Relational dynamics and experiences of inpatient and intensive community care for children and young people: matters for service engagement and recovery

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As part of a wider randomised controlled trial comparing Intensive Community Care Services (ICCS) with treatments as usual (TAU) across the UK, including inpatient and generic community care models, this paper examines how young people experience these different models. Fourteen young people participated in a semi-structured visual interview study to reflect on their service experiences, with a focus on recovery journey and service engagement. A thematic decomposition analysis was conducted on the data, and specific themes relevant to satisfaction and engagement with services were examined in-depth. A central theme emerged was the importance of relational dynamics. In particular, we explored relationships with mental health professionals and the peer and family relationships that shape and impact experiences of service use and recovery. Young people shared mixed experiences with mental health services. Inpatient care and generic community services received both praises for individual staff commitment and reassuring diagnoses and containment, and criticisms such as inflexible approaches, inadequate staff attention, and untimely appointments. Relationships with support network were commonly reported to be unstable and unsustainable. On the contrary, the ICCS model was valued for the personalised approach, including beneficial home visits. The approach facilitated development and mobilisation of positive relationships in the community with the surrounding support network. The findings serve as a reminder of the significance to build trust-based relationships with young people that go beyond mental health assessment and treatment. Future research and service development should focus on resolving common systemic issues that hinder continuity of care, such as understaffing, long wait times, and high turnover. Background There has been a steady increase in the prevalence of mental health challenges amongst children and young people (CYP) across all geographical locations, especially following the Covid 19 pandemic, but even before this period (Kauhanen et al, 2023). Despite an increase in Child and Adolescent Mental Health Services (CAMHS), especially in higher-income countries, existing services are often unable to keep up with the high demand for care (Pitchforth et al., 2018). Inpatient care has been the traditional treatment option for severe mental health disorders, but recent evidence from community interventions reveals a promising community alternative (Ougrin et al, 2021). Inpatient care can often be a distressing experience for CYP, preventing patients from receiving satisfactory care or leading to further post-hospital traumatisation (Bartl et al., 2024; Reavey et al, 2017). Involuntary admissions into hospitals are especially negative for service users, with issues like higher rates of suicide, dissatisfaction with care, increased risk of readmission, and biased treatment towards marginalised populations (Bartl et al., 2024). This form of treatment shows little to modest improvement following discharge and has received predominantly negative feedback, even from the healthcare workers in these inpatient settings. Relationships between staff and CYP in inpatient services have also been found to be less than satisfactory and presented as a barrier to successful treatment and long-term recovery (Hartley et al., 2022). These findings have prompted a transition to alternative, community-based interventions shown to be beneficial for CYP (Keiller et al., 2023). Those discussing their experiences of inpatient care have noted that community-based organisations might address difficulties in a timelier fashion, which in turn serves to reduce involuntary admissions and lead to more positive mental health outcomes in the long term (Ougrin et al., 2021). Community-based services are an especially effective solution to improving the mental well-being of young people when they are connected to other relevant service providers in education and primary care. As an example, Forward Thinking Birmingham is a community-based approach to mental health care that was established following the success of the pilot initiative Youthspace. Youthspace allowed young adults to access mental health services, divided work amongst teams and communicated with general practitioners (GPs) to efficiently provide these patients with care. The organisation also used the internet and social media to broaden its access, connecting young adults to advice, education, and individualised assessment (Vyas et al., 2014, McGorry et al., 2013). Community-based organisations (CBOs) are also helpful for marginalised persons at risk of poor mental health, as the community space provided allows young people to feel comfortable with their identities and build a sense of empowerment and improve mental health within these communities (Bloemraad & Terriquez, 2016). Identifying barriers in access to care and understanding the contexts that shape an individual’s mental health are both important in executing preventative services. Discourse in recent policies has lost focus on these contextual factors that are known to be important in the development of psychological distress (Callaghan et al., 2016). Community-based care returns the spotlight to these key origins of mental health challenges, allowing carers to provide patients with effective medical care. Along similar lines, group therapy has emerged as an important intervention for adolescent mental health treatment (Meza et al, 2023). The supportive environment created by a group setting is effective in mitigating self-harm and suicidal ideation among young persons, which decreases the need for crisis intervention services. A community and/or embedded community group-based approach allows for successful intervention for mental health issues surrounding identity or crisis. The intervention is also purported to be better at building positive therapeutic relationships between staff and CYP, in comparison with inpatient services. Building positive relationships is crucial to engagement with treatments and overall recovery, though it is currently under-explored in ICCS (Gerstl et al., 2024; Hartley et al., 2022). The positive results yielded from community interventions support the importance of implementing community-based services to improve the well-being of CYPs and provide effective care in the long term (Clisu et al, 2022; Kwok et al, 2022). Understanding the significance of these community services, especially in comparison with inpatient care, is required; thus, this present study aims to examine more directly how young people experienced ICCS and inpatient services to better understand the enabling features and some of the barriers to appropriate and well-received mental health care for CYP. Although participant numbers were too limited for a direct comparison, some description of the differences and similarities between inpatient TAU and ICCS will be presented, where relevant. Rationale Community-based care comes in various forms that generally focus on adults and older adults with severe mental illnesses (SMI), as detailed in the recent NHS Mental Health Implementation plan. This study looks specifically at ICCS, established as a treatment for CYP with severe psychiatric disorders, outside the inpatient setting. The ICCS intervention provides treatment in a comfortable community setting, such as school or at home. It prevents the CYP from being removed from daily activities, such as school and extracurriculars (Keiller et al., 2023). Research underpinning ICCS is minimal, and yet the recent shift from inpatient to community-based care makes this research even more important in determining the effectiveness of this intervention and measuring its impact compared with TAU modalities. Previous findings show ICCS to be a more beneficial treatment than TAU (Ougrin et al., 2021). The present study’s objective is to compare ICCS with inpatient TAU from the perspective and lived experiences of the CYPs receiving these services. Methods The qualitative material analysed here was collected as part of a broader NIHR funded Randomized Controlled Trial across seven NHS trusts in England and Wales. The purpose of the trial was to collect data from each NHS trust delivering acute care to children and young people at risk and eligible for Tier 4 inpatient care. ICCS was then compared with a TAU arm for measures relating to global functioning, self-harm, educational engagement, and quality of life. As part of this large national trial, qualitative data in the form of visual-qualitative interviews (see below) were collected to evaluate how both TAU and ICCS were experienced by both staff and service users in terms of the perceived effectiveness of the interventions, feelings associated with giving and receiving treatment, and overall perceived effect on mental health outcomes. The project was concerned with capturing service users' feelings and lived experiences, so attention to detailed descriptions was central to how the interviews were conducted. The research reported here was primarily based on visual-semi-structured interviews with service users. There were a further thirty-five interviews with staff across TAU and ICCS, ranging from consultant psychiatrists, nurse managers, registered nurses, clinical psychologists, and clinical care support workers. The data reported in this paper is drawn from fourteen interviews with young people aged 14-17, ranging from four intensive community care services Core CAMHS (6) to intensive community care service users (4). Each interview lasted between 45 and 90 minutes. Ethical approval was obtained from London South Bank University and King’s college, London University ethics boards in addition to the West Midlands and Black Country Research Ethics Committee (REC Reference: 20/WM/0069). To ensure confidentiality, all the participant names used in this paper are pseudonyms. The interviews used a photo-production methodology (Boden & Eatough, 2014; Reavey & Brown, 2021) to elicit more specific and rich responses relating to lived experiences of service use and mental health, generally. The participants used their phones to take the photographs, as this was the most familiar means of collecting images. The images were then sent to the researcher primarily responsible for data collection (OA), who checked the young person had adhered to the inclusion and exclusion criteria and then uploaded them before the face-to-face interview. Interviews were conducted in person or online, depending on the young person’s preference. The photo-production technique required the participants to take photographs of spaces and places related to their treatment and their lives as mental health service users. They were provided with clear guidance on completing the photo-production task, including instructions relating to exclusion and inclusion within the images. For example, participants were not permitted to include other people in their images. This visual-qualitative approach has been used in the context of examining diverse experiences of distress in mental health settings and beyond, including first episode psychosis with young people, inpatient service use experiences in CAMHS (Reavey et al, 2017), forensic mental health service use (Reavey et al, 2019; Brown et al, 2019; Tucker et al, 2019) and community mental health care (Jenkins, Reavey et al, 2024). A visual approach is adopted to elicit metaphorical, symbolic, and difficult-to-reach feelings (Boden & Larkin, 2020; Reavey, 2020). The interviews followed a semi-structured format to the extent that a schedule developed by all researchers was used to guide the conversation. However, the interview was guided primarily by the participant's engagement with the visual material and was set at their pace. The order of questioning was led by the participant whilst discussing the photographs they produced prior to the interview (Reavey & Brown, 2021). Overall, participants engaged with the visual material and interview questions well, with varying levels of engagement with material of a more personal nature. The interviews were digitally recorded and transcribed verbatim. Participant names were replaced by pseudonyms chosen by the researcher. The photographic images were given meaning by the participant only, in the context of the interview, rather than treated as data to be analysed independently (Reavey & Prosser, 2012). The authors’ analytical reading of the audio material was guided by the overall research question: how did participants experience their mental health intervention during their time either in hospital or in the community? The visual data is not included in the final analysis presented here, as the focus is on narratives of service use and mental health. A choice was made, therefore, to stay close to the verbal narratives as the main data source. After notating and coding the material