Interpersonal counselling for adolescent depression delivered by youth mental health workers without core professional training: the ICALM feasibility RCT

Inclusion criteria

• Age 12–18 years.

• Seeking help for low mood (as the primary presenting difficulty).

• Able to provide written informed consent or, for under-16s, written informed assent and parent/guardian consent.

• Of a level of illness where they would normally receive treatment from the service.

Exclusion criteria

• Learning disability necessitating non-mainstream schooling.

• Current psychotic disorder.

• Current substance dependence.

• Current significant suicidal ideation (Kiddie Schedule for Affective Disorders and Schizophrenia – Present and Lifetime version – ‘suicidal ideation’ threshold – ‘often thinks of suicide and has thought of a specific method’).

In line with the approach used successfully in the pilot, eligibility criteria were kept to a minimum to increase the external validity of the trial in the context of non-specialist services.

Excluded young people would be signposted to appropriate services. Young people would not be excluded based on insufficient English language skills. Interpreting/translation services and foreign language Revised Children’s Anxiety and Depression Scale (RCADS) were available.

There was not a numerical upper severity threshold for depression symptoms or suicidal ideation. However, we anticipated that the criterion ‘of a level of illness where they would normally receive treatment from the service’ would exclude young people presenting with significant suicidal ideation. Participants expressing significant suicidal ideation or planning at the time of screening remained ineligible for the study.

The planned recruitment period for the feasibility RCT was January–December 2020 (12 months). In order to recruit the target 60 participants, it would have been necessary to recruit an average of 5 participants per month across all sites; this was predicted to be lower in early stages of the study and higher in later stages, as more therapists completed training. The aim was to have six IPC therapists trained in each of the two counties who would each treat two to three young people with IPC. With IPC taking around 10 weeks (taking into account holidays), this means that, on average, each participating therapist would have one ongoing IPC case per half of the recruitment year.

Participants would be young people accessing participating services via the service’s standard referral pathways. Young people were triaged and assessed according to each service’s standard procedures. If the assessment identified low mood as a presenting difficulty, the case would be discussed with a clinical member of the research team (without identifying the young person) to ascertain likely suitability for the trial. The service was given the option of using the RCADS depression scale to help determine suitability, with a cut-off of 11 or over suggesting suitability (this cut-off was not an absolute).

Potential suitable young people were invited to participate, and those who expressed an interest met with the trial’s research practitioner, who carried out informed consent procedures and screened the young person to ensure they met the above criteria.

Process evaluation

Please refer to Chapter 4, Methods.

Changes to referral pathways

Although the majority of teams had agreed to offer both IPC-A and TAU, due to difficulties with retention of trained IPC-A staff, clinical capacity, lack of suitable cases and stagnant waiting lists, there were a number of changes to referral pathways as well as the type of intervention teams were able to offer.

Caseloads of therapists

As Early Help managers were aware of the pressures faced by Site-10_Central referral point due to staff shortages and the backlog of cases, they expressed a concern of ‘flooding the services’ by highlighting an incident where approximately 600 cases had been referred from Site-10_Central referral point to another team within a short period of time.

This is an emotive subject for the services because Site-10_Central referral point can see this as a way of offloading cases and may lead to a lot of disquiet. You don’t want to send the message that Site-10_Central referral point is offloading cases. I am concerned that we are not opening the flood gates.

Concerns about the suitability of the cases for their services

The managers felt a number of referrals received from Site-10_Central referral point were not appropriate for their service (even after being advised what the criteria for the service are) and that although they may come through as low mood, there may be other confounding factors which are the cause of this presentation. The main challenge with the referral of cases from Site-10_Central referral point was that there was not a feedback loop which allowed for cases to be returned to the hub if considered inappropriate. The managers of the service therefore felt that there needed to be a feedback loop or support mechanism in place in case the identified cases were beyond the service’s remit.

Site-10_Central referral point not triaging cases before referring

Team managers felt that Site-10_Central referral point did not triage the cases fully, leading to teams not having the full information on the case to decide whether they would be apprioriate for their service. Site-10_Central referral point needed to identify cases that have low-level issues and exclude those that have complexities, for example, violence, safeguarding issues, eating disorders, adoption or learning disabilities.

Usual support

Some teams reported not having TAU for low mood. They would need to ensure provision is made for young people randomised to the TAU arm. This also impacted on practitioners’ willingness to randomise a case they thought suitable for IPC.

Following these concerns from the teams, the plan was to identify a small number of eligible young people (maximum 5) for each of the participating teams based on the capacity of participating therapists and how many cases the practitioners needed to qualify as an IPC-A therapist. The agreed plan was as follows:

Step 1

Site-10_Central referral point clinician to identify potential referrals based on ICALM inclusion and exclusion criteria. Site-10_Central referral point clinician would need to go through the general practitioner (GP) areas to ensure that the cases are being referred to the correct location and right teams. Site-10_Central referral point to refer cases to one of three teams, depending on location: Site-01_Early Help and NEET Team/ Site-02_Early Help and NEET Team/ Site-04_Wellbeing Service to speak to potential participants to see if they would like to find out more about the study:

• If no – no further action with person for ICALM.

• If yes – referral is made to the teams.

Step 2

The cases get reviewed by a team manager for appropriateness before assigning them to the team. If appropriate, the team manager will notify Site-10_Central referral point clinician that the case has been assigned to a manager so that it can be closed at the Site-10_Central referral point and noted that it has been assigned to the ICALM study.

Step 3

Team to refer suitable participants to ICALM team for baseline assessment. If they are eligible for ICALM team consent (young person and family), complete baseline measure and randomise participants (this can take up to 3 weeks).

Step 4

ICALM Trial manager to inform the team of the randomisation outcome. When referred to the team, the young people will be in contact with family support practitioners (FSPs) as per usual.

The perceived benefit of the process included reducing the long waiting list for ‘green’ cases while ensuring that services are not inundated with inappropriate referrals.

The Site-10_Central referral point clinician screened 1300 cases, of which only 31 cases were identified as potentially having ‘low mood’.

I filtered out the queues and removed all cases for potential or a diagnosis of ASD or ADHD, l removed learning disabilities, young people suffering from trauma or who are being violent and having anger issues. I also screened the list for the correct GP practices based on the areas of Bury and Ipswich, leaving only 31 cases.

In total I believe there are 19 possible ones for one of the teams and 12 for another – the ones in red (not referring to RAG rating) I am pretty sure on, however this is purely due to a lack of referral info.

For the 1300 referrals that were screened, only 4 young people were then referred to the ICALM team. None of these referrals consented to take part in the study due to not being able to be contacted prior to the recruitment deadline, and one person declined to participate.

Thematic analysis

Conversation analysis

Types of mental health support provided by the services

Tier 2 services (Early Help and targeted services) are designed to offer a range of support, including early and short-term interventions for CYP experiencing mild to moderate mental health problems. Service providers estimated that approximately 40–90% of the cases referred to their services involve some element of mental health difficulty, in particular low mood and anxiety. Other mental health difficulties seen by the services included panic attacks, phobias, suicidal ideation, obsessive–compulsive disorder (OCD), emotional dysregulation, poor emotional literacy and emotionally unstable personality disorder/self-harm (EUPD, also referred to as borderline personality disorder).

While all services included in the study are designed to offer early help, only four services (Site-04_Wellbeing Service, Site-05_Charity, Site-06_Charity, Site-07_Charity) offered targeted services for mild to moderate mental health problems. Targeted services were already providing support other than IPC-A to CYP experiencing mild to moderate mental health difficulties such as anxiety, low mood and mild trauma-type presentations. Types of support target services offered for these presentations included advice, guidance, counselling, treatment/therapeutic interventions [including cognitive behavioural therapy (CBT)-informed interventions] and guided self-help. Interventions offered by the services were typically short-term (six to eight sessions) one-to-one interventions, delivered either virtually (during and post COVID-19) or in various settings according to preference of CYP.

