A blog by Mrs Lizzy Archibald, Chair of the Scottish CAMHS AHP Leadership Group, Divisional Lead Occupational Therapist and CAMHS AHP Lead, NHS Grampian. Professional Advisor to the Perinatal and Infant Mental Health Programme Board, Scottish Government (current secondment)
My name is Lizzy and I’m an Occupational Therapist. I graduated in 2002 from Queen Margaret University I’ve worked in NHS Scotland for the last 21 years. I want to tell you about the joy of my career so far. Without doubt, the best bit has been my time working in CAMHS. The privilege of working closely with young people and families, in their time of need, is one I’ve never taken for granted.
I want to tell you a bit about the role of a CAMHS Occupational Therapist. Occupational Therapists belong to a family of professions called Allied Health Professions (AHPs). AHPs are regulated by the Health and Care Professions Council (HCPC) and professional bodies such as the Royal College of Occupational Therapy. Some CAMHS teams have a group of AHP staff including Speech and Language Therapists, Physiotherapists, Dietitians and Arts Therapists. These AHPs are embedded in the CAMHS multidisciplinary team and have much to offer children, young people and families. Let me tell you more.
I worked in adult acute mental health wards and an adult mental health rehabilitation outreach team and community rehabilitation unit before joining CAMHS. I had a good grounding in both the acute and community treatment side of mental health care. I was a bit wary about working with children and families but decided to go for a job in CAMHS. I’m so pleased I took the plunge!
In the beginning, working in CAMHS felt very different. I had to make sure I left time during appointments for both young people and their families. I had to learn a bit more about child development, neurodevelopmental conditions, children’s rights and motor sensory assessment and intervention. At the time, I was the only Occupational Therapist working in CAMHS in the North East of Scotland so I sought support and supervision from my CAMHS Occupational Therapy colleagues in Lothian, Fife and Tayside and I am forever grateful for their support.
I was forging a new role in a new area and there was lots of learning to do. I had to learn about CAMHS but I also had to learn to protect my professional role as part of a busy multidisciplinary team. A big part of this was teaching those in my team about the potential of the Occupational Therapy contribution. So what is Occupational Therapy? The Royal College of Occupational Therapists (2017) describe Occupational Therapy:
“You take an asset-based approach, analysing and utilising the strengths of the individual, the environment, and the community in which a person lives and functions. You work with the person, their family and/or carers and their communities where appropriate, to identify solutions and enhance their ability to engage in the occupations they want, need, or are expected to do.”
This is a great broad definition of Occupational Therapy but how would this actually work day to day? I sought out different practice models and settled on incorporating the Model of Human Occupation (Kielhofner 2008) into my CAMHS clinical practice. This model of practice conceptualises the young person and their environment and focuses on their habits, routines, motivation, skills and competence. There is also a suite of standardised assessment tools which can be utilised alongside this model of practice. I used these to set goals with young people and to evidence the outcomes of my contribution.
Occupational Therapists are good value for money. We are generically trained and can work in any area of health and social care. We can see individuals and can confidently facilitate groups. We promote public health, prevent worsening of conditions and provide the right intervention at the right time. Children love to play and we see play as an essential occupation in children and young people. We can also transfer our Occupational Therapy specific skills to generic working, for example, applying our knowledge and skills to generic treatment of anxiety in young people where we might take a more behavioural approach.
So what do Occupational Therapists do in CAMHS? I want to share some stories with you and these scenarios would be typical of the work I did in CAMHS (please note I have used pseudonyms).