with these questions in mind, the data were re-organised into themes and subsequently considered in the light of literature that could assist in contextualising the analysis. A thematic decomposition (Stenner, 1993) approach was used to analyse the data, which sought to identify processes through which mental health service use was enacted, understood, and experienced. This thematic decomposition was achieved by following several stages of analysis commonly found across all forms of qualitative analysis (Willig, 2008). This involved familiarisation with the data via repeated readings of the transcripts, generating initial codes by paying close attention to meanings embedded in every line of talk, followed by matching the initial codes together to form candidate themes and sub-themes, with the research questions as organisational guides. Each of the authors participated in discussions around whether the generated theme titles and definitions adequately captured the essence of the data. There was cross-validation at all analytical stages, including initial data coding, the expansion of coding into themes and the discussion of themes using key data. The interpretative process further involved exploring the implicit meaning of the material rather than a more descriptive reading. The validity of the findings was addressed using conventional qualitative procedures, including group analysis by key researchers and peer review, to ensure the analysis was sufficiently grounded in the data (Creswell & Miller, 2000). Analysis Before discussing the main theme of this paper, we provide an overview of the general perspectives on ICCS and TAU, to offer a context to the data extracts that follow. General summary of service experience in child and adolescent mental health services Service users presented a range of personal experiences with mental health services, particularly the ICCS, Child and Adolescent Mental Health Services (CAMHS), and inpatient facilities, reflecting both positive and negative aspects of care. Inpatient service experiences were divided, with several patients reporting that their needs were effectively addressed, particularly regarding receiving appropriate diagnoses, therapeutic interventions, medication adjustments, and other reporting problems with the ‘sterile’ approach to care. For those who found inpatient care negative, relationships with staff were highlighted, where staff attention was disproportionately focused on high-risk individuals, leading to a chaotic environment and a perceived lack of support for other patients. Community services, particularly those provided post-discharge, were appreciated for their personalised approach, a testament to the dedication of the healthcare professionals. Home visits were seen as beneficial for patients transitioning from inpatient care. Nevertheless, significant issues were raised regarding the systemic shortcomings of these services, including understaffing, extended waiting times, and the frequent turnover of caregivers. These factors contributed to feelings of frustration, as patients were often required to repeat their histories to new professionals, undermining continuity of care. Patients reported frustration at repeatedly explaining their history to new caregivers, which impeded continuity of care and undermined the therapeutic relationship. Standard community CAMH services elicited more divided responses. While some patients acknowledged the commitment of individual staff members, the service was frequently critiqued for its impersonal and standardised approach, particularly with time-limited therapies. This often made it difficult for patients to form meaningful connections with healthcare providers, and the therapeutic interventions were perceived as generic and inadequately tailored to individual needs. The following section will draw out further insights from the data, according to one major or superordinate theme, which addresses the key aspects related to service use experience, both in terms of engagement with the service and recovery in general. In particular, the focus is on how relationships appear to serve a primary function in relation to levels of engagement with services and recovery. This theme speaks to the interconnected nature of service use and broader community relations, including relations with family, peers, mental health professionals and friends. To better understand young people’s engagement with service use, it is necessary to grasp the relational networks that inform and influence young people in their journey. Throughout, we will focus on a series of key study objectives, such as young people’s feelings and thoughts about the services they encounter as well as the role of their broader relational dynamics in this. Relational dynamics in engaging and sustaining service use All young people described relationships that enabled or disrupted their engagement with services, both in inpatient care and in ICCS. These included relationships with family members, peers, friends and mental health professionals. For some young people, building relationships with mental health professionals constituted a significant part of their recovery, especially when family relations were problematic. In the first section of this analysis, we examine how young people experienced relationships with mental health professionals across ICCS and TAU. We focus on what young people found helpful to their service use and recovery and discuss challenges to their engagement. Professional connectedness: life context and experience-near knowledge One of the key aspects of care that felt important was when the professional staff made efforts to get to know the young person and go beyond standardised reporting of symptoms or risk. Participants valued the informal relationships they forged with staff and saw this as essential to building trust. When professionals talked to young people in a way that emphasised formal assessments, behavioural surveillance and procedures, this was met with suspicion and mistrust (see also Reavey et al, 2017) “Because it was like a waste of time, it was just annoying, I don’t want to talk to them. They would just sit there and ask if you were okay so it was just a waste of time because what do they expect me to say” ( Tish ) Taking time to get to know the young person was part of many young people’s experiences of ICCS and was deemed fundamental to establishing trust and openness. A sense of closeness, context and ‘experience-near’ treatment was heralded as the most positive part of the treatment: “Like if I were to compare my own experiences – community and then home treatment and then in-patient, I think for me, with my struggles, home treatment has been the best because they step a little bit closer to you, they get to look at things that community might not have” ( Sibley ). Knowing the person as a whole, beyond their mental health challenge, was considered especially valuable, as it provided the young person with a sense of being cared for and valued as a complete character: “The ETS, I got given when I was coming out of ward because it was kind of classed as an extreme therapy, people talk to you every day, they come and see you every other day…when I got it I would say it was extremely helpful because CAMHS, if you didn't want to go, they wouldn’t make you, but ETS was like they would make compromises with you in the way that they’d still speak to you. Instead of basing it on how they got taught, they would take what they’d been taught and know how to approach the patient with what they like, about your hobbies, which gets you more comfortable and with talking they’re very good with how quick they help you. And I was very lucky to get people who I felt comfortable with talking to and I think that’s really important. They’re very good with saying that if you aren’t comfortable, then we’re more than happy to get someone else, whereas at CAMHS that would take you a while to get a new coordinator” ( Ellen ). Once more, this idea of building a relationship based on ordinary language, informality and building a sense of comfort was presented as crucial. Going beyond professional discourse and ‘how they got taught’ helped orient young people to believing that the service was in their best interests and not simply a container space for managing their symptoms or risky behaviour. Young people were very attuned to knowing the difference between relationships designed to ‘monitor’ them and ‘care’ for them; without the latter, they appeared to find it difficult to engage. Knowing their life context was central to the start of this process of feeling cared for and highlighted as significant by many: “I think one of my nurses in the unit ... mental health service is probably the person who cares most. How I know they care is that it feels like they make an active effort to speak to me, even though I’m not even on their patient list, but they’re still making an effort. This is someone I’ve known quite a long time and he has been there and I have seen him change with the services, he’s seen me change with the services” ( Georgette ). Knowing someone over time and in context, as described above, was considered fundamental to building trust, as the young person could speak freely outside the confines of assessment and checklists, which was something they valued highly. This was facilitated when young people could be seen outside the confines of traditional service spaces, which they believed to be an enabler for open and honest conversation about mental health, but also contributed to feelings of care and connection: “I like the idea of that because on days that I was struggling and I did not want to leave the house, it was not like I would not get a session or they would just shut me out like we cannot come to you, it is like someone’s not given up on you, you’re not left alone to deal with it yourself. They’d help you, they’d communicate, and they would say, because you’re struggling, why don’t we go for a walk, we’ll go together, something like that; I like the idea that they do not just shut you out ( Ellen ).” Professionals who were able to recognise that a young person was struggling and meet them in a place that was familiar and comfortable for them were experienced as invaluable. For some who directly connected traumatic experiences of inpatient care, this was not only desirable but necessary: “When I had home visits, I think they were better than going to a hospital because I have a problem whenever I see especially the **** Hospital – that exact image – I get very … I wouldn’t say PTSD, but I get a lot of past images about that place ( Ellen ).”.” Being seen in a familiar place was soothing and reassuring for some and unrelated to negative institutional experiences. Many described not feeling alone or ‘shut out’ and valued the idea that someone had not given up on them. Engagement was more likely when young people felt that they had been seen, heard, and connected with on their terms. Young people considered consistency in staff vital to connecting with professionals and speaking openly. Consistency enabled young people to believe that engagement was possible as their mental health recovery journey could be better understood, contributing to the feeling they were genuinely cared for. When they encountered multiple staff members for short bursts of time, there was a marked difference between ‘knowing’ they had been cared for and ‘feeling’ it. “Actually, I don’t really feel like a lot of people are involved in my recovery. I know there are because I’ve seen them. They all once did this media call of all the people involved in my care and there was a lot. There were so many faces that I didn't even recognise. So, I do know there are a lot of people involved but it doesn’t feel like it” ( Yazid ). Not knowing mental health professionals or being granted the opportunity to build a trusting relationship with them was presented as a major obstacle to a meaningful engagement with the service and a reason for wanting to withdraw or contributed to feelings of abandonment: “I think, I didn't feel that I knew them very well. I hadn’t known them for long. I was just like, ‘I don’t care. I just want to give up.’ Which was really out of character for me. I’m very … I like to do well in school; I like to go out and see my friends. I was just a completely different person” ( Eda ) Of note in the extract above is an emphasis on how relationships contribute to the young person’s sense of well-being and character. They clearly describe being capable of maintaining meaningful relationships, even when unwell, but experiencing a sense of alienation from the service due to not having the time or space to develop relationships with professionals. However, this was not confined to ICCS, as young people described being able to engage with treatment in inpatient services, but only when a successful relationship had formed: Inpatient services offered some young people a safe, contained and continuous space to work on developing coping strategies. However, of note is the central importance placed on this occurring in the context of a good and constant (24-hour care) relationship with staff: “I think, as I started to do better by engaging with the therapies and the one-to-one support that was, like, twenty-four-hour care, I started to see more … They were very good at helping me through flashbacks: episodes where I didn't know where I was or what was happening or who people were. And they helped me learn how to deal with that and cope”. ( Eda ) Some participants believed that immediate and constant care was advantageous, especially when community care was not delivered in a timely manner: “As an inpatient, I think my struggles and needs were addressed very, very well. I think support from most staff was valuable. I got the diagnoses I needed to get the right therapies. They changed my meds, which, in the community, I’d been waiting months to see a psychiatrist. ( Georgette ) In other cases, there were examples of withdrawal and disengagement due to negative or neglectful experiences with professionals, which directly contributed to feelings of abandonment. “The worker that I had … was horrible, really, I’m trying to find the right word, but she was not right or fit for her position, the things that she would say to me I’ve been told that they were absolutely unacceptable. She essentially discharged me from the services, despite seeing me struggling” ( Sibley ). Quite often I will wake up having nightmares about that and also one of my big things is that I feel quite abandoned by other people and going in there and interacting with all these people on a daily basis and then suddenly having to leave them, it didn’t really help with that ( Georgette ). Feeling abandoned by services was less common in ICCS, given that there were more opportunities for connection. However, for some young people who did not have positive or significant peer or family support, the consequences of continuing to struggle without support are concerning. In the next section, we look at the relational dynamics outside of services to examine how these relationships operate alongside traditional mental health service provision. Young people emphasised the importance of these networks in their engagement with services and their overall recovery journey, whether positive or negative. Peer relationships: attachments, solidarity and mirroring Working alongside service provision were relationships that young people deemed highly significant in shaping their mental health challenges and recovery journey. Information regarding the relationships in a young person’s life is crucial for understanding their influences on mental health, both positive and negative. Feeling better or worse could sometimes be directly connected to what was occurring in a relationship and the forms of support or disruption emerging from it. Young people could connect aspects of their mental health with observations about the contributing role of their attachments, feelings of safety and unsafety and emotional investments in relationships that they believe to be important and relevant to their treatment. As the following extract highlights, however, relationships can shift and alter the course of a young person’s distress, making it even more important to enquire after background relational dynamics to better understand the ebbs and flows of their distress: “Before I got help from my parents and then I started getting help from CAMHS, I had a boyfriend at this time and I basically relied on him for everything. I had noticed that when I talked to him, I’d feel better, safer, I didn't feel the need to self-harm and that was helpful up to a certain point where it became toxic on my side, but we were both struggling” ( Ellen ). In contrast, for some young people, fluctuating intimate relationships could significantly disrupt mental health in ways they themselves recognized as highly significant and destructive: “Obviously as expected, Covid had kind of wiped quite a lot of us out, but it came to a point where, if he wouldn’t call me or text me for a certain amount of time, I wouldn’t feel okay anymore, I would get really unsafe, I’d end up self-harming, then it would go back and forth, this really unhealthy attachment. But then around one Christmas he broke up with me for good after I was just going back and forth like a game of tennis and I obliterated my leg, it was covered in cuts, ( Ellen ).” The destructive potential of intimate relationships is undoubtedly worthy of deeper scrutiny when it comes to understanding forms of distress and self-harm, and yet it was often overlooked in treatment. Little is known about the impact of intimate relationships on young people’s mental health, and yet what is known is the vital importance of relationships in young people’s perceptions of their wellbeing and levels of mental distress (Price et al., 2016). Previous literature suggests professionals are either not aware of the relationships in a young person’s life or actively discourage peer relationships that form through service use (Reavey et al, 2017). And yet, young people do develop peer relationships and friendships in services, which can significantly contribute to the young person’s journey through the service and their recovery. In the extract below, the participant describes a model of peer relating based on mentoring, where young people advise and pass on their knowledge of treatments to support others in the management of symptoms and distress. “I got to know some patients very, very well, especially ones that were my age and admitted around the same time as me. When I was first admitted, the patients who had been there much longer and were going to be discharged soon and were in a much better place, they would try and encourage me to engage with the help. Patients would also give each other hugs and encourage each other to use DBT skills if they were actively struggling. And she spent a lot of time just playing cards with other patients, hearing bits about their lives.” ( Eda ) Some even described the development of friendships that they believed to be fundamental to their recovery. “Yes, we got along together. We were not alone; we were in this together. We were good friends. I felt good. It helped me a lot. We knew what each other was going through. That’s what made me well. I was able to interact with the others and become friends ( Ujana ).” Advising and mentoring were seen as promoting hope, especially where closeness and connection were not as readily available. In inpatient services, in particular, where bank staff turnover was high, young people relied on the advice and support of their peers to maintain hope: “And, also, seeing them did show me that there was hope, in a way. Because, it’s all very well, some random nurse telling you – that you’ve never met before – that it will get better but seeing another patient who’s been in that position was encouraging, I guess” ( Eda ). Inevitably, not all relationships were considered positive, and some lasted for the duration of the (inpatient) treatment only. “I think the vast majority of the people I met there and formed a relationship with didn’t end so well, it was like we all got out and realised we had nothing in common. People would get upset over really little things and make it impossible for you to fix that relationship. it’s definitely possible to form a strong relationship with someone in the psychiatric unit, but I think it’s quite hard to maintain those relationships once those people leave ( Georgette ).” In particular, participants described how being left to take on others’ mental health issues was a barrier to their own recovery, introduced ideas that they would not have otherwise thought of, or add to the emotional burden they are already managing at an individual level: “I think it probably would be the opposite, I don’t think that’s good for me because I do have a very bad tendency to take in, I’ve always been the therapist friend, I’m always hearing people’s stories and what they have to say, and I’m always the one helping, and that’s probably been a thing that’s also affected me because I can only take so much. So, I feel like interacting with other people around me, a listening process, that might just give my brain room for more exploration which it should not be exploring ( Ahadi ).” The relational dynamics surrounding the young person seem crucial to their overall mental health picture, given the data presented above. However, what is important is the meaning of the relationship for the CYP, in order to ascertain whether a relationship forms a positive or negative part of their mental health journey and sense of psychological safety. Finally, the role of family members was positioned as central to ongoing feelings of safety or otherwise. Feelings of safety, created by family members, was directly to parental involvement with services, even if the YP experienced did not wish to directly communicate with parents. The extracts below indicate that parents attending appointments and advocating on behalf of the CYP was sufficient to generate feelings of safety, care and ongoing support and love. Definitely my parents, they were constantly making sure I was okay, and not okay like physically, I also mean mentally, they were checking, but obviously I wasn’t in a place to talk to them and I didn't want to, that’s why I didn't go to them for help, but they also made sure I was safe online, they made sure I was safe in life, I knew what was going on with me, I knew what was going on in general. Yes, my parents were very much there and I didn't doubt that they didn't love me or care for me ( Ellen )”. Yes, because she was coming to CAMHS with me at that time so she understood, because I wasn’t going to school so we became closer and she understood what I was going through ( Ashley).” I think my parents definitely cared. And they would try and advocate for me at the doctors,’ on crisis lines, in general hospital. They’d be like, ‘You cannot send her home with no care.’ So, they were really trying to help me. So, I knew they cared (Eda).” Services interacting with parents and listening appear to play a crucial role for YP, even if it’s a form of ‘vicarious’ care and even if CYP are unable to directly communicate their thoughts and feelings to parents. For services, the involvement of parents is not just important for gathering information on the CYP’s wellbeing and treatment engagement, it appears a crucial element in the communication of overall care being provided and the CYP’s feelings of safety and support. Discussion The current study revealed benefits and drawbacks for each of the three acute mental health care models. Consistent with previous research (Gill et al., 2016 ; Reavey et al., 2017 ), the inpatient wards provide a sense of containment and safety, but the inherent risk-based approach can be seen as impersonal and can lead to young people’s needs being overlooked. Generic community care can excel given the exceptional commitments of individual staff members, but it is often perceived as over-standardised, impersonal, and not delivered in a timely manner. Addressing these shortcomings, ICCS teams tend to be commended for their personalised and flexible approach, providing the necessary foundation for trust and openness in the therapeutic process. However, they can be restricted by systemic limitations such as understaffing and high staff turnover. An overarching theme of the experiences reported by the service users in the current study is the importance of relational dynamics in recovery, reinforcing findings from previous research (Broome et al., 2002 ; Topor et al., 2006 ). Successful engagement with the service users is primarily built on and enhanced by the strong interpersonal connections between the young person and their support circle, including the care professionals, peers, and family. Opportunities for building a reciprocal relationship with social networks are critical (Salehi et al., 2019 ). An effective mental health service tends to mobilise and maximise the social capital surrounding the young person and enable their support network to rally behind them in the recovery process. What stands out is that certain elements of perceived good care are expected and met on a clinician level instead of a service level. For instance, a strong therapeutic alliance is the basis to effective treatment especially for young people who self-harm (Jerome et al., 2024 ), and it is possible regardless of the setting. Across all service models, young people reported positive experiences with dedicated clinicians who went above and beyond to demonstrate a willingness to understand them on a personal level. Informal relationships that are not necessarily ‘part of the job’ are valued and make service users more likely to adhere to the intervention (Freake et al., 2007 ). Consistency of the support is reported to be critical and should be achieved across all services. Seeing the same clinician regularly helps young people feel genuinely cared for, corroborating with previous findings that continuity of care increases engagement (Wong et al., 2024 ). Nevertheless, there