Support offered by Early Help teams and NEET teams in Suffolk focused on supporting families, young people at risk of being NEET and delivery of interventions and support to families in receipt of social care and child protection (CP). Apart from IPC-A, Early Help teams did not offer any specific mental health support but addressed mental health-related issues, for example, peer-related issues, emotional health promotion, motivation, confidence and self-esteem, including low mood occurring within the young person’s life. In Norfolk, support offered by Site-08_Community NHS Trust and Site-09_Family Support Team primarily focused on emotional resilience and confidence building. The teams also depended on targeted services via onward referral for support with specific mental health-related issues, such as low mood.

Mental health is a very small part of what we do but is also very common. Our interventions focussed on safety predominantly but then health and wellbeing is a secondary important focus. We would work alongside any families experiencing any mental health problem, we wouldn’t necessarily take the lead on the mental health part.

SPQ, Site-01_Early Help and NEET Team

There’s no other intervention [apart from IPC-A] that’s specifically focussed on mental health, just our Trauma Informed Practice and our use of Signs of Safety, which is a way to map worries.

SPQ, Site-02_Early Help and NEET Team

Referral pathways into non-specialist services involved in the ICALM study

In Suffolk, young people (and parents) can self-refer either directly to all non-specialist mental health services or through a central referral point (Site-10_Central referral point in Suffolk). Other major gateways into the services include general practice, schools and social care [via common assessment framework (CAF)]. In Norfolk, referrals to the Early Help teams (family support teams) are received from professionals via the Children’s Advice and Duty Service (CADS) or directly from young people and families. Referrals to targeted services (i.e. Site-05_Charity and Site-06_Charity) are received from professionals via a single point of access (SPOA).

Site 10_Central referral point

The majority of CYPs presenting at General Practice with mental health difficulties get referred to the services through Site 10, which is a central referral point for families, professionals and young people (age 0–25) to access mental health services. The referral point consists of a team of 10 staff members, including 7 clinicians, whose role is to screen referrals and triage them by rating them against risk criteria and identifying the right service for them. The referral pathway to and from the referral point is outlined in Figure 6. Each case is RAG (red, amber, green) rated by two qualified clinicians within 24 hours, and the outcome and rationale are recorded.

FIGURE 6.

The referral pathway for Site-10_Central referral point. YP, young people.

Red cases: High risk of harm to self (and others); severe mental health difficulties, for example, eating disorders, signs of psychosis, actively suicidal (not just thoughts/plans but showing a clear intent), not leaving the house for over a year; and severe OCD. These cases are dealt with within 24 hours by referring them straight to secondary services (tier 3) or emergency departments.

Amber cases: Moderate risk, for example, suicidal ideation – but with lesser intent/ planning, self-harm requiring medical intervention alongside presenting issues and some chronicity/impulsivity, safeguarding concerns, significant phobias, symptoms having a significant impact on daily life or self-care, multiple trauma, significant tics and selective mutism. These cases are seen within 72 hours. These cases may go to secondary services (tier 3) or primary services (tier 2, e.g. Under 18 wellbeing Service).

Green cases: Mild risk, for example, low mood, anxiety due to COVID-19, trauma, bereavement, mild to moderate OCD, attachment difficulties, safeguarding, anger management and emotional dysregulation. These cases are dealt with within 28 days.

Assessment processes for eligibility into the services – Suffolk

Services reported using various assessment processes, frameworks and measures to make decisions on whether referred cases were appropriate for their service or needed signposting/escalation. Assessment processes differed between and within services providing Early Help /family support teams and targeted support services in Norfolk and Suffolk. The services reported holding regular triage or transfer meetings to discuss referrals classed to be outside the service remit or needing escalation. The meetings are attended by representatives from Early Help teams, Point 1 services and well-being (tier 2 Norfolk) services and tier 3 services, for example, Norfolk and Suffolk NHS Foundation Trust (NSFT) and social care who would work together to identify the right services for cases.

Assessment processes for services NOT offering targeted mental health services

Suffolk Early Help and NEET Teams (Site-01, Site-02 and Site-03): Early Help teams within the same organisation, for example, Suffolk County Council had a similar assessment process, which involved three stages (Figure 7): (1) an initial triage involving assessment of the CAF by a practice lead and speaking to CYP or referrer (e.g. parents, school) to identify presenting need, history, etc.; (2) a risk assessment using a threshold matrix to identify whether the service threshold is met. The matrix classifies cases into four categories and gives an indication of the type of support that may be required at each level: level 1 (children with universal needs), level 2 (low risk to vulnerable – early help or targeted support services), level 3 (medium risk/high or complex level of additional needs ranging from targeted early help to CIN) and level 4 (high risk/complex or acute level of additional needs requiring specialist or statutory integrated response). While the matrix serves as a decision-making guide, it recommends professional judgement to always be informed by any known evidence and in consideration of views of children and families and the impact that any risk or uncertainty is likely to have on their safety and well-being. 48 Therefore, the teams reported making case-by-case judgements of CYP suitability for the service and (3) cases meeting the service threshold are assigned to a FSP or a young person’s worker (YPW), who then meets with young person, family and professionals to map Signs of Safety, strengths/protective factors and worries/difficulties using the Signs of Safety and well-being model. This holistic map with family and professionals guides the team to provide a tailored intervention plan. Where there is a safety concern, the teams consult with consultant social workers who offer advice and appropriate next steps. Early Help then develops a family plan (normally CYP-led except where there are safety concerns) in consultation with other professionals. The plans are only individual (not family-oriented) if young person has capacity to be independent. CAF cases last around 6 months from assessment to closure, some longer than a year if complex.

FIGURE 7.

Assessment process for Early Help and NEET Teams (Site-01, Site-02 and Site-03).

Community NHS Trust (Site-08): The assessment process for Site-08_Community NHS Trust (Figure 8) also involves an initial triage by speaking to the referrer (if necessary) and undertaking a risk assessment. However, unlike the Early Help teams in Suffolk, Site-08_Community NHS Trust uses the RAG rating document to assess risk: green = low risk (appropriate for CCS, e.g. new low mood or anxiety); amber = moderate risk (need further discussion) and red = significant risk (e.g. severe mental health difficulties, low mood associated with other risk factors such as self-harm or suicide plan; ongoing issues (over several years); bereavement; experience of domestic abuse).

FIGURE 8.

Assessment process for Site-08_Community NHS Trust.

Red cases are deemed unsuitable for the service and escalated immediately to targeted tier 2 services, for example, Point 1 or Wellbeing Service. Point 1 is a tier 2 commissioned service which provides assessment, support and therapeutic help by skilled professionals for CYPs aged 0–18 years old who are experiencing early signs of mild to moderate mental health issues and emotional difficulties. Following the triage, green or amber cases are further assessed for day functioning, motivation, young people’s aims and goals and risk of self-harm or suicidal ideation, etc. using RCADS to decide if appropriate for Site-08_Community NHS Trust pathway. A score over 80 on the RCADS is deemed unsuitable and is escalated to tier 3 CAMH services. If appropriate, a resilience worker gets in touch with young people and offers six to eight sessions of low-level CBT-informed work (not CBT therapists but have some training).

Family Support Team (Site-09): The process for this family support team involves assessing referrals (mainly those coming from CADS) and using professional judgement to decide whether the case falls within the service remit, that is self-esteem and emotional work or if there is an apparent mental health issue. Where there is a mental health issue or CYP identified as requiring a more specialist service and more intrusive treatment (e.g. self-harm), the teams make decisions in consultation with CAMHS and trauma-based workers during a Point 1 group supervision to decide what intervention is needed. Alternatively, they refer young people to general practice so that they can obtain a referral to CAMHS.

Assessment processes for Services offering targeted mental health services (Site-04_Wellbeing Service, Site-05_Charity, Site-06_Charity and Site-07_Charity).

