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Family therapy in an inpatient CAMHS setting: Dilemmas and possibilities

Authors:
  • Independent Researcher

Abstract

Providing family therapy within an inpatient Child and Adolescent Mental Health Service (CAMHS) raises some dilemmas and challenges for various reasons, including that therapeutic work is usually limited to the period of admission, the long distances that some families have to travel to the unit, the therapeutic culture and climate of the unit, along with different perceptions of the role of a family therapist in this context. This paper explores the role of the Family Therapist in an inpatient CAMHS setting in the UK
Context 182, August 2022
14
Hugh Palmer
Introduction
Providing family therapy within an
inpatient child and adolescent mental
health service (CAMHS) raises some
dilemmas and challenges for various
reasons, including that therapeutic work is
usually limited to the period of admission,
the long distances that some families
have to travel to the unit, the therapeutic
culture and climate of the unit, along
with different perceptions of the role of a
family therapist in this context.
Whilst most inpatient units have
historically offered either family work
or therapy, this has not always been
provided by qualified family therapists,
and it is only comparatively recently that
the Quality Network for Inpatient CAMHS
(QNIC) Service Standards (Thompson
& Clarke, 2013, p. 18) identify that “a
typical unit with 12 beds includes 0.5WTE
family therapist”. This is still currently the
case in the current (2019) tenth edition
of these standards and is in contrast to
earlier editions of these standards that
recommended that a ‘member of the
team’ had 0.5 WTE protected time to
deliver family therapy, without specif ying
the appointment of a qualified family
therapist.
It may be the case that some inpatient
CAMHS units have only recently
appointed qualified family therapists in
line with QNIC standards, and there may
be uncertainty regarding their role within
the service. In addition, much family
therapy in the community is delivered
by a team, often with more than one
qualified family therapist. An inpatient
unit employing a 0.5 WTE family therapist
means having a practitioner who is likely
to be working alone or will have to build
a team of interested colleagues; not an
easy task, especially for a newly qualified
family therapist.
At the same time, literature searches
reveal a lack of research or other writing
that focuses upon the provision of family
therapy within inpatient CAMHS units,
making the task for family therapists
working in these settings even more
difficult. Therefore, this article will
explore the function of family therapy
within inpatient CAMHS and the role
of a family therapist within this type of
service based upon my own experiences
and reflections in the hope of promoting
further discussion and informing
colleagues.
The context: Inpatient CAMHS
units
For those unfamiliar with the four
tiers of CAMHS services, Tier 1 services
are provided by practitioners who are
not mental health specialists working in
universal services, which includes GPs,
health visitors, school nurses, teachers,
social workers, youth justice workers and
voluntary agencies. Tier 2 services are
usually CAMHS specialists working in
community and primary care settings, for
example, primary mental health workers,
psychologists and counsellors working in
GP practices, paediatric clinics, schools and
youth services. Tier 3 CAMHS are generally
multi-disciplinary outpatient services,
providing a specialised service for children
and young people with more severe,
complex and persistent disorders. These
teams often include child and adolescent
psychiatrists, social workers, clinical
psychologists, community psychiatric
nurses and other therapists. Tier 4 services
include day units, highly specialised
outpatient teams and inpatient units.
There are just over 100 UK inpatient
CAMHS units, with around 70% of these
being provided by NHS trusts and 30%
by private agencies. Since April 2013,
tier 4 inpatient services have been
commissioned on a national basis by NHS
England, replacing the system of local
commissioning by primary care trusts.
Historically, there have been significant
problems with access to tier 4 inpatient
services. In some cases, children and
young people’s safety has sometimes
been compromised while they wait for
an inpatient bed to become available.
Young people have had to wait at home,
on a general paediatric ward, or even in
some instances in an adult psychiatric
ward or a police cell. Often when beds
are found, they may be in distant parts of
the country, making contact with family
and friends difficult and leading to longer
stays. Even under ideal circumstances,
admission to an inpatient CAMHS unit
can be a traumatic experience for the
young person and their family, and wider
contextual problems can compound the
difficulties even further.
Inpatient CAMHS admission:
Implications for young people
and their families
Inpatient admission can interrupt and
disconnect a young person from many
aspects of their life; they are removed
from their family home as well as
educational and social contexts, and their
family has to contend with the absence
of one of its members. Difficulties with
the young person’s mental health or
behaviour leading up to admission may
have led to worries and frustration for
family members, and parents have talked
of feeling both relief and guilt regarding
the admission of their child. This
disconnection from protective factors,
including family, peers, hobbies/activities
and pets, can be exacerbated by poor
communication between the service and
family. Conversely, in some situations, at
least part of the young person’s context
of home, peers or school has been so
detrimental to their wellbeing that
admission can provide some respite.