are evident advantages to the ICCS approach that make it more likely for the connectedness with care professionals to truly prosper. One key element of ICCS is that the clinical contacts tend to take place in young people’s homes or nominated places in the local community (Keiller et al., 2023 ). Compared to the often trauma-inducing inpatient settings, young people tend to feel more in familiar settings which facilitates building a therapeutic relationship and engagement (Sweeney et al., 2014 ). Young people who are going through severe mental health challenges also frequently report struggles to leave the house. In generic community services, this likely results in multiple missed appointments and eventual discharge from the service, exacerbating a sense of social exclusion and even abandonment. On the other hand, ICCS services often incorporate assertive outreach elements (Wright et al., 2003 ), such as a no-dropout policy and motivational engagement mechanisms, in addition to clinicians making efforts to come to the young people’s homes regularly. As reported in the current study, these approaches help young people connect with the clinician, as they could feel that they were indeed not given up, even when they were at their lowest. Apart from contributing to better professional connectedness, there are promising signs that the ICCS model can enhance the connectedness with peers and family. The vital role of healthy social connections is evident in the current study and previous research. Informal peer support helps reduce feelings of isolation and restore a certain sense of normality (Savaglio et al., 2022 ; Shalaby & Agyapong, 2020 ). Whilst the camaraderie with peers in the inpatient ward can have a stabilising effect on the young person, it can also be detrimental if not safely monitored (Salehi et al., 2019 ). The interviewed young people described the intimate personal relationships with other young people who are in the same position to be encouraging but often not sustainable, especially following discharge. There is often associated additional burden as they feel a responsibility to support their peer’s mental health struggles, sacrificing emotional capacity and space to navigate their own recovery. The chaotic environment of inpatient wards adds to the difficulty for professionals to be always aware of these intricate, fluctuating dynamics between young people. In comparison, ICCS clinicians have the opportunity to understand each young person on a personal level, including the background relational dynamics. They are better placed to help young people in building healthy, consistent, and safe peer relationships in the community. Young people mentioned the destructive distress that comes with rejection or toxic peer relationships, sometimes resulting in self-harm or relapses. Regular clinical contact and close observation in the community help contain the effects of fluctuating personal relationships in the course of recovery. Young people can be promptly supported to identify certain triggers and/or any unhealthy thinking patterns, and to develop healthy coping mechanisms before resorting to risky behaviours. The same applies to the relational dynamics within family. In the current study, young people who received ICCS care commonly reported being feeling the care and affection they received from their family. The ICCS model seemingly provides a favourable space for supportive and reassuring parents to be involved in the recovery in the community, as well as for young people to be aware of it. As previous literature revealed, this often produces a protective effects against relapses (Muehlenkamp et al., 2013 ). Incorporating family in the recovery process have been shown to increase service engagement, and lead to better advocacy and more efficient utilisation of existing family strengths (Gopalan et al., 2010 ). The shared experience of the recovery journey, such as attending appointments and setting shared goals, can also strengthen the parent-child bond as parents gain a deeper and more personal understanding of their child's struggles. This study is subject to at least two limitations. The interview did not fully capture the fundamental differences in the healthcare professionals that the participants interacted with. Inpatient wards typically rely on bank or temporary staff, whereas ICCS teams are composed of multi-disciplinary clinicians. The diversity in clinicians might have contributed to the heterogeneity in service experiences found in the current study. Secondly, obstacles in the recruitment in some study sites resulted in a geographically and socio-demographically uneven sample. How this affected the study findings remains unclear. Conclusions It is evident that relational dynamics have a central role in young people’s recovery from acute mental health difficulties. Across all service settings, young people value and benefit from having clinicians that go above and beyond to connect with them on a personal level. Notably, the ICCS model provides an advantageous foundation that supports positive relationships between young people and their clinicians, peers, and family, thus facilitating better service engagement and more efficient treatment. To improve further, service planners and commissioners are recommended to focus addressing some common organisational limitations of ICCS teams, such as staff turnover and insufficient resources. Declarations Consent was gained from all participants - consent forms and signatures all present and correct. Ethical Approval Ethical approval was obtained from the West Midlands and Black Country Research Ethics Committee and the Health Research Authority in the UK, REC reference: 20/WM/0069. The trial was conducted in compliance with the principles of the Declaration of Helsinki (1996), the principles of GCP and in accordance with all applicable regulatory requirements including but not limited to the UK policy framework for health and social care research. The Sponsor trust granted Local Research and Development approval. Informed consent was obtained from all participants. Funding This study was part of a randomised controlled trial, funded by the NIHR HTA Programme (Ref: NIHR127408). The funder plays no role in the trial design, delivery, and interpretation of data, the writing of the report; and the decision to submit the report for publication. Trial registration The IVY trial was registered on April 29, 2020, ISRCTN number: ISRCTN42999542. Availability of data and materials Anonymised data will be available on request. Competing interests The authors declare no competing interest. Authors' Contributions PR, OA, and BHCW contributed to the main manuscript as well as data collection. All authors contributed to recruitment and critical review. Consent for publication Not applicable. All personal identifiable information has been excluded in the manuscript. References Barbui, C., & Saraceno, B. (2015). 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Assertive outreach teams in London: Models of operation: Pan-London Assertive Outreach Study, Part 1. British Journal of Psychiatry , 183 (2), 132-138. https://doi.org/10.1192/bjp.183.2.132 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5574483","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":500996978,"identity":"bf0f51e6-7fd8-4933-964b-dcf27598553a","order_by":0,"name":"Paula 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London","correspondingAuthor":false,"prefix":"","firstName":"Thilipan","middleName":"","lastName":"Thaventhiran","suffix":""},{"id":500996984,"identity":"67d7e869-fc97-4dcc-ad39-dcbaae87962a","order_by":6,"name":"Veronika Dobler","email":"","orcid":"","institution":"Cambridge University Hospitals NHS Foundation Trust","correspondingAuthor":false,"prefix":"","firstName":"Veronika","middleName":"","lastName":"Dobler","suffix":""},{"id":500996985,"identity":"f93b02ac-7eaa-466a-a551-0a3467900c41","order_by":7,"name":"Ruth Woolhouse","email":"","orcid":"","institution":"East London NHS Foundation Trust","correspondingAuthor":false,"prefix":"","firstName":"Ruth","middleName":"","lastName":"Woolhouse","suffix":""},{"id":500996986,"identity":"6a5a3dd2-6c01-4266-bf95-ecc17884c325","order_by":8,"name":"Toby Zundel","email":"","orcid":"","institution":"South London and Maudsley NHS Foundation 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Trust","correspondingAuthor":false,"prefix":"","firstName":"Leon","middleName":"","lastName":"Wehncke","suffix":""},{"id":500996990,"identity":"a141a3cb-d151-4a20-b712-d764432bc24f","order_by":12,"name":"Tauseef Mehdi","email":"","orcid":"","institution":"Royal Berkshire NHS Foundation Trust","correspondingAuthor":false,"prefix":"","firstName":"Tauseef","middleName":"","lastName":"Mehdi","suffix":""},{"id":500996991,"identity":"9b398dad-ca60-450a-b26e-4dd8ad1c7d21","order_by":13,"name":"Rhys Bevan-Jones","email":"","orcid":"","institution":"Cwm Taf Morgannwg University Health Board","correspondingAuthor":false,"prefix":"","firstName":"Rhys","middleName":"","lastName":"Bevan-Jones","suffix":""},{"id":500996992,"identity":"9e37d27b-7a9c-422b-ab55-d6ebfd9b479e","order_by":14,"name":"Dennis Ougrin","email":"","orcid":"","institution":"Queen Mary University of London","correspondingAuthor":false,"prefix":"","firstName":"Dennis","middleName":"","lastName":"Ougrin","suffix":""}],"badges":[],"createdAt":"2024-12-03 18:38:08","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5574483/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5574483/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":101881399,"identity":"4a6bf4e9-3e98-4487-bb05-4bb544fb2eab","added_by":"auto","created_at":"2026-02-04 15:11:53","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":704982,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5574483/v1/c8180776-7c85-4d01-834b-267d99524040.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Relational dynamics and experiences of inpatient and intensive community care for children and young people: matters for service engagement and recovery","fulltext":[{"header":"Background","content":"\u003cp\u003eThere has been a steady increase in the prevalence of mental health challenges amongst children and young people (CYP) across all geographical locations, especially following the Covid 19 pandemic, but even before this period (Kauhanen et al, 2023). Despite an increase in Child and Adolescent Mental Health Services (CAMHS), especially in higher-income countries, existing services are often unable to keep up with the high demand for care (Pitchforth et al., 2018). Inpatient care has been the traditional treatment option for severe mental health disorders, but recent evidence from community interventions reveals a promising community alternative (Ougrin et al, 2021). Inpatient care can often be a distressing experience for CYP, preventing patients from receiving satisfactory care or leading to further post-hospital traumatisation (Bartl et al., 2024; Reavey et al, 2017). Involuntary admissions into hospitals are especially negative for service users, with issues like higher rates of suicide, dissatisfaction with care, increased risk of readmission, and biased treatment towards marginalised populations (Bartl et al., 2024). This form of treatment shows little to modest improvement following discharge and has received predominantly negative feedback, even from the healthcare workers in these inpatient settings. Relationships between staff and CYP in inpatient services have also been found to be less than satisfactory and presented as a barrier to successful treatment and long-term recovery (Hartley et al., 2022). These findings have prompted a transition to alternative, community-based interventions shown to be beneficial for CYP (Keiller et al., 2023). Those discussing their experiences of inpatient care have noted that community-based \u0026nbsp;organisations might address difficulties in a timelier fashion, which in turn serves to reduce involuntary admissions and lead to more positive mental health outcomes in the long term (Ougrin et al., 2021).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCommunity-based services are an especially effective solution to improving the mental well-being of young people when they are connected to other relevant service providers in education and primary care. As an example, Forward Thinking Birmingham is a community-based approach to mental health care that was established following the success of the pilot initiative Youthspace. Youthspace allowed young adults to access mental health services, divided work amongst teams and communicated with general practitioners (GPs) to efficiently provide these patients with care. The organisation also used the internet and social media to broaden its access, connecting young adults to advice, education, and individualised assessment (Vyas et al., 2014, McGorry et al., 2013).