Initial screening processes, including measures and tools used, also differed between services providing targeted mental health interventions (see Figure 7). For example, Site-06_Charity and Site-04_Wellbeing Service tended to carry out an initial triage process to screen cases against risk before carrying out an in-depth assessment, whereas Site-05_Charity and Site-07_Charity did not (Figure 9). Although the in-depth assessment processes for these services involved similar activities (i.e. setting up meetings with young people and parent/carer to look through history, presenting issues, risk and safety planning and identifying suitable treatment), the services described used different measures and tools to further decide on suitability of the cases. For example, while both Site-04_Wellbeing Service and Site-07_Charity described using the RCADS, Site-06_Charity employed the Five P’s formula as an aid to identify both current and historic factors affecting CYP, and Site-05_Charity completed a detailed assessment in collaboration with the young person and his/her family as part of the first session of the treatment package (a specification of pathway) which they use to allocate young people to either youth-centred counselling or youth-centred mental health work, which are standard offers for the service.

FIGURE 9.

Assessment process for teams offering targeted intervention for mental health (Site-04_Wellbeing Service, Site-05_Charity, Site-06_Charity and Site-07_Charity). PHQ, Patient Health Questionnaire.

Staff characteristics

A summary of the staff characteristics for the services is presented in Table 13. Most services consisted of a small number of staff members (12–20 staff, including management) employed on a mixture of full- and part-time contracts. Staff expertise differed according to whether the services were offering early help only or targeted mental health services. Generally, Early Help teams tended to primarily consist of staff with no professional mental health backgrounds, whereas targeted service providers consisted of some staff with mental health qualifications.

Services offering early help primarily consisted of FSP and YPW. FSPs had no professional qualification and came from a mixture of backgrounds, including a qualification in a related subject (e.g. Level 3 qualification in Health and Social Care, Nursery Nursing or Child Development) or relevant experiences (e.g. education, social care, police, health, health visitors, parenting support and Early Childhood Family Service or children centres). YPWs were primarily Joint Negotiating Committee-qualified youth workers (with a degree focused on Youth, e.g. Youth and Community Studies/Youth and Community Development/Youth Work) or had a Level 3 qualification in Health and Social Care. Promotion to Senior FSP was primarily based on experience. Site-08_Community NHS Trust largely consisted of a team of workers known as REHPs (Band 4) who did the bulk of the interventions and had a similar background to FSPs, with some coming from a school/pastoral and children centres' backgrounds. Practice leads and practice management staff also had similar backgrounds as FSPs and YPWs, with promotion based on experience.

Services offering targeted services were primarily made up of a team of CWPs, PMHWs, CBT and counsellors. CWPs do not have a core professional mental health qualification but hold a postgraduate CWP practice qualification (with undergraduate degree in a related field). The CWP qualification is a yearlong course supervised by a trained CWP supervisor and involves working with the clinical team to complete pre-specified clinical hours with CYP/parents and various written tasks, for example, portfolio and reflections on practice. The course teaches various therapeutic interventions, including graded exposure and psychoeducation for young people aged 12 + presenting with anxiety; behavioural activation for young people aged 12 + presenting with low mood; and parent-led graded exposure ‘helping children with fears, worries and feelings of distress’ for children under 12 presenting with either anxiety or low mood.

Primary mental health workers come from a mixture of backgrounds (e.g. nurses, school nurses, social workers, drama therapists), have a core mental health qualification and are registered with respective professional bodies, that is Social Work England, Royal College of Nursing, etc. Cognitive–behavioural therapists are trained and qualified CBTs and registered with British association for behavioural and cognitive behavioural psychotherapists.

Ongoing training and support

There were wide variations in the types of ongoing mental health training and support offered to staff, delivering early help only and targeted services.

Most Early Help practitioners received basic short-term optional mental health training as part of their professional development. The staff also have access to an online database of resources and tools which includes modules on mental health topics such as anxiety, low mood, confidence, self-harm, basic CBT, attachment, etc. Some resources also focus on skill enhancement, including (1) mental health first aid training for family support works (FSWs); (2) trauma-informed practice; (3) the Graded Care Profile training (an assessment tool designed to help workers identify when a child is at risk of neglect by assisting them to measure the quality of care being given to a child in respect of capacity, communication, interaction and well-being); and (4) Brief Solution-Focused Therapy (Yearlong course – manager only) or 2-day Signs of Safety practice (including brief therapy). The team also have access to 1 : 1 consultation with a clinical psychologist who provides clinical supervision, addresses mental health concerns and helps with unsticking stuck cases by considering the mental health issues. Clinical psychologists also facilitate workshops on various mental health and emotional well-being topics.

Site-08_Community NHS Trust team received a 3-day Accredited Mental Health Training (Association for Psychological Therapies) and CBT training from a Clinical Psychologist (although they are not CBT therapists). They also undertook Solihull training; a relationship-based training focused on attachment and brain development with three main principles, including containment, reciprocity and behaviour management. The Solihull training is an initial 2- to 3-day training, followed by an annual top-up. The team also completed mindfulness training and have access to online training, including trauma-based training and understanding of the teenage brain.

Other teams offering targeted mental health services reported receiving very little or no additional mental health-focused training apart from qualifications and their ongoing continuing professional development (CPD).

Societal contextual features

Stakeholders attributed the high volume of referrals to a combination of (1) social contextual factors (Table 14), including increased population awareness of mental health challenges, inappropriate or changing use of specific mental health language by parents and other health professionals and (2) the COVID-19 pandemic (Table 15).

In recent years, the national effort to increase mental health awareness and reduce the stigma around mental illness through national campaigns, television and social media49 has contributed to an increase in people seeking mental health support, in part a desired effect. However, variations in credibility of information sources and differing levels of education amongst the population with respect to mental health have contributed to misinformation and inappropriate use of mental health language at the point of referral to the services. There is also a lack of understanding of the role of society and a lack of or inconsistent guidance for advice and signposting services, in supporting positive well-being and mental health of CYP, leading to an increase in public perception of mental health services providing gold standard interventions or ‘fixes’. Thus, in recent years, the services have experienced a continuously increasing demand for assessments (and ‘a diagnosis’) for certain mental health conditions, for example, ADHD amongst CYPs and parents.

The lack of knowledge of (and support for) front-line staff (e.g. primary health care and school personnel) regarding mental health conditions and support pathways also contributes to the inappropriate use of mental health language and inadequate information provided on referral forms. The Site-10_Central referral point receives referrals from professionals and the general population and has a small team of clinicians who must triage each case before identifying the appropriate service. Having inadequate information on referral forms means that practitioners have to do a lot more information gathering from referrers to aid accurate decision-making, thus creating significant delays in the referral process.

Developing and establishing a common language with regard to mental health difficulties and education with regard to the role of society in supporting positive mental health is therefore crucial in managing some of the current challenges faced by the services. There is also a need for more interventions to help build resilience in CYP and manage emotions. To ameliorate the poor completion of referral forms, some services are in the process of adapting online referral forms to facilitate the completion of all required information. There is also a need to support front-line services, especially general practices where the bulk of the referrals originate, to ensure that referrals made are appropriate and have all the information needed.

Currently, there is a local transformation plan underway which aims to create more streamlined services for CYP. The plan is based on the THRIVE model and aims to create more seamless and closer working between Early Help/Social Care teams, primary mental health services (tier 2 services) and Secondary Services (tier 3 CAMHS). The plans also aim to introduce mental health specialists (link workers) into general practice to support under-18 services. Link workers will offer psychoeducation where needed and signposting and assessment advice to practitioners as well as promote mental health education amongst health practitioners within surgery. The implementation of the transformation plan has, however, been delayed by the COVID-19 pandemic.

The COVID-19 pandemic

The study commenced approximately 1 month before the earliest reported cases of COVID-19 in the UK (January 2020). The impact of the pandemic and ensuing restrictions on mental health services in general and the ICALM study are summarised in Table 15. During the COVID-19 pandemic, from SPQs and interviews, the services reported a sharp increase in mental health difficulties and associated levels of risk amongst CYP with (social) anxiety, low mood, self-harming, OCD-type behaviour, germ-phobic behaviour, emetophobia due to fear of sickness, fear or vomit and agoraphobia. Most services, including those delivering targeted mental health support and interventions, reported receiving referrals that were far beyond their capacity and service threshold with regard to level of need. This created major challenges in identifying suitable cases for IPC-A, with participating services reporting CYP to be more concerned with addressing anxiety than low mood.

