her foster mother as an emergent secure attachment figure. However, Anna appears to have a difficult time relying on Rachel to provide support when she became distressed. At those moments Anna would appear to freeze in the middle of the room. Anna appeared to become particularly distressed and cover her ears if she believed something would make a loud noise. Observations of Anna suggested that she was developmentally delayed in her fine motor movements, and speech. Anna also demonstrated potential delays in social-emotional development.

Mental Health Treatment and Therapeutic Outcomes

At the end of the initial visit, the mental health provider engaged in a short educational intervention, using augmented protocols from the circle of security program (Zanetti et al., 2011). We described the impact of children’s trauma on development and highlighted the ways Anna’s trauma was playing out in her relationship with Rachel. Trained Circle of Security providers ( https://www.circleofsecurityinternational.com/trainings/about-trainings/ ) introduced the circle and being with Anna on the circle. The provider and Rachel practiced identifying when Anna was on the top or bottom of the circle over the course of the medical exam. The mental health team referred Anna to receive a full DC-0-5 screening from our team and engaged with two brief emergency intervention sessions to build Rachel’s skills on identifying when Anna was experiencing distress and how to help soothe that distress. The team also assisted Rachel in setting up respite caregiving services. Anna was referred to and subsequently engaged in early childhood day-treatment therapy services. Rachel also engaged with a circle of security group through our partner community clinics. Outside of the mental health and medical interventions described above, Anna received OT services for her speech and sensory concerns. At a follow-up appointment approximately one year later with AMC, Anna was still placed with the same foster family. They reported that many of the interventions helped reduce Anna’s symptoms and that they are hoping to move forward with adoption.

Piloting the Early Childhood Mental Health Evaluation Protocol

In the pilot of the evaluation protocol that Anna took part in at the AMC, there were 105 children like Anna seen by the clinic team in the span of ten months. Children ranged from 0.7 to 71 months of age and were 41.38 months on average. They were 43.3% female and 72% (n = 75) of the children were in foster care. There were thirty-one domestically adopted children and twenty children adopted internationally. Of those adopted internationally, fourteen had experiences of institutional care. On average children experienced 2.35 transitions, but this ranged from one transition to seven. Children were 10.61 months old on average at their first primary caregiver transition, and children were 24.49 months at their most recent transition. All children had experienced some form of neglect or abuse, with the most common experience being parental drug use (n = 49 parental drug use; n = 64 prenatal drug exposure; n = 43 prenatal alcohol exposure). Of the children seen at the clinic, 21 experienced physical abuse, 19 witnessed domestic violence, and 36 experienced neglect.

Approximately 68% (n =71) of primary caregivers noted behavioral, social, or emotional concerns for their children at the onset of the visit. Concerns included failure to thrive, broad developmental delays, sleep difficulties, feeding difficulties, high amounts of emotional distress and difficulty soothing. Clinical observations noted that 24% (n = 25) of children exhibited maladaptive stress behaviors. However, the vast majority of children sought and received comfort from their caregivers effectively (n = 82; 79%). There were five children who exhibited significant levels of indiscriminate friendliness by clinician observation.

Only 32% (n = 23) of these children were accessing psychological services at the time of their visit, and 29% (n = 30) of all children had seen a neuropsychologist. Three of those receiving neuropsychological evaluations were based in DC:0-5 protocols (2016). DC:0-5 evaluations review the development and functioning of young children in the context of their relationship with caretakers and other environmental inputs such as traumatic events. Of the children who had caregiver reported emotional and behavioral concerns or exhibited difficulties in the clinic, six were referred for an immediate consultation or brief therapeutic interventions with the early childhood mental health team.

At the time of this manuscript, four of those referrals have been fulfilled. Of the two whose referral has not been fulfilled, one lived out of state and the other is unknown. Further, twenty-six individuals were referred for a full mental health assessment with our team and eleven of those have been fulfilled. Many families traveled to the clinic from multiple hours away and either preferred to see a provider closer to them and/or we also recommended they could receive services from a member of the community closer to their homes. We recommended that forty-eight children (46.7%) receive a trauma-informed diagnostic assessment and pursue evidence-based therapeutic treatment.