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCommunity-based organisations (CBOs) are also helpful for marginalised persons at risk of poor mental health, as the community space provided allows young people to feel comfortable with their identities and build a sense of empowerment and improve mental health within these communities (Bloemraad \u0026amp; Terriquez, 2016). Identifying barriers in access to care and understanding the contexts that shape an individual\u0026rsquo;s mental health are both important in executing preventative services. Discourse in recent policies has lost focus on these contextual factors that are\u0026nbsp;known to be important in the development of psychological distress (Callaghan et al., 2016). Community-based care returns the spotlight to these key origins of mental health challenges, allowing carers to provide patients with effective medical care. Along similar lines, group therapy has emerged as an important intervention for adolescent mental health treatment (Meza et al, 2023). The supportive environment created by a group setting is effective in mitigating self-harm and suicidal ideation among young persons, which decreases the need for crisis intervention services. A community and/or embedded community group-based approach allows for successful intervention for mental health issues surrounding identity or crisis. The intervention is also purported to be better at building positive therapeutic relationships between staff and CYP, in comparison with inpatient services. Building positive relationships is crucial to engagement with treatments and overall recovery, though it is currently under-explored in ICCS (Gerstl et al., 2024; Hartley et al., 2022).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe positive results yielded from community interventions support the importance of implementing community-based services to improve the well-being of CYPs and provide effective care in the long term (Clisu et al, 2022; Kwok et al, 2022). Understanding the significance of these community services, especially in comparison with inpatient care, is required; thus, this present study aims to examine more directly how young people experienced ICCS and inpatient services to better understand the enabling features and some of the barriers to appropriate and well-received mental health care for CYP. Although participant numbers were too limited for a direct comparison, some description of the differences and similarities between inpatient TAU and ICCS will be presented, where relevant.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRationale\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCommunity-based care comes in various forms that generally focus on adults and older adults with severe mental illnesses (SMI), as detailed in the recent NHS Mental Health Implementation plan. This study looks specifically at ICCS, established as a treatment for CYP with severe psychiatric disorders, outside the inpatient setting. The ICCS intervention provides treatment in a comfortable community setting, such as school or at home. It prevents the CYP from being removed from daily activities, such as school and extracurriculars (Keiller et al., 2023). Research underpinning ICCS is minimal, and yet the recent shift from inpatient to community-based care makes this research even more important in determining the effectiveness of this intervention and measuring its impact compared with TAU modalities. Previous findings show ICCS to be a more beneficial treatment than TAU (Ougrin et al., 2021). The present study\u0026rsquo;s objective is to compare ICCS with inpatient TAU from the perspective and lived experiences of the CYPs receiving these services.\u0026nbsp;\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThe qualitative material analysed here was collected as part of a broader NIHR funded Randomized Controlled Trial across seven NHS trusts in England and Wales. The purpose of the trial was to collect data from each NHS trust delivering acute care to children and young people at risk and eligible for Tier 4 inpatient care. ICCS was then compared with a TAU arm for measures relating to global functioning, self-harm, educational engagement, and quality of life. As part of this large national trial, qualitative data in the form of visual-qualitative interviews (see below) were collected to evaluate how both TAU and ICCS were experienced by both staff and service users in terms of the perceived effectiveness of the interventions, feelings associated with giving and receiving treatment, and overall perceived effect on mental health outcomes.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe project was concerned with capturing service users\u0026apos; feelings and lived experiences, so attention to detailed descriptions was central to how the interviews were conducted. The research reported here was primarily based on visual-semi-structured interviews with service users. There were a further thirty-five interviews with staff across TAU and ICCS, ranging from consultant psychiatrists, nurse managers, registered nurses, clinical psychologists, and clinical care support workers.\u003c/p\u003e\n\u003cp\u003eThe data reported in this paper is drawn from fourteen interviews with young people aged 14-17, ranging from four intensive community care services Core CAMHS (6) to intensive community care service users (4). Each interview lasted between 45 and 90 minutes. Ethical approval was obtained from London South Bank University and King\u0026rsquo;s college, London University ethics boards in addition to the West Midlands and Black Country Research Ethics Committee (REC Reference: 20/WM/0069). To ensure confidentiality, all the participant names used in this paper are pseudonyms.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe interviews used a photo-production methodology (Boden \u0026amp; Eatough, 2014; Reavey \u0026amp; Brown, 2021) to elicit more specific and rich responses relating to lived experiences of service use and mental health, generally. The participants used their phones to take the photographs, as this was the most familiar means of collecting images. The images were then sent to the researcher primarily responsible for data collection (OA), who checked the young person had adhered to the inclusion and exclusion criteria and then uploaded them before the face-to-face interview. Interviews were conducted in person or online, depending on the young person\u0026rsquo;s preference.\u003c/p\u003e\n\u003cp\u003eThe photo-production technique required the participants to take photographs of spaces and places related to their treatment and their lives as mental health service users. They were provided with clear guidance on completing the photo-production task, including instructions relating to exclusion and inclusion within the images. For example, participants were not permitted to include other people in their images.\u003c/p\u003e\n\u003cp\u003eThis visual-qualitative approach has been used in the context of examining diverse experiences of distress in mental health settings and beyond, including first episode psychosis with young people, inpatient service use experiences in CAMHS (Reavey et al, 2017), forensic mental health service use (Reavey et al, 2019; Brown et al, 2019; Tucker et al, 2019) and community mental health care (Jenkins, Reavey et al, 2024). A visual approach is adopted to elicit metaphorical, symbolic, and difficult-to-reach feelings (Boden \u0026amp; Larkin, 2020; Reavey, 2020).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe interviews followed a semi-structured format to the extent that a schedule developed by all researchers was used to guide the conversation. However, the interview was guided primarily by the participant\u0026apos;s engagement with the visual material and was set at their pace. The order of questioning was led by the participant whilst discussing the photographs they produced prior to the interview (Reavey \u0026amp; Brown, 2021). Overall, participants engaged with the visual material and interview questions well, with varying levels of engagement with material of a more personal nature.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe interviews were digitally recorded and transcribed verbatim. Participant names were replaced by pseudonyms chosen by the researcher. The photographic images were given meaning by the participant only, in the context of the interview, rather than treated as data to be analysed independently (Reavey \u0026amp; Prosser, 2012). The authors\u0026rsquo; analytical reading of the audio material was guided by the overall research question: how did participants experience their mental health intervention during their time either in hospital or in the community?\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe visual data is not included in the final analysis presented here, as the focus is on narratives of service use and mental health. A choice was made, therefore, to stay close to the verbal narratives as the main data source.\u003c/p\u003e\n\u003cp\u003eAfter notating and coding the material with these questions in mind, the data were re-organised into themes and subsequently considered in the light of literature that could assist in contextualising the analysis. A thematic decomposition (Stenner, 1993) approach was used to analyse the data, which sought to identify processes through which mental health service use was enacted, understood, and experienced. This thematic decomposition was achieved by following several stages of analysis commonly found across all forms of qualitative analysis (Willig, 2008). This involved familiarisation with the data via repeated readings of the transcripts, generating initial codes by paying close attention to meanings embedded in every line of talk, followed by matching the initial codes together to form candidate themes and sub-themes, with the research questions as organisational guides. Each of the authors participated in discussions around whether the generated theme titles and definitions adequately captured the essence of the data. There was cross-validation at all analytical stages, including initial data coding, the expansion of coding into themes and the discussion of themes using key data.\u003c/p\u003e\n\u003cp\u003eThe interpretative process further involved exploring the implicit meaning of the material rather than a more descriptive reading. The validity of the findings was addressed using conventional qualitative procedures, including group analysis by key researchers and peer review, to ensure the analysis was sufficiently grounded in the data (Creswell \u0026amp; Miller, 2000).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAnalysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBefore discussing the main theme of this paper, we provide an overview of the general perspectives on ICCS and TAU, to offer a context to the data extracts that follow.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eGeneral summary of service experience in child and adolescent mental health services\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eService users presented a range of personal experiences with mental health services, particularly the ICCS, Child and Adolescent Mental Health Services (CAMHS), and inpatient facilities, reflecting both positive and negative aspects of care. Inpatient service experiences were divided, with several patients reporting that their needs were effectively addressed, particularly regarding receiving appropriate diagnoses, therapeutic interventions,\u0026nbsp;medication adjustments, and other reporting problems with the \u0026lsquo;sterile\u0026rsquo; approach to care. For those who found inpatient care negative, relationships with staff were highlighted, where staff attention was disproportionately focused on high-risk individuals, leading to a chaotic environment and a perceived lack of support for other patients. Community services, particularly those provided post-discharge, were appreciated for their personalised approach, a testament to the dedication of the healthcare professionals. Home visits were seen as beneficial for patients transitioning from inpatient care. Nevertheless, significant issues were raised regarding the systemic shortcomings of these services, including understaffing, extended waiting times, and the frequent turnover of caregivers. These factors contributed to feelings of frustration, as patients were often required to repeat their histories to new professionals, undermining continuity of care. Patients reported frustration at repeatedly explaining their history to new caregivers, which impeded continuity of care and undermined the therapeutic relationship.\u003c/p\u003e\n\u003cp\u003eStandard community CAMH services elicited more divided responses. While some patients acknowledged the commitment of individual staff members, the service was frequently critiqued for its impersonal and standardised approach, particularly with time-limited therapies. This often made it difficult for patients to form meaningful connections with healthcare providers, and the therapeutic interventions were perceived as generic and inadequately tailored to individual needs.