We certainly opened it up to where young people were presenting with low mood and anxiety, we certainly did start trying to recruit people. I guess it’s when they’re clearly saying they’re getting tummy ache before school, and in school holidays they’re absolutely fine. It’s literally a worry about going to school. We’ve not offered it (IPC-A) to those young people because I think, you know, there’s not a feeling that their mood is a significant factor, it is really significant and very precise worry about school.

Stakeholder-03, Site-08_Community NHS Trust

For most services, the COVID-19 pandemic also led to reduced capacity to deliver support or interventions due to high levels of staff sicknesses and school closures (and the need for homeschooling). During this time, managers reported having to prioritise the well-being of staff and continuity of service by not participating in activities that were seen as ‘extra’, including research (i.e. ICALM). For some Early Help teams, the focus of the service provision shifted to more safety planning for CYP at home due to the sharp rise in adult mental health challenges and potential safeguarding concerns.

We just had to be quite strict about how we prioritised our time management, all time during the pandemic. And anything additional we just had to be really clear that we weren’t going to take on, for our own wellbeing and therefore the continuity of the service. Nobody has had the capacity I think, or few people have had the capacity to do extra anything, and a trial ends up feeling like extra.

Stakeholder-09, Site-05

At the start of the pandemic, teams also had to adapt to more flexible ways of delivering services, whereby both assessments and interventions were delivered remotely via Zoom, MS Teams or telephone. By the end of the study, most services had adopted a blended model of delivery whereby assessments and interventions were being offered online or face to face depending on CYP preference or need. This mode of delivery increased accessibility, enabling the services to reach CYP living further from the service centres. The virtual delivery of the sessions worked well for some CYPs, with some schools also setting up rooms to support attendance. However, not all CYPs engaged with the virtual sessions due to a preference for face to face and/or increased severity of cases. The COVID-19 restrictions and shift to a virtual way of working also meant that teams had limited access to CYP homes, thus unable to pay close attention to more serious cases that would have ordinarily required intense face-to-face contact and multiple visits. This posed a challenge to the teams in predicting serious incidents, as some families stopped engaging with services or were not allowing professionals in their houses owing to COVID-19.

Policy

A challenge of implementing the different key mental health policies relevant to CYP set out in Table 16 which address some of the social contextual challenges highlighted above, has been a lack of specificity about how to allocate funds to different resources, including the costs for different staff resources. This leads to a disconnect between workforce strategy and policy objectives about meeting different young people’s needs. An additional challenge here is that workforce capacity-building strategies, which are often focused on training and recruiting less experienced clinical staff, do not typically include commissioning senior clinical supervision roles, with senior clinicians typically allocated to seeing high-priority children as a short-term strategy to reduce waiting times, rather than a longer-term view to capacitate the workforce to meet young people’s needs over time.

I think mental health services for young people is very under resourced to meet the need… And so, everybody is really [under] huge pressure, and this is why my service as well as many others are finding themselves picking up cases from the Site-10_Central Referral Pointwaiting list trying to kind of deal with that backlog but it’s often not the services that families want.

Stakeholder-04, Site-01_Early Help and NEET Team

The lack of clarity about how to operationalise mental health policy at a service level is most recently evident in the NHS Long Term Plan, which has objectives to improve access to care by providing a 0–25 service and 24/7 crisis service. However, there is a lack of specificity about how to provide these services, how to implement these services, how many staff are required to support how many children and how senior clinical roles will be deployed to supervise new staff/trainees. Without such specificity, trainees will not be able to develop their skills to build the required specialist workforce over the longer term, perpetuating insufficient capacity across the whole mental health system to meet the ever-increasing demand.

Problems of capacity are not isolated within mental health services, and other service sectors are also overwhelmed with demand for care. As a consequence, young people have experienced being referred across multiple mental health, voluntary, social care and health services, driven by individual providers placing boundaries around which types of problems they treat and do not treat in order to manage that demand. This is reinforced by a lack of system strategy and shared definitions of mental health problems and conditions across services. Oversight, strategy governance and co-ordination of service provision within and across sectors are therefore critical for ensuring young people’s needs are met – a key gap highlighted in the 2017 Care Quality Commission (CQC) report.

A lot of the time it’s [volume of referrals] driven by process and system issues, and the fact that services are overstretched and they’re trying to move people on a lot of the time, and not rightly or wrongly.

Stakeholder-01, Site-10_Central referral point

I will slow think [Signs of Safety term] and I will not take anything on [accept a referral] unless I know my FSP can do it. If it’s just wellbeing [mental health], I won’t take it if it is not on a wellbeing pathway and if it’s not, then my job is to find out why not – talk to the GP, talk to CAMHS and get their input. If, following consultation, with mental health services, we can implement their advice, we will do that. Because once you’ve got their input, they’re responsible for the actions.

Stakeholder-05, Site-02_Early Help and NEET Team

A central policy agenda has been to reduce waiting times in specialist mental health services. However, this agenda set within a context of overwhelming demand has arguably created a public perception that mental health services provide a gold standard set of interventions for young people that are worth waiting for, that all mental problems require specialist support and that the solution lies in enabling access to those services. This suggests that greater effort is required to promote the philosophy of mental health as ‘everyone’s business’,50 namely how effective treatment for mental health problems can be provided across the health and social care system as well as within schools and colleges.

I think we all have to take responsibility as a society don’t, we. We’re quite rightly say you have to stand up for your child’s rights, if children’s services or health are failing you, you have to bring that to someone’s attention. I guess as a society speaking as a parent you take a choice, do I do the tough job as a parent or do I give it to somebody and take away responsibility. I think we have an increased amount of that.

Stakeholder-06, Site-09_Family Support Team

Within this context, the challenge of asking mental health services to implement the IPC-A intervention and feasibility trial becomes clear. While IPC-A as an adaptation of IPT is included within NICE guidance for CYP, it is not a priority of Health Education England, and clinical supervision for CWPs is not available. Targeted investment in IPC-A would be required if IPC-A was to be implemented as a treatment for mild to moderate depression, a significant challenge given the overarching problem of insufficient resources to meet increasing demand. Similarly, evidence-based mental health interventions such as IPC-A are not seen as core elements of Early Help services for CYP or competency/ training and development frameworks for youth services; hence it is difficult to introduce provision in this era of reduced capacity and funding alongside trying to manage increasing demand.

Increase in complexity of cases initially classed as ‘mild to moderate’

The backlog at the Site-10_Central referral point led to the prioritisation of red and amber cases and long waiting times for green cases, for example, low mood and anxiety. The prioritisation of red and amber cases impacted referrals into the ICALM study by inhibiting referral of green cases into services which had IPC-A-trained staff. In some cases, the delay in obtaining support had led to CYP (and parents) finding other ways of coping or seeking help elsewhere. However, other green cases on the waiting list deteriorate, leading to increased complexity and severity of cases being referred to the services. This consequently leads to an increased need to escalate cases from Early Help teams to targeted services and from targeted services to tier 3 services.

With a large proportion of cases having an element of mental health difficulty, a major challenge for Early Help teams, who currently do not take the lead in delivering mental health support, is the delay in accessing help from tier 2 targeted mental health services. Most early help services, recognising the dangers of waiting lists due to the increased likelihood for cases to deteriorate and increase in complexity, have highlighted the need for transparency with CYP and parents about the likelihood of getting a therapeutic service and the type of support on offer (i.e. short term).

I’ve learnt from 20 years of doing the job that a waiting list is a very dangerous thing to have, because if you have someone on the waiting list who’s got low mood, and they’re tenth on the list, if someone comes in and they’ve got, you know, a more severe sort of need, they trump, so that person goes to 11, then they go to 12. Waiting list gives false hope, what happens in [the] meantime. Waitlists allocate a worker, which looks like they are receiving help when they are not and leads to inability to get other services.

Stakeholder-05, Site-02_Early Help and NEET Team

If families really understood the state of mental health services in Suffolk are such that unless the needs are particularly high the likelihood of you actually getting a therapeutic service is very, very low. I think if families knew that perhaps they would look around to other types of service for support. But I think if they’re just put on a waiting list they’re just there with their fingers crossed just waiting for that phone call, which probably isn’t ever going to come.