The reasons for admission to an
inpatient CAMHS unit are usually as a
Family therapy in an inpatient CAMHS setting: Dilemmas and possibilities
Family therapy in an inpatient
CAMHS setting: Dilemmas and
possibilities
15Context 182, August 2022
response to the severity of the young
person’s difficulties and to manage
associated risk. While there may be an
argument for assessing the young person
outside of the family context, it could
equally be argued that the context of
an inpatient unit may not permit an
opportunity for an ‘objective’ assessment
of the young person either.
Admission can create further
difficulties; there may be cases where
an attempt to find a solution creates
additional problems. For example, there
is a risk that inpatient admission and
treatment may identify or reinforce the
idea of the young person as either being
(or containing) the ‘problem’ rather
than seeing difficulties as relational
and contextual. For example, anorexia,
self-harm or psychosis may be perceived
and responded to as located ‘in’ the
young person, rather than a response to a
complex relational context.
Immediate concerns of safety rightly
inform the planning treatment and
care for the young person, but the
focus will need to shift in line with
recovery. Managing risk and the choice
of strategies to achieve this may be an
influential factor in how the culture of
the unit has evolved over time, and this
culture itself may impact the young
person and the family. If the culture is
very much focused upon control and
containment, for example, there may
be high expectations of compliance
with unit rules by the young person
as a condition for continuing the
admission, with negative sanctions
for behaviour that does not meet the
level of compliance expected by staff.
These sanctions may impact upon the
family too, for example, ‘reflective leave’
where a young person may be sent
home to think about their commitment
to inpatient admission following an
incident of negative behaviour may be
seen as punitive or counter-productive
by the parents who may have to make
sudden changes in arrangements to
accommodate this unexpected leave.
Loss of control for young people can
lead to increased anxiety, and differing
or conflicting attitudes and approaches
within the staff team (for example,
controlling and confrontational styles
versus more laissez-faire or even collusive
styles) can also increase anxiety for young
people. Exposure to other young people
with unusual or distressing behaviour
may have a significant impact upon the
young person and be a concern for the
family too. If the family are anxious about
the wellbeing of their child on the unit,
this is likely to be recursive and lead to
increased anxiety for the young person
and so on.
It is evident that there is a potential
for an “us and them” mentality between
young people and staff and/or between
groups of young people to emerge
within an inpatient unit, and this can
perpetuate problems too. For example,
an anorexic subculture may develop, in
which young people may try to lose more
(or gain more) weight than their peers,
or sometimes unhelpful competition
can emerge between young people who
exhibit challenging behaviour on the
unit. Some destructive behaviour, like
ligaturing, cutting or head-banging, can
be picked up by other young people
who may see this as a way of gaining
attention, particularly if another patient
who exhibits a lot of these behaviours
appears to be getting more input
from staff, for example, high levels of
observation or seclusion.
How can family therapy help in an
inpatient CAMHS?
The diagram above was co-created
with colleagues (nurse, occupational
therapist and locum psychiatrist)
in a training session, where we
conceptualised the admission of a
young person as being a journey
of three phases; the pre-admission
context of the young person’s life, the
disruption of admission, followed by
the reintegration process of discharge,
often with increasing periods of home
leave. Admission can mean disconnection
and dislocation from protective factors
including family, peers, hobbies/activities,
pets and so on, as well as disrupting more
negative factors, too. Family therapy
can prove to be an important bridge
Family therapy in an inpatient CAMHS setting: Dilemmas and possibilities
© 2015 Hugh Palmer, Diane Harbour, Susannah Giles and Nandini Bandikatla
Context of young person’s life Disruption Reintegration
Pre-admission Inpatient Discharge
Family therapy can help bridge the gap
Inpatient focus on:
· Illness (medical model)
· Pathology
· The child is, or has, the ‘problem’
· Managing risk and safety
· Compliance with treatment regime
Family therapy focus on:
· Family and wider networks
· Normality
· Resources
· Structural and systemic issues that can
maintain or resolve difficulties
Holidays
Hobbies
Sport
Pets
School
Friends
Peers
Relationships
Outpatients
Social services
Therapy
GP Drugs
Cigarettes
Alcohol
Sex
Music
Fashion
Other interests
Religion
Community
Family context
Wider family and social networks
Development of illness/problem
Other health issues
16 Context 182, August 2022
during the period of admission and help
to minimise the effects of disruption
through supporting or helping to
repair positive connections with family
and other networks. Family therapy
has an important role in helping shift
emphasis from the problem being ‘in’
the young person to the problem being
relational and contextual, a message
that sometimes needs to be reinforced
with both colleagues and families. This
is helped by maintaining a degree of
neutrality and curiosity. However, it is
essential to recognise that maintaining a
neutral position is a delicate balance for
a family therapist embedded within an
inpatient service.