\u003c/p\u003e\n\u003cp\u003eThe following section will draw out further insights from the data, according to one major or superordinate theme, which addresses the key aspects related to service use experience, both in terms of engagement with the service and recovery in general. \u0026nbsp;In particular, the focus is on how relationships appear to serve a primary function in relation to levels of engagement with services and recovery. This theme speaks to the interconnected nature of service use and broader community relations, including relations with family, peers, mental health professionals and friends. To better understand young people\u0026rsquo;s engagement with service use, it is necessary to grasp the relational networks that inform and influence young people in their journey.\u003c/p\u003e\n\u003cp\u003eThroughout, we will focus on a series of key study objectives, such as young people\u0026rsquo;s feelings and thoughts about the services they encounter as well as the role of their broader relational dynamics in this.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eRelational dynamics in engaging and sustaining service use\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll young people described relationships that enabled or disrupted their engagement with services, both in inpatient care and in ICCS. These included relationships with family members, peers, friends and mental health professionals. For some young people, building relationships with mental health professionals constituted a significant part of their recovery, especially when family relations were problematic. In the first section of this analysis, we examine how young people experienced relationships with mental health professionals across ICCS and TAU. We focus on what young people found helpful to their service use and recovery and discuss challenges to their engagement.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eProfessional connectedness: life context and experience-near knowledge\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOne of the key aspects of care that felt\u0026nbsp;important was when the\u0026nbsp;professional staff made efforts to get to know the young person and go beyond standardised reporting of symptoms or risk. Participants valued the informal relationships they forged with staff and saw this as essential to building\u0026nbsp;trust. When professionals talked to young people in a way that emphasised formal assessments, behavioural surveillance and procedures, this was met with suspicion and mistrust (see also Reavey et al, 2017)\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Because it was like a waste of time, it was just annoying, I don\u0026rsquo;t want to talk to them. They would just sit there and ask if you were okay so it was just a waste of time because what do they expect me to say\u0026rdquo; (\u003cem\u003eTish\u003c/em\u003e)\u003c/p\u003e\n\u003cp\u003eTaking time to get to know the young person was part of many young people\u0026rsquo;s experiences of ICCS and was\u0026nbsp;deemed fundamental to establishing trust and openness. A sense of closeness, context and \u0026lsquo;experience-near\u0026rsquo; treatment was heralded as the most positive part of the treatment:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Like if I were to compare my own experiences \u0026ndash; community and then home treatment and then in-patient, I think for me, with my struggles, home treatment has been the best because they step a little bit closer to you, they get to look at things that community might not have\u0026rdquo; (\u003cem\u003eSibley\u003c/em\u003e).\u003c/p\u003e\n\u003cp\u003eKnowing the person as a whole, beyond their mental health challenge, was considered especially valuable, as it provided the young person with a sense of being cared for and valued as a complete character:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;The ETS, I got given when I was coming out of ward because it was kind of classed as an extreme therapy, people talk to you every day, they come and see you every other day\u0026hellip;when I got it I would say it was extremely helpful because CAMHS, if you didn\u0026apos;t want to go, they wouldn\u0026rsquo;t make you, but ETS was like they would make compromises with you in the way that they\u0026rsquo;d still speak to you. \u0026nbsp;Instead of basing it on how they got taught, they would take what they\u0026rsquo;d been taught and know how to approach the patient with what they like, about your hobbies, which gets you more comfortable and with talking they\u0026rsquo;re very good with how quick they help you. And I was very lucky to get people who I felt comfortable with talking to and I think that\u0026rsquo;s really important. They\u0026rsquo;re very good with saying that if you aren\u0026rsquo;t comfortable, then we\u0026rsquo;re more than happy to get someone else, whereas at CAMHS that would take you a while to get a new coordinator\u0026rdquo; (\u003cem\u003eEllen\u003c/em\u003e).\u003c/p\u003e\n\u003cp\u003eOnce more, this idea of building a relationship based on ordinary language, informality and building a sense of comfort was presented as crucial. Going beyond professional discourse and \u0026lsquo;how they got taught\u0026rsquo; helped orient young people to believing that the service was in their best interests and not simply a container space for managing their symptoms or risky behaviour.\u003c/p\u003e\n\u003cp\u003eYoung people were very attuned to knowing the difference between relationships designed to \u0026lsquo;monitor\u0026rsquo; them and \u0026lsquo;care\u0026rsquo; for them; without the latter, they appeared to find it difficult to engage. Knowing their life context was central to the start of this process of feeling cared for and highlighted as significant by many:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;I think one of my nurses in the unit ... mental health service is probably the person who cares most. \u0026nbsp; How I know they care is that it feels like they make an active effort to speak to me, even though I\u0026rsquo;m not even on their patient list, but they\u0026rsquo;re still making an effort. \u0026nbsp;This is someone I\u0026rsquo;ve known quite a long time and he has been there and I have seen him change with the services, he\u0026rsquo;s seen me change with the services\u0026rdquo; (\u003cem\u003eGeorgette\u003c/em\u003e).\u003c/p\u003e\n\u003cp\u003eKnowing someone over time and in context, as described above, was considered fundamental to building trust, as the young person could speak freely outside the confines of assessment and checklists, which was something they valued highly. This was facilitated when young people could be seen outside the confines of traditional service spaces, which they believed to be an enabler for open and honest conversation about mental health, but also contributed to feelings of care and connection:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;I like the idea of that because on days that I was struggling and I did not want to leave the house, it was not like I would not get a session or they would just shut me out like we cannot come to you, it is like someone\u0026rsquo;s not given up on you, you\u0026rsquo;re not left alone to deal with it yourself. \u0026nbsp;They\u0026rsquo;d help you, they\u0026rsquo;d communicate, and they would say, because you\u0026rsquo;re struggling, why don\u0026rsquo;t we go for a walk, we\u0026rsquo;ll go together, something like that; I like the idea that they do not just shut you out (\u003cem\u003eEllen\u003c/em\u003e).\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eProfessionals who were able to recognise that a young person was struggling and meet them in a place that was familiar and comfortable for them were experienced as invaluable. For some who directly connected traumatic experiences of inpatient care, this was not only desirable but necessary:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;When I had home visits, I think they were better than going to a hospital because I have a problem whenever I see especially the **** Hospital \u0026ndash; that exact image \u0026ndash; I get very \u0026hellip; I wouldn\u0026rsquo;t say PTSD, but I get a lot of past images about that place (\u003cem\u003eEllen\u003c/em\u003e).\u0026rdquo;.\u0026rdquo;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBeing seen in a familiar place was soothing and reassuring for some and unrelated to negative institutional experiences. Many described not feeling alone or \u0026lsquo;shut out\u0026rsquo; and valued the idea that someone had not given up on them. Engagement was more likely when young people felt that they had been seen, heard, and connected with on their terms.\u003c/p\u003e\n\u003cp\u003eYoung people considered consistency in staff vital to connecting with professionals and speaking openly. Consistency enabled young people to believe that engagement was possible as their mental health recovery journey could be better understood, contributing to the feeling they were genuinely cared for. When they encountered multiple staff members for short bursts of time, there was a marked difference between \u0026lsquo;knowing\u0026rsquo; they had been cared for and \u0026lsquo;feeling\u0026rsquo; it.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Actually, I don\u0026rsquo;t really feel like a lot of people are involved in my recovery. I \u003cem\u003eknow\u003c/em\u003e there are because I\u0026rsquo;ve seen them. They all once did this media call of all the people involved in my care and there was a lot. There were so many faces that I didn\u0026apos;t even recognise. So, I do know there are a lot of people involved but it doesn\u0026rsquo;t \u003cem\u003efeel\u003c/em\u003e like it\u0026rdquo; (\u003cem\u003eYazid\u003c/em\u003e).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNot knowing mental health professionals or being granted the opportunity to build a trusting relationship with them was presented as a major obstacle to a meaningful engagement with the service and a reason for wanting to withdraw or contributed to feelings of abandonment:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;I think, I didn\u0026apos;t feel that I knew them very well. I hadn\u0026rsquo;t known them for long. I was just like, \u0026lsquo;I don\u0026rsquo;t care. I just want to give up.\u0026rsquo; Which was really out of character for me. I\u0026rsquo;m very \u0026hellip; I like to do well in school; I like to go out and see my friends. I was just a completely different person\u0026rdquo; (\u003cem\u003eEda\u003c/em\u003e)\u003c/p\u003e\n\u003cp\u003eOf note in the extract above is an emphasis on how relationships contribute to the young person\u0026rsquo;s sense of well-being and character. They clearly describe being capable of maintaining meaningful relationships, even when unwell, but experiencing a sense of alienation from the service due to not having the time or space to develop relationships with professionals. However, this was not confined to ICCS, as young people described being able to engage with treatment in inpatient services, but only when a successful relationship had formed:\u003c/p\u003e\n\u003cp\u003eInpatient services offered some young people a safe, contained and continuous space to work on developing coping strategies. However, of note is the central importance placed on this occurring in the context of a good and constant (24-hour care) relationship with staff:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;I think, as I started to do better by engaging with the therapies and the one-to-one support that was, like, twenty-four-hour care, I started to see more \u0026hellip; They were very good at helping me through flashbacks: episodes where I didn\u0026apos;t know where I was or what was happening or who people were. And they helped me learn how to deal with that and cope\u0026rdquo;. (\u003cem\u003eEda\u003c/em\u003e)\u003c/p\u003e\n\u003cp\u003eSome participants believed that immediate and constant care was advantageous, especially when community care was not delivered in a timely manner:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;As an inpatient, I think my struggles and needs were addressed very, very well. I think support from most staff was valuable. I got the diagnoses I needed to get the right therapies. They changed my meds, which, in the community, I\u0026rsquo;d been waiting months to see a psychiatrist. (\u003cem\u003eGeorgette\u003c/em\u003e)\u003c/p\u003e\n\u003cp\u003eIn other cases, there were examples of withdrawal and disengagement due to negative or neglectful experiences with professionals, which directly contributed to feelings of abandonment.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;The worker that I had \u0026hellip; was horrible, really, I\u0026rsquo;m trying to find the right word, but she was not right or fit for her position, the things that she would say to me I\u0026rsquo;ve been told that they were absolutely unacceptable. She essentially discharged me from the services, despite seeing me struggling\u0026rdquo; (\u003cem\u003eSibley\u003c/em\u003e).