Stakeholder-04, Site-01_Early Help and NEET Team

The long waiting times for green cases and increase in complexity were some of the barriers highlighted by the services in identifying appropriate cases for the ICALM study. As such, interventions targeting ‘mild’ presentations, for example, IPC-A, became less helpful to the services owing to the range of mental health issues in young people, including some extremely challenging and/or dangerous behaviours towards themselves or others. The long waiting times also led to poor engagement following the implementation of a new referral pathway for green cases from Site-10_Central referral point to the services.

It didn’t work [new pathway] …out of the people that we identified that could be appropriate [for ICALM], I don’t think any of them wanted to do it or didn’t engage or couldn’t get through by phone. And that’s a large part of the problem when people have got wellbeing issues, they are more likely to be the people that are hardest to engage.

Stakeholder-05, Site-02_Early Help and NEET Team

Restrictive or unclear service specifications and treatment pathways

The primary focus for Early Help interventions is safety, with health and well-being as a secondary focus. Therefore, apart from offering IPC-A (delivered as part of the ICALM study), Early Help teams’ mental health support primarily consists of promotion of mental health and well-being, confidence and motivation-building interventions and re-engaging with community networks and schools. According to the threshold matrix used by Early Help teams to assess whether referred cases fall within the Early Help service remit, CYP displaying signs of deteriorating mental health and episodes (e.g. low mood/mild depression or those with low-level mental health or emotional issues requiring intervention) should be classed as level 2 and are suitable for early help or targeted support services. This recommendation differs from what is happening at a service provision level, whereby Early Help teams refer cases with mental health difficulties, including low mood, to targeted mental health services or work alongside mental health professionals where advice is given on how they can help. The lack of standard treatment for mild to moderate mental health difficulties in some of the services therefore highlighted the challenges of running a RCT in this setting, as at times it was difficult to establish what TAU for low mood was being delivered by the services.

Early Help support is primarily delivered by non-mental health professionals from various backgrounds with basic mental health training; thus, they are currently not fully equipped to deal with a wide range of mental health difficulties. For example, apart from having access to online resources on mental health, some teams described only receiving a 2-day Signs of Safety training course aimed at equipping them to conduct Signs of Safety-based assessments. ICALM adopted a model which aimed to recruit and train Early Help practitioners, who are not professionally trained but work with mental health, to deliver IPC-A. IPC-A, being relational in its focus, should theoretically fit with the philosophy of the Early Help approach. However, the limited knowledge and expertise in teams that were not mental health focused presented challenges in identifying appropriate young people for the IPC-A intervention. Considering that a large proportion of the cases seen by Early Help teams will have some form of mental health difficulty, the lack of training and low involvement in tackling mental health challenges presents a missed opportunity that could help reduce pressures on mental health services, and indeed, Early Help services.

Apart from the limited role in supporting mental health difficulties, the service specification for Early Help is expanding to include more social service roles, for example, supervised contact of Looked After Children. There is also a current review of the role of FSP, which might lead to more social services roles, thus impacting the direct work the services do with young people and other interventions which are not part of their core offer, for example, IPC-A. This provision of both Early Help and statutory services, coupled with the reduced capacity of the workforce, had an impact on ICALM. Managers reported the challenges of protecting time for IPC-A-trained therapists while prioritising delivery of their core offer, which is not specifically mental health focused.

Due to the increased complexity of cases and the variability and subjectivity of assessment processes used, both Early Help teams and targeted services did not appear to be operating using a clear and/or up-to-date service specification with regard to mental health. Targeted services seemed to be more flexible and confident than Early Help teams in supporting CYP that would not ordinarily fall within their remit. These services described offering ‘holding interventions’ until appropriate help was identified through triage/patient flow/transfer meetings where senior managers from different services discuss cases that get stuck between the services. However, even with the transfer meeting, the teams highlighted that there are still gaps in the services whereby CYPs are not falling within any service remit or have a condition/illness which has no clear support pathway. The lack of clarity in referral pathways, which some teams have described as a ‘system level dysfunction’ is therefore a major challenge for the services.

Capacity

Capacity challenges in the mental health sector have been a long-standing issue which has been exacerbated by the COVID-19 pandemic. The numbers of staff varied between the services, with Early Help teams such as Site-01_Early Help and NEET Team having 14 staff members (including managers) supporting 390 families a year and targeted services such as Site-04_Wellbeing Service having 18 practitioners supporting approximately 1250–1500 cases a year. Factors driving the insufficient capacity include lack of funding and recruitment/retention challenges. The teams attributed some of the recruitment challenges to perceptions of some mental health trusts as ‘failing trusts’, perceptions of mental health as being under pressure and understaffed, the nature of the role, stigma around mental health and risk and poor job advertisements leading to audience misunderstanding of what roles involve.

A major challenge for targeted services was the poor retention of CWPs or PMHWs, who are often employed on short-term contracts, thus offering them no job security. This poor retention and high turnover were a significant barrier to the progression of ICALM, where several staff that had received training to deliver IPC-A either left the services or moved on to other roles. For the purposes of the ICALM study, these challenges especially affected services delivering targeted services (i.e. services with mental health support as their core offer), as only a small proportion of their staff members do not have a prior mental health qualification (CWP’s) and hence are eligible to train and deliver IPC-A. For example, Site-04_Wellbeing Service initially trained 12 CWPs to deliver IPC-A, but at the time of the interviews, only one practitioner remained in the service, with others either leaving or moving on to focus on a core profession. The high numbers of referrals also impacted on CWP’s capacity to deliver IPC-A, as they prioritised their primary role within the services, which was to carry out assessments with CYP, parents and referrers.

Structure and delivery

Interpersonal counselling for adolescents was delivered over six to eight 60-minute sessions, either virtually or in person, depending on need or preference of the young person. Key aspects of IPC-A, including its structure, duration and focus on specific areas, received both positive and negative feedback. Young people reported having a positive experience during the sessions and felt that the structure and duration of the sessions were important for providing stability. Some therapists also enjoyed delivering the intervention, with some highlighting the collaborative nature and the structure of the intervention as positive aspects.

I thought they were good [IPC-A sessions], especially the length of them I thought was really good because it was long enough to get something covered but not long enough that I was being drained afterwards. I could still continue with my day.

YP-IPC-01, Site-02

I absolutely love it… I loved the structure. Although there was some flexibility in it, but I liked the fact that we focused on one problem area because often in our service you have one area of problem and other things crop up, and you tend to dive away from the main problem area, so I like the fact that we made it quite clear that we’ve identified the problem area.

Therapist-IPC-01, Site-08

Other therapists and stakeholders, however, felt that the duration of the intervention (six sessions) was too restrictive, especially where young people needed more support. Other stakeholders, particularly those who were already offering other interventions for low mood, also felt that although IPC-A fitted well with young people experiencing specific problems in the four focal areas (i.e. big changes, relationship disputes, grief and loneliness/isolation), the intervention was too narrow as low mood can be impacted by a lot of other factors. These stakeholders felt that selecting a particular area of focus was difficult because young people are changeable each day and struggle to make decisions.

So, your low mood can be impacted by the fact that you’re not eating properly. That you’re not sleeping properly…. we’ve got kids who are sitting on our list, or were sitting on our list, who have multiple things going on. So, when you tell a young person to pick one, they’re going to go ‘What do you mean, I don’t even know which one is the biggest issue today’.

Stakeholder-08, Site-07_Charity

This feedback raises an important point about how the IPC-A model was understood by some stakeholders/managers. The IPC-A model is designed for the practitioner and young people to work together collaboratively in selecting a focus area rather than asking the young people to pick an area. This misinformation around the model of IPC-A might have also contributed to recruitment issues, especially where managers were responsible for screening referrals.

Issues around the structure of IPC-A sessions and their impact on implementation and theoretical fidelity are further discussed below under Implementation and theoretical fidelity.