Focusing on what is normal for the
family and engaging in ‘problem-free’
talk about other aspects of family life, for
example, hobbies and interests can be
really helpful in helping to identify what
already works for the family and what
may be potential resources for future.
This can help alleviate some pressure
on the young person by shifting the
focus away from them, and sometimes
discussing hobbies and interests can lead
to helpful metaphors for change later in
the therapy.
Family therapy can support the family
in supporting their child, and occasionally
this may mean helping parents shift from
potentially maintaining and perpetuating
problems to a position of resolving
problems and developing a more
protective approach. In order to do this, it
is really important to maintain a neutral,
curious and appreciative position.
Supporting these changes is a significant
element in working toward discharge,
and home leaves can be used as testing
beds for the parents in adopting different
approaches.
Ultimately, inpatient family therapy
is an opportunity to create a safe space
for conversation and dialogue where
the family sets the agenda, giving them
some control in a situation where they
otherwise feel they have little. The
therapy often is a contrast with the
family’s experience of other aspects of
the inpatient service.
The organisation can be supported
by their family therapist in becoming
more family orientated, and, as Gross
and Goldin (2008) describe, important
elements of working with families
in inpatient settings include the
collaborative nature of working ‘with
the family-plus-unit-as-a-system’ and
incorporating family-friendly practices
and listening to, and acting upon,
feedback from families.
Limitations and effectiveness of
family therapy in an inpatient
setting
Namysłowska and Siewierska (2008)
identify three broad areas where ethical
dilemmas for family therapists working in
inpatient settings may arise. Firstly what
they describe as ‘the medical character
of the institution’, secondly the wider
psychotherapeutic programme of which
systemic family therapy comprises a part,
and thirdly, the limited time of admission.
In their discussion of the character of
the institution, they indicate that family
therapy may be perceived as a prescribed
treatment, and thus difficult for
concerned families to question or refuse
and note the paradox for some families
who may be feeling they do not need
therapy but not dare to refuse it for fear
of being perceived as pathological.
Because family therapy is typically
limited to the duration of the admission,
which is often uncertain, the constraints
on time mean long term therapy is
not usually viable. The impact of this
is that methods are generally limited
to brief work and interventions,
sometimes utilising solution focussed
or psychoeducational techniques to
support a family through a crisis. The
time constraints require liaison with
community family therapy teams as
necessary, although family therapy may
not always be immediately available on
discharge to community services – if at
all.
With specific regard to anorexia, there
is some evidence that inpatient care
does not change ‘anorexic thinking’
(Fennig et al., 2015), although there is an
increasing evidence base that suggests
family therapy is an effective treatment
for adolescents with anorexia nervosa
(Murray & Le Grange, 2014) however,
this evidence tend to be drawn from
community family-based treatment
programmes. In a later paper, Murray
et al. (2015) recognise that inpatient
hospital settings might be most suited
to the urgent medical stabilisation of
acute anorexia nervosa, and this may
preclude full parental involvement, but
they caution against long term respite
for parents beyond a point when they
could feasibly be involved in the feeding
of their child and go on to acknowledge
that inpatient settings are “uniquely
placed to orient families towards the early
goals of family-based treatment” (Murray
et al., 2015, p. 305) by ‘raising parental
anxiety’ and also working to create unity
between parents. However, given that
family-based treatment is not universal
within the UK, even if inpatient units
could work towards these early goals,
there is no guarantee that this treatment
model would be available on discharge to
community services.
Developing robust outcome-
measurements for a family therapy
service located within an inpatient
setting presents some problems as most
tools are intended to measure progress
towards goals or specific outcomes over
a discrete period of time or number
of sessions. Inpatient stays can be
unpredictable in terms of duration; young
people may be discharged after a brief
period of admission or transferred to
other units. This means setting realistic
and achievable goals with families is
not always possible. Because other
interventions will be offered to young
people in parallel to family therapy,
it may not always be clear which
interventions have the most impact.
In the light of these difficulties,
outcome tools need to be effective in
measuring short term interventions, and
therefore instruments that are validated
by CYP-IAPT were selected and these are:
Session rating scales (SRS V.3.0, 2002,
Scott D. Miller, Barry L. Duncan & Lynn
Johnson)
This tool measures user satisfaction
with each session and covers relationship,
goals and topics, approach or method
and an overall rating (all between 0 and
10), considering;
• If the respondent felt heard, understood,
and respected.