Conclusions and Clinical Recommendations

We found that social, emotional, and behavioral concerns are highly prevalent and a central concern for foster care and adopted children (Measelle & Ablow, 2018; Shonkoff et al., 2012). These concerns often present in addition to the many medical symptoms’ that foster children are experiencing. Working with an interdisciplinary collaborative team can offer the opportunity for an efficient consideration of other etiologies for behavior and intervention programs to address sensory, physical, genetic, or neurodevelopmental issues. In Anna’s case, she was able to benefit from all aspects of these interventions including medical interventions for micronutrient deficiencies, as well as OT services. Collaborative consultation programs lower the amount of time families spend going to appointments as well as the time demands on providers. This is particularly a positive for families who live in rural communities, who have to travel far distances to receive care. It is essential to not only provide recommendations but also explicitly state how families should prioritize these recommendations. Anna needed help to first address her emerging attachment relationship with Rachel in addition to her immediate medical concerns. Following these services, additional pediatric rehabilitation and sensory-based interventions were effectively introduced.

Collaborative environments should create access points to care while also decreasing the strain of accessing care on families who are balancing the many needs of their children. Potential community mental health referrals should be located in a convenient location for families and operate under a developmental and trauma-informed lens and offer evidence-based treatment. Creating referral lines and professional relationships with community clinics that provide this care was an element central to this program’s success.

However, we also found that for cases like Anna’s it is essential to have opportunities for immediate longer therapeutic sessions with a mental health provider. Many families seeking our care are families currently in crisis where children are facing potential long-term harm to their developmental trajectory. This includes highly distressing child symptoms such as self-harm behaviors or those that are highly challenging for caregivers to manage and who are at risk for placement disruption due to these symptoms.

Integrated care settings that specialize in foster and adoptive care experiences in early childhood could greatly reduce the probability that children will sustain long term consequences of early childhood stress. This case study demonstrated the feasibility and need for these services. Future work should evaluate if access to multiple service providers in one meeting decreased the number of appointments for those children and if it increased knowledge, and access to appropriate therapeutic care for families. Further, studies should evaluate if access to therapeutic care reduces the child’s likelihood of foster care displacement.

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Palmer, Alyssa R., Institute of Child Development, University of Minnesota

Dahl, Claire, Department of Pediatrics, University of Minnesota

Eckerle, Judith K., Department of Pediatrics, University of Minnesota

Spencer, MaryJo, Department of Pediatrics, University of Minnesota

Gustafson, Kimara, Department of Pediatrics, University of Minnesota

Kroupina, Maria, Department of Pediatrics, University of Minnesota

Author Note:

Corresponding author is Maria Kroupina, PhD, LP. Department of Pediatrics, University of Minnesota, 717 Delaware St SE, Minneapolis, MN 55414; e-mail: [email protected]

This work was supported by the Minnesota Department of Human Services [1501MNAIPP-75-1516-1536]; The National Institute of Health [T32 MH015755] and the University of Minnesota Interdisciplinary Fellowship to the first author.

We thank the children and families who participated in our services and the work of Amina Qureshi for data processing.

Ethics Statement: The case study and descriptive pilot data provided were approved by the BLINDED Institutional Review Board. All participants provided consent for their data to be included in scientific research and their related products.

*All names presented in this publication have been changed for privacy.

Data Availability: The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

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Module 13: Disorders of Childhood and Adolescence

Case studies: disorders of childhood and adolescence, learning objectives.

