Title: Thriving therapeutic relationships in Child and Adolescent Mental Health Services
Funder: Health Education England

Abstract: Background Relationships are the bedrock of any therapeutic intervention and have the largest impact on treatment outcome (Duncan et al., 2010; Wampold, 2001). They are particularly essential in Child and Adolescent Mental Health Services (CAMHS), being a key predictor of positive benefit of inpatient admissions (Green et al., 2007; Karver 2006; Shirk and Karver, 2003). Nursing staff are key to the provision of inpatient services and are the professional group that have the most contact with young people and their families. Young people and families both value relationships with staff and find them difficult to develop (Gross & Goldin, 2008; Sergeant, 2009; Sischy, 2006; Street & Svanberg, 2003a; 2003b; Garcia and Weisz, 2002), and staff teams face high levels of burnout, turnover and complexity (Johnson et al, 2012; Nixon, 2006; Ellis, 2016). Despite advances in adult service contexts, where there are putative interventions supporting staff to develop helpful relationships (Edwards et al., 2006; Caruso et al., 2013; Berry et al., 2009), these have not been adapted to a CAMHS context, young people's specific needs or inclusive of family relationships. Aim The aim of this study is therefore to develop a theoretically-driven, tailored and publicly-informed intervention that will support the development and maintenance of helpful therapeutic relationships between nursing staff, young people and family members. I will develop a protocol based on existing evidence, extensive stakeholder input and clinical expertise and subsequently evaluate its feasibility and acceptability in CAMHS contexts. Plan In phase 1, the existing literature will be critically reviewed to collate information on current evidence-based intervention strategies targeting the therapeutic alliance between nursing staff and service users. Phase 2 will use in-depth qualitative interviews with young people, family members and nursing staff to explore the difficulties in relationship-building and how alliance is fostered in a helpful way. Drawing these two sources of evidence together, this phase will culminate with a consensus approach, utilising a nominal group technique whereby experts (young people, clinicians, academics, family members and multidisciplinary staff) convene to review the evidence and discuss the nuances of intervention implementation in CAMHS contexts. From this basis, I will produce an intervention protocol that will be evaluated for its feasibility and acceptability across two CAMHS inpatient wards in phase 3; assessing recruitment, retention, staff feedback and multifaceted outcomes. Potential benefit My research will provide a unique insight into the nature of therapeutic relationships between nursing staff, young people and their family members, highlighting factors that foster these and also barriers to their development and maintenance. This information will allow a bespoke intervention package to be created that targets the improvement of therapeutic relationships in CAMHS, which are proven to be a key feature of good outcomes, good experiences and good services. The research will produce an intervention manual and indicators of likely effect sizes that will inform a full evaluation trial. If promising, the intervention can be piloted and trialled fully by future work and ready to be delivered into services within five years. My proposal includes training that extends my current interests and skills while providing a good fit with the nature of the planned research. I will deliver a programme that is clinically-relevant, valuable to the public and accessible to front-line services, while developing myself as a true clinical academic.

Lay abstract: Background: When people are mentally unwell, the most important thing is that they have a good relationship with the people that care for them. Young people and families really value the relationships they have with nursing staff. When these relationships are positive, there is more improvement in mental health. Having good relationships with nursing staff can help especially when young people struggle to open up in one-to-one sessions with therapists. Young people and families might find it hard to develop good relationships with staff because of their own difficulties. Staff might struggle due to the challenging working environment and stress levels. Some things that could help are staff having support and training to understand young people's difficulties and build the relationships with them and their family. Aims: We want to develop a way of supporting good therapeutic relationships that suits young people, families and staff members who are in hospital-based child and adolescent mental health services. Design and methods: Firstly, we will look at what has already been done to help build relationships in other settings, such as with adults. Secondly, we will get the views of young people, family members and staff on what helps and hinders relationships. Next, we will gather together a range of people; including clinical experts, young people, family members and different types of staff, to review the information and discuss how it could be applied to support relationships in services for children and adolescents. We will then test-out these ideas in a number of different services to see if they are feasible and acceptable to the staff, young people and family members. We will achieve this by looking at how many staff members get involved, remain involved and what they think of the support. We will also see if the help for relationships improves other things like young people's, family members' and staff members' wellbeing. If we find that the extra support is acceptable and feasible, then in the future, a larger study could be done. This would say with more certainty whether the extra support is helpful for relationships or not. We hope this will make for better relationships in the long run, and better mental wellbeing. Patient and public involvement: We are committed to involving young people, family members and nursing staff throughout our research. In developing the idea, we have discussed the nature of inpatient stays with all stakeholders, who have expressed their experiences of the value, difficulties and possible ways of improving relationships. We plan to set up a public reference group, to input into all stages of the project design and implementation. This group will consist of young people, family members and nursing staff and we will support the members to decide on a structure and scope for meeting that feels accessible and useful to them. Financial support and training to support involvement will also be available. Dissemination: We intend to disseminate the findings of the study widely, including to young people and family members. The results will be published in peer reviewed journals, national conferences, public research workshops and with key policy makers. We also intend to use social media and video to share our ideas and plans in an accessible way.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: MENTAL HEALTH