\u003c/p\u003e\n\u003cp\u003eQuite often I will wake up having nightmares about that and also one of my big things is that I feel quite abandoned by other people and going in there and interacting with all these people on a daily basis and then suddenly having to leave them, it didn\u0026rsquo;t really help with that (\u003cem\u003eGeorgette\u003c/em\u003e).\u003c/p\u003e\n\u003cp\u003eFeeling abandoned by services was less common in ICCS, given that there were more opportunities for connection. However, for some young people who did not have positive or significant peer or family support, the consequences of continuing to struggle without support are concerning.\u003c/p\u003e\n\u003cp\u003eIn the next section, we look at the relational dynamics outside of services to examine how these relationships operate alongside traditional mental health service provision. Young people emphasised the importance of these networks in their engagement with services and their overall recovery journey, whether positive or negative.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003ePeer relationships: attachments, solidarity and mirroring\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWorking alongside service provision were relationships that young people deemed highly significant in shaping their mental health challenges and recovery journey.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eInformation regarding the relationships in a young person\u0026rsquo;s life is crucial for understanding their influences on mental health, both positive and negative. Feeling better or worse could sometimes be directly connected to what was occurring in a relationship and the forms of support or disruption emerging from it. Young people could connect aspects of their mental health with observations about the contributing role of their attachments, feelings of safety and unsafety and emotional investments in relationships that they believe to be important and relevant to their treatment.\u003c/p\u003e\n\u003cp\u003eAs the following extract highlights, however, relationships can shift and alter the course of a young person\u0026rsquo;s distress, making it even more important to enquire after background relational dynamics to better understand the ebbs and flows of their distress:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Before I got help from my parents and then I started getting help from CAMHS, I had a boyfriend at this time and I basically relied on him for everything. \u0026nbsp;I had noticed that when I talked to him, I\u0026rsquo;d feel better, safer, I didn\u0026apos;t feel the need to self-harm and that was helpful up to a certain point where it became toxic on my side, but we were both struggling\u0026rdquo; (\u003cem\u003eEllen\u003c/em\u003e).\u003c/p\u003e\n\u003cp\u003eIn contrast, for some young people, fluctuating intimate relationships could significantly disrupt mental health in ways they themselves recognized as highly significant and destructive:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Obviously as expected, Covid had kind of wiped quite a lot of us out, but it came to a point where, if he wouldn\u0026rsquo;t call me or text me for a certain amount of time, I wouldn\u0026rsquo;t feel okay anymore, I would get really unsafe, I\u0026rsquo;d end up self-harming, then it would go back and forth, this really unhealthy attachment. \u0026nbsp; But then around one Christmas he broke up with me for good after I was just going back and forth like a game of tennis and I obliterated my leg, it was covered in cuts, (\u003cem\u003eEllen\u003c/em\u003e).\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eThe destructive potential of intimate relationships is undoubtedly worthy of deeper scrutiny when it comes to understanding forms of distress and self-harm, and yet it was often overlooked in treatment. Little is known about the impact of intimate relationships on young people\u0026rsquo;s mental health, and yet what is known is the vital importance of relationships in young people\u0026rsquo;s perceptions of their wellbeing and levels of mental distress (Price et al., 2016).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePrevious literature suggests professionals are either not aware of the relationships in a young person\u0026rsquo;s life or actively discourage peer relationships that form through service use (Reavey et al, 2017). And yet, young people do develop peer relationships and friendships in services, which can significantly contribute to the young person\u0026rsquo;s journey through the service and their recovery. In the extract below, the participant describes a model of peer relating based on mentoring, where young people advise and pass on their knowledge of treatments to support others in the management of symptoms and distress.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;I got to know some patients very, very well, especially ones that were my age and admitted around the same time as me. When I was first admitted, the patients who had been there much longer and were going to be discharged soon and were in a much better place, they would try and encourage me to engage with the help. Patients would also give each other hugs and encourage each other to use DBT skills if they were actively struggling. And she spent a lot of time just playing cards with other patients, hearing bits about their lives.\u0026rdquo; (\u003cem\u003eEda\u003c/em\u003e)\u003c/p\u003e\n\u003cp\u003eSome even described the development of friendships that they believed to be fundamental to their recovery.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Yes, we got along together. We were not alone; we were in this together. We were good friends. I felt good. It helped me a lot. We knew what each other was going through. That\u0026rsquo;s what made me well.\u0026nbsp;I was able to interact with the others and become friends (\u003cem\u003eUjana\u003c/em\u003e).\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eAdvising and mentoring were seen as promoting hope, especially where closeness and connection were not as readily available. In inpatient services, in particular, where bank staff turnover was high, young people relied on the advice and support of their peers to maintain hope:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;And, also, seeing them did show me that there was hope, in a way. Because, it\u0026rsquo;s all very well, some random nurse telling you \u0026ndash; that you\u0026rsquo;ve never met before \u0026ndash; that it will get better but seeing another patient who\u0026rsquo;s been in that position was encouraging, I guess\u0026rdquo; (\u003cem\u003eEda\u003c/em\u003e).\u003c/p\u003e\n\u003cp\u003eInevitably, not all relationships were considered positive, and some lasted for the duration of the (inpatient) treatment only.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;I think the vast majority of the people I met there and formed a relationship with didn\u0026rsquo;t end so well, it was like we all got out and realised we had nothing in common. People would get upset over really little things and make it impossible for you to fix that relationship. it\u0026rsquo;s definitely possible to form a strong relationship with someone in the psychiatric unit, but I think it\u0026rsquo;s quite hard to maintain those relationships once those people leave (\u003cem\u003eGeorgette\u003c/em\u003e).\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eIn particular, participants described how being left to take on others\u0026rsquo; mental health issues was a barrier to their own recovery, introduced ideas that they would not have otherwise thought of, or add to the emotional burden they are already managing at an individual level:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;I think it probably would be the opposite, I don\u0026rsquo;t think that\u0026rsquo;s good for me because I do have a very bad tendency to take in, I\u0026rsquo;ve always been the therapist friend, I\u0026rsquo;m always hearing people\u0026rsquo;s stories and what they have to say, and I\u0026rsquo;m always the one helping, and that\u0026rsquo;s probably been a thing that\u0026rsquo;s also affected me because I can only take so much. \u0026nbsp;So, I feel like interacting with other people around me, a listening process, that might just give my brain room for more exploration which it should not be exploring (\u003cem\u003eAhadi\u003c/em\u003e).\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eThe relational dynamics surrounding the young person seem crucial to their overall mental health picture, given the data presented above. However, what is important is the meaning of the relationship for the CYP, in order to ascertain whether a relationship forms a positive or negative part of their mental health journey and sense of psychological safety.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFinally, the role of family members was positioned as central to ongoing feelings of safety or otherwise. Feelings of safety, created by family members, was directly to parental involvement with services, even if the YP experienced did not wish to directly communicate with parents. The extracts below indicate that parents attending appointments and advocating on behalf of the CYP was sufficient to generate feelings of safety, care and ongoing support and love.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDefinitely my parents, they were constantly making sure I was okay, and not okay like physically, I also mean mentally, they were checking, but obviously I wasn\u0026rsquo;t in a place to talk to them and I didn\u0026apos;t want to, that\u0026rsquo;s why I didn\u0026apos;t go to them for help, but they also made sure I was safe online, they made sure I was safe in life, I knew what was going on with me, I knew what was going on in general. \u0026nbsp;Yes, my parents were very much there and I didn\u0026apos;t doubt that they didn\u0026apos;t love me or care for me (\u003cem\u003eEllen\u003c/em\u003e)\u0026rdquo;.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eYes, because she was coming to CAMHS with me at that time so she understood, because I wasn\u0026rsquo;t going to school so we became closer and she understood what I was going through ( Ashley).\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI think my parents definitely cared. And they would try and advocate for me at the doctors,\u0026rsquo; on crisis lines, in general hospital. They\u0026rsquo;d be like, \u0026lsquo;You cannot send her home with no care.\u0026rsquo; So, they were really trying to help me. So, I knew they cared (Eda).\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eServices interacting with parents and listening appear to play a crucial role for YP, even if it\u0026rsquo;s a form of \u0026lsquo;vicarious\u0026rsquo; care and even if CYP are unable to directly communicate their thoughts and feelings to parents. For services, the involvement of parents is not just important for gathering information on the CYP\u0026rsquo;s wellbeing and treatment engagement, it appears a crucial element in the communication of overall care being provided and the CYP\u0026rsquo;s feelings of safety and support.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe current study revealed benefits and drawbacks for each of the three acute mental health care models. Consistent with previous research (Gill et al., \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Reavey et al., \u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e2017\u003c/span\u003e), the inpatient wards provide a sense of containment and safety, but the inherent risk-based approach can be seen as impersonal and can lead to young people\u0026rsquo;s needs being overlooked. Generic community care can excel given the exceptional commitments of individual staff members, but it is often perceived as over-standardised, impersonal, and not delivered in a timely manner. Addressing these shortcomings, ICCS teams tend to be commended for their personalised and flexible approach, providing the necessary foundation for trust and openness in the therapeutic process. However, they can be restricted by systemic limitations such as understaffing and high staff turnover.\u003c/p\u003e\u003cp\u003eAn overarching theme of the experiences reported by the service users in the current study is the importance of relational dynamics in recovery, reinforcing findings from previous research (Broome et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2002\u003c/span\u003e; Topor et al., \u003cspan citationid=\"CR89\" class=\"CitationRef\"\u003e2006\u003c/span\u003e). Successful engagement with the service users is primarily built on and enhanced by the strong interpersonal connections between the young person and their support circle, including the care professionals, peers, and family. Opportunities for building a reciprocal relationship with social networks are critical (Salehi et al., \u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). An effective mental health service tends to mobilise and maximise the social capital surrounding the young person and enable their support network to rally behind them in the recovery process.