• Worked on and talked about what they
wanted to work on and talk about.
• If they felt the therapist’s approach is a
good fit for them.
• Overall, they felt today’s session was
right for them.
My experience was that session rating
scales are a really helpful tool to inform
practice and, over time, data collated
gave a useful overview of general
Family therapy in an inpatient CAMHS setting: Dilemmas and possibilities
17Context 182, August 2022
satisfaction. Occasionally young people
would indicate they didn’t feel heard
in sessions, but on further enquiry, it
emerged they were referring to not being
heard by their parents.
Goal-based outcomes (goal progress
chart – parent/carer version 1, Duncan
Law, Hertfordshire Partnership NHS)
This tool offers the family an
opportunity to discuss and identify a
common goal that they would hope to
achieve from family therapy and record
progress towards this on a scale of 0-10
(achievement being 10, non-achievement
being 0). This was helpful as a tool to
help families collaboratively think about
realistic goals for the family therapy and
monitor their progress in achieving these
goals.
SCORE-15 (Association for Family
Therapy) was being introduced; however,
I left the service before I could fully
evaluate its use in an inpatient setting. I
felt its use as an overall measure of family
functioning may be less applicable if a
key member of the family is an inpatient
rather than living with the family. The tool
can generate ‘sub-scale’ scores from the
five items on each of three dimensions
of ‘strengths and adaptability,
‘overwhelmed by difficulties’, and
‘disrupted communication’.
The role of an inpatient CAMHS
family therapist
The context of the inpatient service
will have a significant impact on the role
of the family therapist; the structure,
lines of management and culture all
being critical influencing factors. Some
inpatient services are more appreciative
of systemic practice than others. From
conversations with systemic colleagues
in other inpatient services, it is clear
that there are significant differences
and their experiences vary widely,
from feeling supported and valued
to feeling isolated and vulnerable.
If family therapists are employed to
‘tick the box’ without considerable
thought and preparation from the
service regarding the role, it is likely that
difficulties may emerge, and being a
sole family therapist within an inpatient
unit team can present many dilemmas
and challenges, particularly if the role
is not well understood by colleagues
within the service. This may lead to
issues around managing boundaries,
particularly regarding maintaining the
position of neutrality that is so important
in engaging with the young person’s
whole family system. There may be
expectations that the family therapist
should provide both family therapy
and have a wider input that may range
from offering a systemic perspective
to multi-disciplinary meetings and
other clinical meetings, facilitating
staff support and supervision, to other
activities such as supporting mealtimes,
observations or responding to alarms.
It is these additional activities that
present the biggest ethical dilemmas,
often in situations that impact the ability
to maintain neutrality as a therapist
whilst wishing to be supportive of
under-staffed and stressed colleagues
and ‘mucking in’ through undertaking
generic duties outside of therapy.
Another potential issue within inpatient
settings is whether or not family
therapists should undertake prevention
and management of violence and
aggression (PMVA) training that will equip
them to restrain young people. While it
may be appropriate to learn breakaway
techniques as part of personal safety, my
own experience of having undertaken
extended training to restrain clients, in
hindsight, was a mistake. Not only did
being involved with restraint significantly
compromise therapeutic alliances with
the young person and their family, having
done this training raises the expectation
from colleagues that I will be involved
and respond to alarms as a matter of
course.
While there may be a trend towards
more generic working within an inpatient
unit, apart from impacting upon
therapeutic relationships, this shift may
also be detrimental to the development
of a more strategic role that can promote
systemic practice within the service.
To help think about the role of a family
therapist within an inpatient setting,
with the support of my service manager,
I developed ideas around the role within
the contexts of direct care, indirect care,
co-working, research and strategy. These
may be helpful for other inpatient units in
developing guidelines around the role of
a family therapist.
Direct care
Direct care involves providing systemic
psychotherapy service to clients and
families, as well as assessment, treatment
and consultation to client systems,
including young people, their families,
carers and professional networks.
Occasionally, systemic therapy with
individual adolescents can be offered
when necessary, although not normally
concurrently with family therapy.
Indirect care
Indirect care covers advice and
consultation regarding systemic
formulations and treatment to CAMHS
colleagues and external agencies.
Co-working
This element of practice incorporates
consultation and joint working with
other disciplines within the service
and also consultation and liaison with
professionals from other agencies. This is
achieved through participation in clinical
review meetings, Care programme
approach (CPA) meetings and multi-
disciplinary team meetings as necessary,
providing a systemic perspective.