• Identify disorders of childhood and adolescence in case studies

Case Study: Jake

Jake was born at full term and was described as a quiet baby. In the first three months of his life, his mother became worried as he was unresponsive to cuddles and hugs. He also never cried. He has no friends and, on occasions, he has been victimized by bullying at school and in the community. His father is 44 years old and describes having had a difficult childhood; he is characterized by the family as indifferent to the children’s problems and verbally violent towards his wife and son, but less so to his daughters. The mother is 41 years old, and describes herself as having a close relationship with her children and mentioned that she usually covers up for Jake’s difficulties and makes excuses for his violent outbursts. [1]

During his stay (for two and a half months) in the inpatient unit, Jake underwent psychiatric and pediatric assessments plus occupational therapy. He took part in the unit’s psycho-educational activities and was started on risperidone, two mg daily. Risperidone was preferred over an anti-ADHD agent because his behavioral problems prevailed and thus were the main target of treatment. In addition, his behavioral problems had undoubtedly influenced his functionality and mainly his relations with parents, siblings, peers, teachers, and others. Risperidone was also preferred over other atypical antipsychotics for its safe profile and fewer side effects. Family meetings were held regularly, and parental and family support along with psycho-education were the main goals. Jake was aided in recognizing his own emotions and conveying them to others as well as in learning how to recognize the emotions of others and to become aware of the consequences of his actions. Improvement was made in rule setting and boundary adherence. Since his discharge, he received regular psychiatric follow-up and continues with the medication and the occupational therapy. Supportive and advisory work is done with the parents. Marked improvement has been noticed regarding his social behavior and behavior during activity as described by all concerned. Occasional anger outbursts of smaller intensity and frequency have been reported, but seem more manageable by the child with the support of his mother and teachers.

In the case presented here, the history of abuse by the parents, the disrupted family relations, the bullying by his peers, the educational difficulties, and the poor SES could be identified as additional risk factors relating to a bad prognosis. Good prognostic factors would include the ending of the abuse after intervention, the child’s encouragement and support from parents and teachers, and the improvement of parental relations as a result of parent training and family support by mental health professionals. Taken together, it appears that also in the case of psychiatric patients presenting with complex genetic aberrations and additional psychosocial problems, traditional psychiatric and psychological approaches can lead to a decrease of symptoms and improved functioning.

Case Study: Kelli

Kelli may benefit from a course of comprehensive behavioral intervention for her tics in addition to psychotherapy to treat any comorbid depression she experiences from isolation and bullying at school. Psychoeducation and approaches to reduce stigma will also likely be very helpful for both her and her family, as well as bringing awareness to her school and those involved in her education.

• Kolaitis, G., Bouwkamp, C.G., Papakonstantinou, A. et al. A boy with conduct disorder (CD), attention deficit hyperactivity disorder (ADHD), borderline intellectual disability, and 47,XXY syndrome in combination with a 7q11.23 duplication, 11p15.5 deletion, and 20q13.33 deletion. Child Adolesc Psychiatry Ment Health 10, 33 (2016). https://doi.org/10.1186/s13034-016-0121-8 ↵
• Case Study: Childhood and Adolescence. Authored by : Chrissy Hicks for Lumen Learning. Provided by : Lumen Learning. License : CC BY: Attribution
• A boy with conduct disorder (CD), attention deficit hyperactivity disorder (ADHD), borderline intellectual disability.... Authored by : Gerasimos Kolaitis, Christian G. Bouwkamp, Alexia Papakonstantinou, Ioanna Otheiti, Maria Belivanaki, Styliani Haritaki, Terpsihori Korpa, Zinovia Albani, Elena Terzioglou, Polyxeni Apostola, Aggeliki Skamnaki, Athena Xaidara, Konstantina Kosma, Sophia Kitsiou-Tzeli, Maria Tzetis . Provided by : Child and Adolescent Psychiatry and Mental Health. Located at : https://capmh.biomedcentral.com/articles/10.1186/s13034-016-0121-8 . License : CC BY: Attribution
• Angry boy. Located at : https://www.pxfuel.com/en/free-photo-jojfk . License : Public Domain: No Known Copyright
• Frustrated girl. Located at : https://www.pickpik.com/book-bored-college-education-female-girl-1717 . License : Public Domain: No Known Copyright