Content

Three young people felt that the content of IPC-A had contributed to the improvement of their symptoms and helped them to have a better outlook, of which, two described IPC-A as helping them to focus on more positive rather than negatives aspects of their lives. However, one young person who felt that her condition had not improved much since IPC-A, argued that the intervention focused too much on positive aspects, without giving space to understand the negative aspects and support the young people through it. The feedback from this young person highlights the complexity of delivering brief, focused interventions.

I know it sounds kind of weird to say it this way but it’s like they’re focusing too much on the good. They need to try and break down the bad… for example, if I was to say I’ve had an emotionally bad day but there have been a few good highlights, usually my counsellor will talk about mostly the good and a little bit about the bad at the very end. And then of course that would leave me feeling down afterwards. So, it would be better if they were to start off with the bad, go into a bit of detail about it so they’d understand my position and how it affected me during the entire day and how it made those little good things that might not be good things for other people, but may feel like more to me and make me feel a bit uplifted when I leave the session.

YP-IPC-02, Site-04_Wellbeing Service

The young person also reported doing weekly tasks/goals outside the sessions, such as keeping diaries of positive/negative experiences and speaking to their parents or head of year as a way of developing positive relationships. While some young people liked having goals, others reported struggling to complete tasks. Apart from noticing young people doing some tasks at home, most parents were not aware of the contents/discussions of the sessions. However, one parent reported being involved in the sessions, initially at the request of the young person who needed their support in explaining previous experiences. This parent also reported receiving helpful support from the therapist with regard to how best to support the young people at home.

If I’m finding something particularly difficult as well, obviously I say to [name of young person], ‘Oh can you just ask [name of therapist] to grab me for two minutes at the end, there’s just something I need to …’ and I’ll have a chat with [name of therapist] and say, ‘Look, something’s occurred, I don’t know if [name]’s mentioned it, but which is the best way to go?’ And then [name of therapist] will say, ‘Oh I’ll send you an email’, yeah. I’ll leave it a few days and I’ll say, ‘Oh [name of young person], [name of therapist] sent these through, and we need to have a try at these’ and we’ll read through it and whatnot. And then quite often that’s just what I need to be able to broach whatever it is that I’ve got niggling, concerning me, because I’ve noticed it.

Parent-IPC-02, Site-04_Wellbeing Service

Suitability for the services

Some services already delivering interventions for low mood felt that IPC-A was a useful alternative approach for low mood that enabled them to provide the most adequate support for that young people tailored to their need. However, the structure of IPC-A and the need to choose an area of focus were perceived to create some tension in other services whose offer was more general.

It [IPC-A] does involve quite specific work, methodology. And our specialism is much more around meeting young people where they are. We have a range of different kinds of ways of working, including things like cognitive behavioural based things or a creative way of working … It’s not always easy for us to hold a very specific offer within our specialism which is a more general offer as opposed to taking them through a very prescriptive method. There are so many agendas imposed on young people currently from school and other parts of their lives the feedback we get…is that they felt that they were listened to and met exactly where they were. So, that’s our primary offer.

Stakeholder-09, Site-05_Charity

Due to the challenges faced by the services in identifying suitable young people and delivering IPC-A, some Early Help managers felt that interventions such as IPC-A would be more suitable for services set up to tackle mental health, such as U18 Well-being Service and school nurses. Others felt that introducing early interventions such as IPC-A in schools would be a better approach, as Early Help usually refers CYP experiencing mental health difficulties to emotional well-being services or school nurses. Some stakeholders expressed the challenges of implementing an individualised intervention such as IPC-A in a service dedicated to supporting families as a unit. These stakeholders felt that, due to the level of young people engagement required, offering IPC-A at the beginning of a case when FSPs are dealing with the whole family and working to develop an intervention plan that has more to do with safety than therapeutic need was challenging. During the study, Family Support Teams resolved this challenge by ensuring that IPC-A was delivered by practitioners who were not case-responsible (i.e. responsible for the family unit). Practitioners felt that in Family Support Teams, IPC-A could work better if offered at the ‘tail end of a sequence of interventions’ (Stakeholder-04, Site-01) when young people are in a more stable situation and environment. Alternatively, some stakeholders felt that IPC-A could be better suited in a school-based setting where ‘young people are worked with individually, and they have that safe space with a professional where they feel safe’ (Stakeholder-04, Site-01).

We’ve found it’s better used when you’re not case responsible. So, if I’ve got a colleague who is case responsible for a family if – so [name of IPC-A trained therapist] was one of our key people, if say my colleague [name of Family Support Practitioner] is working with a family and he identifies that there’s low mood and depressive symptoms in an adolescent he would be able to refer to [name] and then it’s more effective because the roles aren’t blurred. Otherwise…we have tried being case responsible and doing the IPC and it can just be a bit confusing.

Stakeholder-10, Site-03_Early Help and NEET Team

We could probably put IPC as an intervention for every single child on our caseload, but it probably isn’t an intervention that the child is ready to engage with because there are so many other pressing issues on the intervention plan. And it’s often a result of either other family members or other domestic situations that are going on with that child that is impacting and causing their low mood or their poor mental health.

Stakeholder-04, Site-01_Early Help and NEET Team

Fidelity ratings and contamination

Therapists submitted recordings of their sessions to their supervisor to be rated; these sessions included the initial, middle and final sessions (three total). Items were rated on a 0–3 scale: 0 = not attempted, 1 = attempted but incomplete and/or superficial, 2 = completed to a good standard and 3 = completed to an excellent standard. An adequate range of IPC strategies must be demonstrated over training, and for each recorded session, an average score of two or above (for all rated items) was needed for a recording to pass. These ratings indicate how well therapists adhered to the IPC-A manual, which prescribes tasks for each session – differing between initial, middle and final sessions.

Tasks in the initial sessions review the young person’s symptoms, explain depressive symptoms and describe depression as an illness – and not a fault of the young person. The young person’s current coping strategies are also explored, and an interpersonal inventory is conducted. This interpersonal inventory aims to uncover what is going on and who is important to the young person’s life. The therapist and young people may then work together to agree on a problem area to focus on in future sessions by identifying what may trigger and maintain the young person’s depressive symptoms. Middle sessions also involve a review of symptoms and lead to tasks and techniques which are specific to the agreed-upon problem area. The young person’s progress with goals made in each session should also be reviewed and new goals for the next session agreed upon. Final session tasks include reviewing the young person’s progress and improvement by comparing their symptoms and goals across sessions and at the start of IPC-A. Dependent on this progress, the therapist must discuss the possibilities of what should be done once IPC-A has finished. These possibilities range from discharge from the service, maintenance work or referral to more specialist services.

Treatment-as-usual sessions were also rated to assess if IPC-A training led to contamination. No clear systematic use of the principles of IPC-A was identified – suggesting no contamination effects from IPC-A training for the observed TAU therapist, although it is not possible to generalise this with any certainty; see Table 18 for mean ratings for each case, IPC-A and TAU.

Interpersonal counselling for adolescents’ sessions: thematic analysis

Both therapists' and young peoples’ approaches to IPC-A were further explored using a multimethod qualitative approach to identify patterns within the data. Experiences of therapists, young people and parents involved in the ICALM study were considered alongside IPC-A sessions – ‘cases’ refer to the therapist and young people dyads within these sessions; see Table 19 for overview of each case. Thematic analysis was used to explore both session and interview data. Conversational analysis was then used on session data to support findings of the thematic analysis.

One main theme emerged from the data relating to the role of therapist and young peoples’ and interactions between the two in effective delivery of IPC-A: engagement from young people as crucial for successful, collaborative intervention. Within this theme, several subthemes were developed which consider the mechanisms and contextual features of IPC-A sessions and how these can be utilised to encourage engagement and progress for the young person. These subthemes were interactional styles and participation within intervention sessions; importance of feeling heard; orienting discussions to young person’s perspective; and reliability of interpersonal relationships: mini goals and advocacy. It is worth noting the difficulty in defining what is a mechanism of action and what is a contextual feature of IPC-A sessions. Using these terms, we aim to highlight components which are important to the successful delivery of IPC-A. See Table 20 for a summary of findings and recommendations.

