During my placement at the Child and Adolescent Mental Health Service (CAMHS), I worked with Olivia, a 17-year-old dealing with complex trauma, attention deficit hyperactivity disorder (ADHD), self-injury, and disordered eating characterised by restrictive eating. My main objectives were to understand and implement therapeutic approaches, manage potential risks, and assist Olivia in transitioning from CAMHS to adult care. Under the supervision of one of my practice supervisors, I conducted a five Ps assessment , attended weekly sessions with Olivia, and participated in multidisciplinary team (MDT) meetings, including a Care-Programme Approach (CPA) meeting to review Olivia's care plan.
Initially, I felt concerned about supporting someone with high-risk behaviours. Collaborating with Olivia, I found it emotionally difficult to balance engaging in positive risk-taking and adopting risk-averse strategies. Olivia's declaration, "I feel trapped here and I have nothing left to lose!" during the CPA meeting heightened my worries for her safety and well-being. I also experienced at times a sense of responsibility towards Olivia, aiming to ensure that she was acknowledged and supported during her treatment.
The encounter was characterised by the development of a strong therapeutic connection with Olivia, fostered by effective communication and empathy. The 5 Ps assessment provided a comprehensive understanding of Olivia's needs (Macneil et al. 2012), while the collaborative approach of the MDT facilitated holistic care planning. Nevertheless, I found it mentally and emotionally draining to handle the complex process of evaluating and making decisions about potential risks, especially when considering Olivia's wish for greater autonomy versus the necessity of maintaining a supervised setting to ensure her well-being.
Moreover, managing the transition from CAMHS to adult treatment required a sophisticated understanding of both systems. Alongside this, I had to consider my well-being and I have taken a note to reflect on how I am feeling and appreciated the clinical supervision with Jasmine (my practice assessor). I am beginning to reflect on how my emotions and anxieties might impact my decision making which may impact my practice and the outcomes for the people I work with.
Utilising the biopsychosocial model and conducting the 5 Ps assessment allowed me to gain a comprehensive understanding of Olivia's overall requirements, considering her adverse childhood experiences (ACEs) and their impact on her mental well-being (Sampogna, Luciano, and Fiorillo, 2023).
The 5 Ps framework is a tool used to understand an individual's difficulties and identify targets for intervention. The 5 Ps are:
• Presenting problem: The primary problem
• Predisposing factors: Factors that predispose the individual to the problem
• Precipitating factors: Factors that precipitated the problem
• Perpetuating factors: Factors that perpetuate the problem
• Protective/positive factors: Factors that are protective or positive
Macneil, C. A., Hasty, M. K., Conus, P., & Berk, M. (2012). Is diagnosis enough to guide interventions in mental health? Using case formulation in clinical practice. BMC Medicine, 10(111), 1–3
The Tidal Model offered a framework to perceive Olivia's experiences as dynamic, acknowledging the combined and varied factors contributing to her present condition (Barker, 2001). The shift from CAMHS to adult services presented notable challenges, requiring careful planning and assistance. The input from the MDT and the advice provided by supervisors played a vital role in developing a person-centred care plan that aimed to balance safety and independence.
Understanding the links between ACEs and trauma is crucial in my practice as a student nurse because it allows for a deeper comprehension of the underlying factors contributing to a person’s mental and physical health issues (Gu, 2022). ACEs, such as neglect, abuse, and household dysfunction, have long-lasting effects on an individual’s health, leading to increased risks of mental health disorders, substance abuse, and chronic diseases (Hughes, et al. 2016). Recognising these connections enables me to adopt a trauma-informed approach using psychosocial interventions, which involves being sensitive to the impact of trauma on behaviour and health, ensuring that care is holistic and considers the person’s past experiences. This understanding promotes empathy, reduces re-traumatisation, and fosters a safe and supportive environment conducive to healing.
Incorporating Olivia’s interests, particularly her love for art, into her care plan significantly enhanced her engagement and therapeutic outcomes. Providing her with paint brushes and art supplies allowed her to express her emotions and experiences creatively, which she found difficult to verbalise. This personalised approach not only made Olivia feel understood and valued but also facilitated a non-verbal means of communication, making it easier for her to share her feelings. As a result, Olivia was more open during sessions, which helped in developing a more accurate and effective care plan. This experience taught me the importance of individualised care and the need to consider a person’s strengths and interests in therapeutic interventions. I also realised that people will express themselves and find certain things difficult when talking about their experiences.