Ben is 11 years old. He is due to move to secondary school soon and is starting to feel really anxious about this. His anxiety is so bad that he requires to be seen in CAMHS. This meant that his psychological and physiological symptoms were of a level that were impacting on his day to day functioning, in school and at home. Having had some training in Cognitive Behavioural Therapy Approaches for Children and Adolescents, I first met Ben as part of a psychoeducation group for young people who were feeling anxious. I facilitated the group with another member of the CAMHS team and as an Occupational Therapist, I incorporated activities into the group to provide some experiential learning to those attending the group. I used my group work skills and I used outcome measures before and after the group to identify whether young people benefitted from the group or required some more help. Ben didn’t speak much in the group and he clearly needed some further help around his anxiety to ensure a smooth transition to secondary school. As an Occupational Therapist treating anxiety, I had the benefit of getting alongside Ben and getting out of the clinic environment to meet Ben in situ during an anxiety provoking activity, in a graded way. Being able to do this meant that there was less pressure on Ben to recall how he felt in anxious situations during a clinic appointment. Instead I was able to observe his anxiety symptoms and work with him in the moment in an anxiety provoking environment. Successful treatment of his anxiety meant that Ben was on track for a successful transition to secondary school, equipped with the tools for managing his anxiety when needed.
Home visits were a big part of my role in CAMHS. This might not seem like an intervention in itself but it certainly was. Compared to my multidisciplinary colleagues, Occupational Therapists are much more able, and should, be in amongst young people in their environments. Our core skills lie in assessing environments and checking if young people’s skills match those environments. Lucy is a 15 year old who has been receiving help from my Psychiatry and Psychology colleagues for over a year. She has Obsessive Compulsive Disorder and usual treatment has had limited success. The team wonder what her environment looks like and if it would give some clues as to her slow progress. I was able to meet Lucy at home with her mum. I was able to observe the space where she performed her daily routines and rituals and was able to observe how compulsively she performed these routines in her own space. I was able to see how her mum responded to her in the home environment, where OCD often showed up the most. I was able to model and reinforce psychological strategies taught in the clinic environment. The information gained during this home visit, even in one visit, enriched multidisciplinary and multi-agency planning for Lucy by giving a context to her struggles. I was also able to visit Lucy at school and speak to her teachers about how environmental accommodations could support Lucy. This combination of support helped Lucy to function better in school and at home.
The main tool in an Occupational Therapist’s toolkit is activity, or as we call it, occupation. When young people and families attend a clinic environment, we see a tiny snapshot of their lives. It can feel like a pressured interaction and relies on therapeutic rapport being established quickly for this type of assessment and intervention to work well. Young people are complex in a beautiful way. They are growing, learning, coping and gaining their sense of self. Some young people do not respond well in a clinic environment which makes it hard to complete an assessment of their mental health and needs. We hear concern from parents, carers, schools, other agencies about young people but in clinic we can’t figure out what might be going on for them. This is where Occupational Therapists come into their own. In this scenario I have been able to get alongside young people in their usual environments with no specific purpose but to assess how they are getting on so that I can contribute to a team discussion and formulation. Anyone could observe a young person in different spaces but it the unique skill set of an Occupational Therapist to give an excellent assessment of a young person in this way. I found this type of work very rewarding and it allowed me the opportunity to really learn about a young person and how they orchestrate their daily life. How lucky I was to be able to work with young people and families in different environments.
Another big part of my work was in supporting young people to access education, which is a major occupation for young people. Due to a number of factors, some young people struggle to attend school. I worked with a young person called Alex who had been treated in CAMHS for anxiety and depression. During his worst times, Alex was unable to attend school and much of his day was spent in bed. I worked with Alex to understand what his school environment looked like in terms of the physical space, the social environment and the learning environment. I took into account what he enjoyed doing at school (felt competent at) and what felt like a challenge for him (out with current skills and competence). I used standardised assessments to understand this a bit more. Where was he succeeding at home, and could we translate some of that to his school setting? First and foremost we worked together to establish realistic goals. Getting into school all day every day would be too much. It would result in a perpetual feeling of failure. We started small to build Alex’s confidence in his own success. He attended school for one hour, three times a week. To set him up for success, I invested in visiting him at home twice a week in the morning for the first week of the plan. I only stayed half an hour but it was long enough to oversee that he was up, dressed, had eaten and was ready for his school time that day. I was able to model compassionate encouragement towards his goals. His mum told me that she felt empowered to take a similar approach. I was quickly able to reduce this contact to two telephone check ins a week to reinforce his goals and praise his successes. At times I also called upon the skills of our AHP Health Care Support Worker to do additional visits as needed. I also acted as an advocate for Alex in terms of making sure that school attendance goals were achievable and proportionate to his recovery, with his permission. Young people showed me that being out of school for a couple of years is not the end. I saw so many young people get back to school and flourish.