Recruitment of participants

Due to low recruitment, potential suitable cases being stuck on a ‘green’ list and services not always having TAU or IPC-A capacity, new pathways were set up which appeared to fit with the changing environment. The new pathways were provided so that services could work together to identify and treat individuals depending on their randomisation to the appropriate service. A fast-track service was also set up from Site-10_Central referral point so that those under a RAG rating of ‘green’ that were potentially suitable could be referred to the ICALM study. The fast track helped with the fact that services were reporting increased complex referrals that were not suitable for ICALM. Although the changes to referral routes were not successful, the different services showed great flexibility and went above expectations to help the study.

As discussed in the process evaluation, due to challenges faced by services in recruiting suitable young people and delivering IPC-A, it was felt by Early Help managers and practitioners that IPC-A may be more suitable for U18 well-being services and school nurses, as they were overtly set up to treat mental health difficulties. The well-being and school services are also normally the first points of call to refer CYP experiencing mental health difficulties.

To encourage recruitment, teams were willing for ICALM to attend allocation, triage and team meetings. This allowed questions to be answered directly, for ICALM to understand referral difficulties, help identify possible referrals and build working relationships across the network. Teams were mostly happy to test alternative procedures and showed a willingness to be involved in the study.

It was also noted that half of participants came from services within NHS Trusts and not Early Help teams. A possible reason for this is due to experience in research studies or a culture of research and evidence-based practice within traditional health services, leading to more confidence and also knowledge/education around the randomisation process. As was suggested by Early Help managers, NHS Trusts are more likely to be set up to identify and screen for mental health, possibly leading to more referrals.

COVID-19 and the recurrent lockdowns impacted clinical presentations of low mood. An increase in presentation of anxiety cases amongst services was noticed with the start and progression of the pandemic. Despite comorbidities between anxiety and low mood, young people expressed greater preference in having their anxiety rather than low mood treated. Since ICALM’s core criterion was to provide IPC-A to young people presenting with low mood, many young people were screened ineligible and were not further referred from services, influencing the number of referrals received in ICALM. Receiving mild to moderate cases of depression is what the study demanded, but such cases appeared to either no longer exist or did not come into the services or to their attention. Ultimately, the study was unable to recruit the required number of participants despite repeated mitigation measures being put in place.

Recruitment of therapists

A high turnover of staff in the services meant that the majority of staff who had received training to deliver IPC-A either left the services or moved on to other roles. By the end of the study, only half of the teams had active therapists who were attending supervision sessions. This reduction meant that regardless of the number of participants coming through, capacity from existing therapists and sites was limited. The previous single-arm study (pre COVID-19) had a high retention rate, and the calculation of the number of trained staff required was based on this study.

A lack of staff trained to deliver IPC-A added pressure to the remaining IPC-A practitioners. This especially affected services delivering targeted services (i.e. services with mental health support as their core offer), as only a small proportion of their staff members do not have a prior professional mental health qualification (CWP qualification). As the study progressed and teams had a reduced number of IPC-A-trained staff, further training sessions were offered, but after the second training offer, no further staff members expressed an interest nor were any put forward by their managers. Future studies may wish to consider funding staff to be trained as IPC-A therapists and deliver the therapy as a core offer, as happened in the initial single-arm pilot.

A major barrier to this trial’s working was existing staff being unable to deliver the trial intervention for multiple reasons. A future study would be more likely to be successful if it also funded staff time for study treatments, training and supervision. We accept this is not normally done for research in NHS services, as such treatment is often considered ‘core business’. However, we have demonstrated the additional barriers to conducting RCTs in tier 1/2 services, which may justify this extra funding.

Randomisation

Initially, staff participants struggled with the concept of randomisation, voicing that they felt it was unfair to refer a young person for the study, knowing that they may not receive IPC-A. This was particularly noticeable within social care settings. One team manager stated that he would not be putting any young person forward as he thought randomisation was unethical. Changes to training were made to include more information on randomisation and less of a focus on IPC-A; however, randomisation continued to be a barrier throughout the study. Once identified as suitable for IPC-A, clinical staff struggled to accept that their standard offer would be of benefit.

Participants in the study expressed concern mostly around the randomisation of the study and getting the help they needed. Some expressed disappointment when randomised to the TAU arm of the study, while one participant was concerned about being allocated to IPC-A as it was an untested intervention without evidence of effectiveness.

Using a cluster randomised trial (CRT) could potentially offer solutions to some of the above-mentioned barriers. In a CRT, there would be dedicated sites for either TAU or IPC-A, meaning all people within a service would receive the same intervention, potentially avoiding staff’s ethical concerns about service users receiving different treatments within the same service. A CRT would also reduce the chance of contamination due to all those within a cluster being treated similarly. 59

Research assessments

The proposed outcome measures appeared to be acceptable to young people. Most measures, researcher-led and self-completed, were completed, and young people did not appear to find the measures to be a burden. One participant found the assessments beneficial as they enabled them to see how their mental health had improved since the start of the study. COVID-19 restrictions led to some complexity in completing measures, which was eventually overcome by incorporating new technological solutions such as video consent procedures.

Acceptability of the intervention

It was reported by a couple of participants that IPC-A focused too much on the positive aspects of their relationships. These young people stated that they would have preferred a greater focus on the more difficult elements and were able to understand these before moving on to positive aspects.

Some parents were not aware of the contents/discussions of the sessions. However, when one parent was included at the request of the young person, the parent had reported this as being helpful to be able to learn how to support the young person at home.

In interviews, IPC-A was acceptable to both young people and parents, with IPC-A being seen as offering positive benefits for young people. As reported in the process evaluation, young people reported being more open to family, socialising with friends and being able to engage in ordinary activities such as shopping. Parents also reported improvements in young people’s well-being after the second or third session.

As reported in the process evaluation, young people reported having a positive experience during sessions and felt that the structure and duration of the sessions were important for providing stability. They felt that the sessions provided a private space which allowed them to open up about the challenges they were facing. They felt that the developing of a positive relationship was an important factor in facilitating discussions, as well as being focused on the positive rather than negative aspects of their lives which helped contribute to the improvement of their symptoms and have a better outlook. Overall, IPC-A as an intervention appeared to be acceptable.

Quantitative analysis

This study was not powered to detect any significant changes in outcomes, and from the data collected there were no clinically significant differences between the two interventions. Half of the participants who were randomised to IPC-A and completed 23-week measures did not receive the intervention; therefore, this would have had an impact on this finding. The mean changes in the outcome measures suggest they are sensitive to change. Therefore, if the intervention was effective, this would be able to detect differences in a future trial.

Health economic analysis

The health economic measures appeared to perform well and were completed. The CHU-9D had a high rate of completion and showed a possible improvement over time. The responses were also spread over a majority of levels. This suggests that there is scope for the CHU-9D to detect differences over time and that there is scope for improvements in health to reflect in the CHU-9D. Similarly, for the CSRI, the majority of fields appeared to have been completed for most cases, showing reduced healthcare use over time. It should be noted, however, that most of the health care was not mental health-related. Due to the CSRI performing well, it would be a potential candidate for use in a future trial of ICALM; however, it would likely benefit from simplification. Owing to the very small number of individuals who had the IPC-A intervention, it was difficult to estimate what the likely cost of the intervention would be. Of particular interest would be turnover of staff. A very high turnover rate, as seen in this study, means that many staff are likely to need to be trained to provide intervention sessions, and much of the benefits of this training may be lost if staff move on to different roles.

Workforce capacity building strategies and research culture

Workforce capacity challenges were a key recruitment barrier in the ICALM study, as the increased pressure at central referral points led to the prioritisation of urgent cases and consequently long waiting times for ‘green cases’ (e.g. low mood) and low referral rates into services delivering IPC-A. Process evaluation findings also indicate a lack of research culture and research capacity amongst the participating teams, which cannot be isolated from the high demand faced by the services. The findings indicate that some services did not view research as a priority, considering it as something ‘extra’ that could be left out to ease pressure as demand increased, particularly during the COVID-19 pandemic. The IPC-A training sessions and meetings with teams also unveiled a lack of familiarity with research processes, particularly randomisation by the teams, with some teams expressing reluctance to randomise young people.