Balancing positive risk-taking and risk-averse approaches in mental health care involves several key factors (Ahmed, et al. 2021). First, ensuring the immediate and long-term safety of the person is paramount. This includes assessing the risk of self-harm, suicide, and other harmful behaviours. Empowering people to take control and responsibility over their care is crucial for their recovery and wellbeing. The availability and level of support systems, such as family, friends, and healthcare providers, play a vital role in determining the feasibility of positive risk-taking. Assessing the person’s capacity, discussing options, considering their readiness for change and their ability to cope with the consequences of their actions is essential, involving evaluating their mental and emotional resilience within their current situation. Using clinical judgment while working in collaboration to weigh the potential benefits and harms of different approaches ensures that decisions are evidence-based and in the best interest of the person. Implementing a plan for continuous monitoring and reassessment to adjust the care plan as needed ensures the person’s safety and well-being.
Through this placement, I gained an understanding of the significance of therapeutic connections and effective communication in delivering care that focuses on the individual. The major lessons were comprehending the intricacies of risk management and recognising the importance of a comprehensive approach to mental health care. This experience also emphasised the need for resilience and emotional intelligence when dealing with difficult situations. In the future, I acknowledge the importance of ongoing education and growth, especially in fields such as trauma-informed care, psychosocial interventions and risk assessment.
To improve my future professional skills, I intend to participate in additional training focused on trauma-informed care and the handling of ACEs. My objective is to enhance my proficiency in risk assessment and management through community-based assignments and guidance from ‘seasoned experts’. Furthermore, I shall persist in formulating tactics for maintaining an appropriate balance between recognising beneficial risks and safeguarding people. My specific goals are to enhance my knowledge of the transition procedures between CAMHS and adult services and to improve my skills in providing therapeutic interventions such as DBT and ACT. For example, ABC Please Skill - Dialectical Behavior Therapy (DBT) Tools
In conclusion, using Gibbs' Reflective Cycle to reflect on my placement at CAMHS has provided great insights into my practical experience. Through the process of reflection, assessing results, and formulating a strategic course of action, I have identified areas in need of improvement and established clear objectives for my professional growth. This systematic reflection will assist me in improving my skills as a dual-field nursing student and ultimately contribute to enhanced care in my future profession.
A few weeks after this experience a letter arrived at the university for me, if was from Olivia thanking me for my help and wishing me well in my studies. This was on a beautiful hand painted card that she had made at her art class. Working with Olivia helped me connect theory and practice. I was able to see how my practice made a difference to Olivia; reflecting on this and the card I received gave me a real feeling of hope for her future.
Reference list:
Ahmed, N. et al. (2021). Mental health professionals’ perceived barriers and enablers to shared decision-making in risk assessment and risk management: a qualitative systematic review. BMC psychiatry, 21, pp.1-28. Available at: 10.1186/s12888-021-03304-0 (Accessed: 18/07/2024)
Barker, P. (2001). The tidal model: Developing a person‐centred approach to psychiatric and mental health nursing. Perspectives in psychiatric care, 37(3), pp.79-87.Available at: DOI: 10.1111/j.1744-6163.2001.tb00631.x (Accessed: 17/07/2024)
Gibbs, G. (1988). Learning by doing: A guide to teaching and learning methods. Further Education Unit.
Gu, W. (2022). Impact of adverse childhood experiences on the symptom severity of different mental disorders: a cross-diagnostic study. General psychiatry, 35(2). Available at: doi: 10.1136/gpsych-2021-100741 (Accessed: 16/07/2024)
Hughes, K. et al. (2016). Relationships between adverse childhood experiences and adult mental well-being: results from an English national household survey. BMC public health, 16, pp.1-11. Available at: https://doi.org/10.1186/s12889-016-2906-3 (Accessed: 16/07/2024)
Macneil, C.A. et al. (2012). Is diagnosis enough to guide interventions in mental health? Using case formulation in clinical practice. BMC medicine, 10, pp.1-3. Available at: doi: 10.1186/1741-7015-10-111 (Accessed: 16/07/2024)
Sampogna, G., Luciano, M. and Fiorillo, A. (2023). The Psychiatric Formulation. In Tasman’s Psychiatry (pp. 1-13). Cham: Springer International Publishing. Available at: https://doi.org/10.1007/978-3-030-42825-9_120-1 (Accessed: 16/07/2024)
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