\u003c/p\u003e\u003cp\u003eWhat stands out is that certain elements of perceived good care are expected and met on a clinician level instead of a service level. For instance, a strong therapeutic alliance is the basis to effective treatment especially for young people who self-harm (Jerome et al., \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2024\u003c/span\u003e), and it is possible regardless of the setting. Across all service models, young people reported positive experiences with dedicated clinicians who went above and beyond to demonstrate a willingness to understand them on a personal level. Informal relationships that are not necessarily \u0026lsquo;part of the job\u0026rsquo; are valued and make service users more likely to adhere to the intervention (Freake et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2007\u003c/span\u003e). Consistency of the support is reported to be critical and should be achieved across all services. Seeing the same clinician regularly helps young people feel genuinely cared for, corroborating with previous findings that continuity of care increases engagement (Wong et al., \u003cspan citationid=\"CR96\" class=\"CitationRef\"\u003e2024\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eNevertheless, there are evident advantages to the ICCS approach that make it more likely for the connectedness with care professionals to truly prosper. One key element of ICCS is that the clinical contacts tend to take place in young people\u0026rsquo;s homes or nominated places in the local community (Keiller et al., \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Compared to the often trauma-inducing inpatient settings, young people tend to feel more in familiar settings which facilitates building a therapeutic relationship and engagement (Sweeney et al., \u003cspan citationid=\"CR82\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). Young people who are going through severe mental health challenges also frequently report struggles to leave the house. In generic community services, this likely results in multiple missed appointments and eventual discharge from the service, exacerbating a sense of social exclusion and even abandonment. On the other hand, ICCS services often incorporate assertive outreach elements (Wright et al., \u003cspan citationid=\"CR99\" class=\"CitationRef\"\u003e2003\u003c/span\u003e), such as a no-dropout policy and motivational engagement mechanisms, in addition to clinicians making efforts to come to the young people\u0026rsquo;s homes regularly. As reported in the current study, these approaches help young people connect with the clinician, as they could feel that they were indeed not given up, even when they were at their lowest.\u003c/p\u003e\u003cp\u003eApart from contributing to better professional connectedness, there are promising signs that the ICCS model can enhance the connectedness with peers and family. The vital role of healthy social connections is evident in the current study and previous research. Informal peer support helps reduce feelings of isolation and restore a certain sense of normality (Savaglio et al., \u003cspan citationid=\"CR80\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Shalaby \u0026amp; Agyapong, \u003cspan citationid=\"CR81\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Whilst the camaraderie with peers in the inpatient ward can have a stabilising effect on the young person, it can also be detrimental if not safely monitored (Salehi et al., \u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). The interviewed young people described the intimate personal relationships with other young people who are in the same position to be encouraging but often not sustainable, especially following discharge. There is often associated additional burden as they feel a responsibility to support their peer\u0026rsquo;s mental health struggles, sacrificing emotional capacity and space to navigate their own recovery. The chaotic environment of inpatient wards adds to the difficulty for professionals to be always aware of these intricate, fluctuating dynamics between young people. In comparison, ICCS clinicians have the opportunity to understand each young person on a personal level, including the background relational dynamics. They are better placed to help young people in building healthy, consistent, and safe peer relationships in the community. Young people mentioned the destructive distress that comes with rejection or toxic peer relationships, sometimes resulting in self-harm or relapses. Regular clinical contact and close observation in the community help contain the effects of fluctuating personal relationships in the course of recovery. Young people can be promptly supported to identify certain triggers and/or any unhealthy thinking patterns, and to develop healthy coping mechanisms before resorting to risky behaviours.\u003c/p\u003e\u003cp\u003eThe same applies to the relational dynamics within family. In the current study, young people who received ICCS care commonly reported being feeling the care and affection they received from their family. The ICCS model seemingly provides a favourable space for supportive and reassuring parents to be involved in the recovery in the community, as well as for young people to be aware of it. As previous literature revealed, this often produces a protective effects against relapses (Muehlenkamp et al., \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e2013\u003c/span\u003e). Incorporating family in the recovery process have been shown to increase service engagement, and lead to better advocacy and more efficient utilisation of existing family strengths (Gopalan et al., \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2010\u003c/span\u003e). The shared experience of the recovery journey, such as attending appointments and setting shared goals, can also strengthen the parent-child bond as parents gain a deeper and more personal understanding of their child's struggles.\u003c/p\u003e\u003cp\u003eThis study is subject to at least two limitations. The interview did not fully capture the fundamental differences in the healthcare professionals that the participants interacted with. Inpatient wards typically rely on bank or temporary staff, whereas ICCS teams are composed of multi-disciplinary clinicians. The diversity in clinicians might have contributed to the heterogeneity in service experiences found in the current study. Secondly, obstacles in the recruitment in some study sites resulted in a geographically and socio-demographically uneven sample. How this affected the study findings remains unclear.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIt is evident that relational dynamics have a central role in young people\u0026rsquo;s recovery from acute mental health difficulties. Across all service settings, young people value and benefit from having clinicians that go above and beyond to connect with them on a personal level. Notably, the ICCS model provides an advantageous foundation that supports positive relationships between young people and their clinicians, peers, and family, thus facilitating better service engagement and more efficient treatment. To improve further, service planners and commissioners are recommended to focus addressing some common organisational limitations of ICCS teams, such as staff turnover and insufficient resources.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cspan\u003eConsent was gained from all participants - consent forms and signatures all present and correct.\u003c/span\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eEthical Approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was obtained from the West Midlands and Black Country Research Ethics Committee and the Health Research Authority in the UK, REC reference: 20/WM/0069. The trial was conducted in compliance with the principles of the Declaration of Helsinki (1996), the principles of GCP and in accordance with all applicable regulatory requirements including but not limited to the UK policy framework for health and social care research. The Sponsor trust granted Local Research and Development approval. Informed consent was obtained from all participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was part of a randomised controlled trial, funded by the NIHR HTA Programme (Ref: NIHR127408). The funder plays no role in the trial design, delivery, and interpretation of data, the writing of the report; and the decision to submit the report for publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial registration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe IVY trial was registered on April 29, 2020, ISRCTN number: ISRCTN42999542.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAnonymised data will be available on request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePR, OA, and BHCW contributed to the main manuscript as well as data collection. \u0026nbsp; All authors contributed to recruitment and critical review.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable. All personal identifiable information has been excluded in the manuscript.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBarbui, C., \u0026amp; Saraceno, B. (2015). Closing forensic psychiatric hospitals in Italy: A new revolution begins? The British Journal of Psychiatry, 206, 445\u0026ndash;446. https://doi.org/ 10.1192/bjp.bp.114.153817\u003c/li\u003e\n\u003cli\u003eBartl, G., Stuart, R., Ahmed, N., Saunders, K., Loizou, S., Brady, G., Gray, H., Grundy, A., Jeynes, T., Nyikavaranda, P., Persaud, K., Raad, A., Foye, U., Simpson, A., Johnson, S., \u0026amp; Lloyd-Evans, B. (2024). 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Assertive outreach teams in London: Models of operation: Pan-London Assertive Outreach Study, Part 1. \u003cem\u003eBritish Journal of Psychiatry\u003c/em\u003e,\u003cem\u003e 183\u003c/em\u003e(2), 132-138. https://doi.org/10.1192/bjp.183.2.132 \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":true,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-5574483/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5574483/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003ePrevious research on young people's experience of inpatient services and community services has often relied on the responses of carers and relevant practitioners. As part of a wider\u003c/p\u003e\n\u003cp\u003erandomised controlled trial comparing Intensive Community Care Services (ICCS) with treatments as usual (TAU) across the UK, including inpatient and generic community care models, this paper examines how young people experience these different models. Fourteen young people participated in a semi-structured visual interview study to reflect on their service experiences, with a focus on recovery journey and service engagement. A thematic decomposition analysis was conducted on the data, and specific themes relevant to satisfaction and engagement with services were examined in-depth.\u003cstrong\u003e \u003c/strong\u003eA central theme emerged was the importance of relational dynamics. In particular, we explored relationships with mental health professionals and the peer and family relationships that shape and impact experiences of service use and recovery.\u003c/p\u003e\n\u003cp\u003eYoung people shared mixed experiences with mental health services. Inpatient care and generic community services received both praises for individual staff commitment and reassuring diagnoses and containment, and criticisms such as inflexible approaches, inadequate staff attention, and untimely appointments. Relationships with support network were commonly reported to be unstable and unsustainable. On the contrary, the ICCS model was valued for the personalised approach, including beneficial home visits. The approach facilitated development and mobilisation of positive relationships in the community with the surrounding support network. The findings serve as a reminder of the significance to build trust-based relationships with young people that go beyond mental health assessment and treatment. Future research and service development should focus on resolving common systemic issues that hinder continuity of care, such as understaffing, long wait times, and high turnover.\u003c/p\u003e","manuscriptTitle":"Relational dynamics and experiences of inpatient and intensive community care for children and young people: matters for service engagement and recovery","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-25 05:34:45","doi":"10.21203/rs.3.rs-5574483/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"7bc82ccd-4cf4-4550-8784-a1b07ffbd908","owner":[],"postedDate":"August 25th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-02-04T10:11:29+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-25 05:34:45","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5574483","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5574483","identity":"rs-5574483","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}