Intensive treatment in CAMHS is often referred to as ‘Tier 4 care’ and is typically provided in an inpatient setting or in the community. When young people are this distressed they, and their families, require multidisciplinary clinical support. Whilst managing risk, assessing and treating effectively, Occupational Therapists are involved with what young people are able to do during this intensive support period. When working with young people in this scenario I would make sure that young people were able to perform as many of their usual routines as was safe. I went about requesting quick support from education colleagues in terms of their ongoing education. Being kept linked in with their usual peer supports and educational network is vital at this time. I’d also advocated for young people to ensure that they were able to participate in their care planning and had age appropriate information in order make decisions about their care and treatment. In the midst of these difficult times, I was able to be with young people and families, doing activities together and getting to know what would bring some balance to their day. Despite their distress, they deserved to live, have joy in their day, learn and to engage in activities that they valued or needed to do such as a basic self-care routines of showering and dressing. I also promoted risk enablement, and in discussion with the care team, I was able to take young people out of the ward environment. This might be to the hospital shop or a visit home. In being alongside young people in this way, I was able to contribute to our team assessments of young people in a unique way making best use of my profession specific knowledge and skills.
Occupational Therapists in CAMHS have a unique skill set and offer in terms of neurodevelopmental assessment of young people. We are able to contribute to pre-assessment input, contextual assessment, diagnostic assessment and post diagnostic support. I have enjoyed working with autistic young people and supporting them to develop a narrative of their strengths and differences. I have used standardised motor and sensory assessments to develop a suite of recommendations for young people. They take these recommendations into their adult life in education, work and relationships.
Another highlight of my work in CAMHS has been facilitating an activity based group with young people. I would typically have 6 young people in a group and we’d do various outdoor and indoor activities together. The activity basis of the group took the pressure off young people to speak and to contribute if they were wary of doing so in a group setting. I involved lots of community projects and third sector organisations in this group planning. Co-facilitators included AHP Health Care Support Workers and Assistant Psychologists. The group was a great opportunity for me to get to know a young person and for a young person to use the group as a supportive environment to work on their personal goals. Each young person attended a pre-group one to one planning session where we set person-centred goals. I used outcome measures and standardised assessments with each young person so that I could track change pre and post group. Each group was successful and it was a pleasure to see each young person develop and achieve their goals as the weeks progressed. For some young people, this was the first time they would be around their peers in over a year. A big focus of the group was to promote community integration after the group finished. I worked hard to link young people into community activities in their local area. Kim attended this activity based group to work on her confidence around her peers. She had recently been discharged from hospital where she spent 4 months recovering from a psychotic episode. She hadn’t been able to attend school for the last two years. She wanted to be able to join in conversation with her peers. In between each group session, I had a quick telephone call with Kim to check in on how she felt she got on with her goals during the last group session. This contact with Kim encouraged her towards her goals and we were able to discuss practical and stepped ways she could achieve her goals during the next session. Being aware of every group participant’s goals meant that I could promote these in the group in a subtle and supportive way. These groups always felt a bit awkward in week one, everyone wary of each other. By the end of the 6 weeks, each group of young people worked together as a group, achieved their goals, had improved communication and interaction skills and confidence in their abilities, skills and competence.
I hope the stories above give some insight into my work as an Occupational Therapist working in CAMHS. If you’re an Occupational Therapist thinking of working in CAMHS, do it, it’s such an honour to work with children, young people and families. If you’re thinking about a career in Occupational Therapy, go for it, you won’t regret it!
Mrs Lizzy Archibald
Chair of the Scottish CAMHS AHP Leadership Group
Divisional Lead Occupational Therapist and CAMHS AHP Lead, NHS Grampian Professional Advisor to the Perinatal and Infant Mental Health Programme Board, Scottish Government (current secondment)
Clinical Lead Adult Autism Assessment Team, NHS Grampian
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AHPs across health and social care. 