The low participation in research, fuelled by the need to manage high demand and the lack of processes and frameworks for identifying and implementing evidence-based interventions in this setting, means there is a lack of evidence-based guidance with respect to what should be offered to whom, resulting in local interpretations of best practice. This is especially true for clinical presentations such as low mood, whereby various interventions (e.g. family interventions, behavioural activation, counselling or I-PCA) might equally be used to treat a clinical presentation. This narrow approach of intervention provision which develops naturalistically within this context poses a challenge for local commissioners to establish processes and frameworks for identifying and implementing evidence-based interventions. Such an approach was also to allow individual services to decide whom they treat and how in isolation as demand increased and overwhelmed them. This meant that clarity of who should get what treatment was further disrupted.

There is, therefore, a requirement to develop effective unifying workforce capacity-building strategies, considering areas of greatest need and the professional requirements, training and supervision which will address these needs. To ensure continuity of service, there is also a requirement to develop and implement workforce retention strategies that could incentivise staff to remain in specific posts. As part of wider workforce capacity-building strategy, developing a culture which recognises the value of developing, evaluating and implementing evidence-based interventions will facilitate future research. More practically, teams could be introduced to research processes gradually, through training to increase understanding of specific processes such as randomisation and by initially involving them with lower-level research, for example, single-arm pilot studies, before and after studies, before exposing teams to large RCTs. There is also a need for commissioners and service leads to develop a framework for identifying and delivering evidence-based interventions that could be incorporated within service models, workforce development and supervision. Building such a research culture and incorporating appropriate frameworks may increase success of recruitment and implementation of RCTs in this setting.

Training and review of core service offers

The ICALM study sought to train teams of young people’s workers to deliver IPC-A within tier 1/2 services. While these workers might support CYP with mental health presentations, they do not typically deliver specific mental health interventions. This task-shifting approach, which has had successes in the primary healthcare setting, was met with several barriers in the ICALM study.

Firstly, due to the lack of mental health training, prior experience and confidence in supporting young people with mental health challenges, Early Help teams struggled to identify suitable young people for IPC-A, assessing most referrals with mental health difficulties to be too complex for their service. The lack of system integration in referral pathways, the variations in frameworks and measures used to assess eligibility of cases and the subjectivity of some aspects of the assessment process meant that some cases may have been classed as too complex by one team and eligible by another. Secondly, interviews with Early Help team managers indicated that despite seeing a large proportion of young people with mental health challenges, the teams did not perceive mental health to be part of their core offer. Thirdly, some Early Help teams did not have a standard intervention for low mood, despite the Early Help threshold matrix indicating that CYP displaying signs of deteriorating mental health and episodes (e.g. low mood/mild depression) should be classed as level 2 and are suitable for Early Help or targeted support services. It was anticipated that IPC-A would be a solution to this, in part because of the relational nature of the therapeutic focus. This posed some challenges with respect to setting up the two trial arms in each service, as young people randomised to TAU were being referred to targeted services (also involved in the trial). Consequently, the additional pressure on targeted services to support young people being referred in from multiple routes, including Early Help teams, posed capacity challenges, which resulted in services having to collaborate to either deliver IPC-A or TAU.

Therefore, if Early Help teams are to be involved in supporting young people experiencing mental health challenges, there needs to be an explicit remit to do so. Early Help practitioners also need adequate mental health training/support to help them identify suitable cases at the triage/assessment stage and to enable them to deliver mental health support for CYP experiencing mild to moderate mental health challenges. Equipping Early Help teams to support young people with mental health challenges has a potential to reduce the capacity pressures currently faced by tier 2 mental health services and to prevent young people from being passed around the system, allowing them to build trusting relationships with one service. Arguably, there is a larger piece of work that is needed to map out the core service offers across the tier 1/2 services, including interventions being delivered to support young people experiencing mental health challenges in order to identify gaps in service provision and capacity to support young people with mental health difficulties. This mapping exercise could then guide both commissioners and researchers in identifying and developing new evidence-based interventions that align with core service offers.

The disconnect between policy and practice

The process evaluation findings highlighted a clear disconnect between mental health policy and transformation models and what happens on the ground with practitioners. The current challenges faced by the central referral point, including poor completion of referral forms from front-line services, a lack of knowledge of front-line staff (e.g. GPs and school staff) with regard to mental health treatment pathways and long waiting times, resonate with the 2020 ‘No wrong door’ report, which highlighted how CYP need to navigate through a very complex system and end up either on a waiting list or falling through gaps where there are no services to meet their needs. The experiences captured through the ICALM study indicate a poor implementation of the core recommendation of this report, which was the need for services to wrap around families and provide support wherever young people present, that is school, general practice. It should be noted that this was during the time and aftermath of the COVID-19 pandemic, which significantly increased demand for all services. There is therefore a need to support front-line services, where young people are presenting with mental health difficulties, especially schools and general practices, to ensure that young people receive interventions at the earliest stage or are supported through the mental health system until they receive the support they need. The transformation plan, which is currently underway, is one way of supporting front-line staff in managing under-18s presenting in general practice with mental health difficulties. To ensure successful implementation of the transformation plan, link workers need to be provided with adequate support, training (especially safeguarding) and supervision to work with under 18s. The successful implementation of the transformation plan could reduce backlogs at central referral points and ensure that CYP receive timely help. Link workers could help increase research capacity by providing much-needed access for recruitment of young people into research investigating evidence-based mental health interventions.

Finally, the increased demand for mental health services and the perception of mental health services providing gold-standard interventions suggest that greater effort is required to promote the philosophy of mental health as ‘everyone’s business’. Establishing a common language with regard to mental health difficulties and educating society with regard to their role in supporting positive mental health is therefore crucial in managing some of the current challenges faced by the services. Such education could, for example, focus on the key components of the Thrive model,60 which is a public health approach to promoting good mental and emotional well-being by supporting and educating schools, communities and parents on the key elements of mental health, the importance of self-care, how to build support within families and communities and when to seek help. More investment in prevention work as part of curriculum is needed by including well-being, resilience, managing emotions and developing healthy relationships. The process evaluation also highlights the need to ensure that acceptance criteria and thresholds for treatment are joined up across the system to ensure easy navigation by young people and families and that there is flow to the most suitable service for the right intervention at the right time.

Implementation and theoretical fidelity discussion

The IPC-A intervention was acceptable to young people, parents and therapists. However, due to the challenges faced in implementing the study, not all stakeholders felt that the intervention was suitable for Early Help services. The process evaluation findings indicated that evidence-based interventions such as IPC-A can be successfully implemented in tier 1/2 settings, although these services are often overwhelmed with ‘new things to do’ meaning that they struggle to have the capacity to implement new interventions systematically. However, in some cases, there appeared to be a tension between delivery of IPC-A according to its structure and engaging with the young person’s needs and desired outcomes, highlighting a tension between implementation fidelity and theoretical fidelity. Observations of the IPC-A intervention recordings suggest that to meet the aims of IPC-A, practitioners should orientate closely to young person’s needs and perspectives, as a focus on correct delivery alone may not always lead to desired outcomes. Such an approach needs practitioners to be flexible and confident to use IPC-A manual/training as a guide rather than a box-ticking exercise, although if delivered regularly as part of routine care, this confidence should develop. To achieve this level of flexibility and confidence requires long-term investment, ongoing supervision and support of the teams. It is worth noting that despite enthusiasm from services to implement new or research interventions, often services are overwhelmed with the additional tasks these involve and do not always have the capacity to be able to support the implementation of them.

The engagement of young people and collaborating with the practitioner are crucial for achieving desired outcomes from IPC-A. Such engagement and collaboration can be facilitated by the practitioner’s use of terms that the young person is comfortable with, an ability to relate to and empathise with the young person’s experiences and adapting activities to suit the young person’s experiences and abilities. Practitioners need to show they are on the young person’s side by acknowledging the young person’s disclosures and acting as an advocate when needed.