The provision of live systemic
supervision within family therapy teams
and monthly systemic group supervision
to the wider team are both important
elements of the role and may support
the strategic aim of informing and
encouraging systemic thinking and
ideas within the service. The systemic
group supervision also aligns with Gross
and Goldin’s (2008) observations about
supporting staff and contributing to self-
reflexivity to improve the experience for
young people and their families.
Research
It is important to utilise theory,
evidence-based literature and research
to support evidence-based practice
and be willing to undertake appropriate
research or provide research advice
to other staff undertaking research. In
terms of evidence-based care, active
involvement with the audit process
and the evaluations and monitoring of
personal work is essential.
Strategy
A family therapist can have a valuable
role in undertaking project management,
including audit and service evaluation,
with colleagues within the services
to help develop and evaluate service
provision, with a primary responsibility to
Family therapy in an inpatient CAMHS setting: Dilemmas and possibilities
18 Context 182, August 2022
Family therapy in an inpatient CAMHS setting: Dilemmas and possibilities
coordinate and propose changes to the
systemic therapy service.
Conclusion
Family therapy in an inpatient unit
is both challenging and rewarding.
The challenges are primarily about the
dilemmas raised by being both a member
of a team and yet maintaining an element
of separation. Eventually, I chose not
to attend every multi-disciplinary team
meeting; even though this may seem
counter-intuitive, it helped keep some
distance and additionally avoided being
drawn into the sometimes dominant
problem-saturated narratives regarding
some young people.
The rewards were tremendous;
I developed excellent therapeutic
relationships with many of the families
I worked with, especially when the
admission period was over several
months, allowing time to form a strong
alliance. In addition, I developed good
working relationships with many
colleagues, particularly those who
worked in one of the teams, and it was
gratifying to be approached by other
members of the nursing team for advice
on aspects of working with families.
To conclude, careful planning and
preparation is required for developing
the role of a family therapist employed
within an inpatient service to ensure
that role boundaries are understood and
clear. Clear role boundaries can maximise
opportunities for the development
of therapeutic engagement with
the patients and their families. With
consideration to these issues, a family
therapist can be a tremendous asset to an
inpatient unit, benefitting young people,
their families, colleagues and the service
as a whole.
References
Fennig, S., Brunstein Klomek, A., Shahar, B.,
Zohar Sarel-Michnik, Z. & Hadas, A. (2015)
Inpatient treatment has no impact on the core
thoughts and perceptions in adolescents with
anorexia nervosa. Early Intervention in Psychiatry,
11(3): 200-207.
Gross, V. & Goldin, J. (2008) Dynamics and
dilemmas in working with families in inpatient
CAMH services. Journal of Clinical Chil d
Psychology and Psychiatry, 13(3): 449-461.
Murray, S.B. & Le Grange, D. (2014) Family
therapy for adolescent eating disorders: An
update. Current Psychiatry Reports, 16: 447.
Murray, S.B., Anderson, L.K., Rockwell, R.,
Gri ths, S., Le Grange, D. & Kaye, W.H. (2015)
Adapting family-based treatment for adolescent
anorexia nervosa across higher levels of patient
care. Eating Disorders, 23: 302-314.
Namysłowska, I. & Siewierska, A. (2008) Ethical
dilemmas of family therapy in the adolescent
psychiatric ward. Archives of Psychiatry and
Psychotherapy, 3: 61-64.
Thompson, P. & Clarke, H. (2013) QNIC Service
Standards (Seventh Edition). London: Royal
College of Psychiatrists Centre for Quality
Improvement.
Hugh Palmer is a systemic family
psychotherapist. Hugh works as an
independent systemic therapist and much
of his recent work has been with a local
authority, supporting families who have
adopted children and foster parents and
staff who work with looked after children.
He has particular interests in trauma,
bereavement, the therapeutic relationship
and the legacy of Gregory Bateson.
Apart from therapy, Hugh enjoys being
a grandparent, and is a keen amateur
photographer.
... This ended up being spread out over many years, starting in the late 1990s when I worked at the University of Leeds and after returning to the United Kingdom (UK) from New Zealand, qualifying in 2007 while running a Foundation Course in Family Therapy at the University of Hull. Eventually, I found myself back working in the National Health Service (NHS), but as a Family Therapist from 2013 in CAMHS, firstly in outpatient services, then in an inpatient unit (Palmer, 2021) and finally in Adult Services. While working at the University, I also had honorary contracts with Relate, the National Society for the Prevention of Cruelty to Children (NSPCC) and a local CAMHS team to undertake family therapy. ...
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  • P Thompson
  • H Clarke
Thompson, P. & Clarke, H. (2013) QNIC Service Standards (Seventh Edition). London: Royal College of Psychiatrists Centre for Quality Improvement.