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A relational approach to young people’s mental health

Cite as: Barnes, N. (2017). A relational approach to young people’s mental health. International Journal of Cognitive Analytic Therapy and Relational Mental Health, 1(1), 130–147.

Int. Journal of CAT & RMH Vol.1 No.1 March 2017/ISSN2059-9919 


In the UK reform of mental health services for children and young people is currently high on the agenda. Demand has never been greater but the risk of perpetuating services that stigmatise and disempower young people needs countering. I propose that a relational approach which offers collaborative, respectful and joined up ways of meeting young people’s needs, might counter this risk. This would involve learning from and integrating individual, family, systemic, youth and community work. Conceptual tools and methods from CAT can help sustain this integrative and relational approach.


In this paper I focus on the need to reformulate the context to children and young people’s mental health work. It puts trust and collaboration at the heart of a relational approach allowing a focus on needs for belonging, identity confusion and a more existential uncertainty about self in the world. Using examples, I explore how CAT can help find a more negotiable and integrative middle ground between different self-states. This is mirrored by the various services being more connected, more community based and offering real relationships with each other and with the children, young people and families.


There is currently a heightened awareness of the growing mental health needs amongst children and young people although there appears to be a paucity of both data and of the exploration of the causes.


There is a greater appreciation of the symptoms or behaviour reflective of this need, but limited understanding of the drivers of distress. We are left with a real sense of mopping the floor, rather than turning off the tap.


This article argues that any integrative and sustainable strategy must be based on the fine detail of a relational approach which combines interpersonal, systemic, developmental and social dynamics and professional contributions in its understanding. In the UK, the profile of children and young people’s mental health has risen exponentially over the last few years – there has never been a greater level of reporting of this issue within the media. A recent literature search by Fonagy et al charted this rise in the media (see figure 1). The focus tends to be on rates of diagnosis and the need for treatment, with far less attention being directed to the context which leads us to reach for the Diagnostic and Statistical Manual, DSM V, for 3 children in every classroom of 30.

Raising awareness will never be sufficient unless there is the capacity to meet demand – and many acknowledge, even with extra funding that ‘specialised’ services will never be able to fully meet the mental health needs of children and young people. I also doubt whether they should ever seek to do so. The shift for me, over recent years has been to explore earlier and more preventative approaches, offered much more within the community, and offering genuine opportunities for children and young people to stem this tidal wave of demand that is unlikely to subside. If we fail to initiate a more preventative approach at an earlier stage then I fear specialist services will find the demand overwhelming, and themselves become exhausted.

Figure 2


I have been particularly keen to develop ways of working preventatively, through CAT theory and with CAT tools in settings that are much more meaningful for young people.


As an example, for some this setting can be football, and partnering up with the foundation arm of a local premier league club Tottenham Hotspur, it was possible to develop a programme under the banner of ‘A Game of 2 Halves’. Over a number of trial sessions, ‘A Game of 2 Halves’ evolved into a 12 weeks programme for young people aged 13-14yrs who were at risk of exclusion from school. By using football in both the dialogue and activity of the sessions, it was possible to help them develop an awareness of what might be going on within themselves and between each other, and to explore how their own actions could be impacting on how others felt about them, as well as reinforcing how they felt about themselves and others.


The sessions also involved support staff from the referring schools, so that a greater awareness could be shared not only within the group (team) on the pitch, but also be taken back into school and allow for a different perspective – a shift in gaze – to be offered to the wider staff team. With positive outcomes achieved from the viewpoint of the child, and an appreciation of further pro-social behaviour reported by the teaching staff, it was clear that a CAT-informed programme, offered within a group (team) setting, and delivered within a ‘dialogue of football’, created the space and opportunity for change for some young people. For the Bakhtinian influence on CAT theory, the dialogue of football represented a distinctly open time and place (chronotope) that gave different meanings to everything within it. It highlighted to me that a relational approach to mental health involves not only our relationships with ourselves and with others but also our relationship with the medium of delivery – on this occasion, football. I was left wondering whether Bakhtin supported a football team?

Barriers to support and loss of trust

In this spirit, much of my own work over the last ten years has focused on making services accessible and not marginalising young people’s needs. We struggle to recognise our professional contribution to this reciprocal relationship of stigmatizing to stigmatized.


When I first started training, I was often faced with children or young people, and their parents, in clinic who simply did not wish to be there.

Figure 3


The ‘systems’ surrounding this young person and their family had eventually resulted in a referral to Children & Adolescant Mental Health Services (CAMHS) as a way of seeking to prevent an exclusion from school. The intention of the referral may well have been positive and supportive – but the young person had ended up feeling blamed, and the parents, often feeling angry, defensive, but most importantly, ashamed.

Figure 4


Time and again I met families in clinics for whom what was on offer meant very little to them, whilst the expectations of the networks surrounding this young person felt that CAMHS would and should offer something ‘magical’ to sort out the problem. The risk of disengagement was always considerable as there was never a collaborative agreement/ alliance about what someone was being asked to engage with. As a result the letter back to the referrer stated that the case had been closed because the young person DNA’d (Did Not Attend). From wanting to be able to offer something magical and helpful, CAMHS now became a place that was useless and unhelpful (see figure 5).

Figure 5 Reciprocal role relationships – expectations of the network alongside the experience of the young person and family when referred to Children & Adolescant Mental Health Services (CAMHS)


The original aim of the referral – prevent exclusion – was often unsuccessful, and the young person’s trajectory towards social isolation or marginalisation was often reinforced by their experience of yet another ‘useless’ service. But the cost of exclusion is not just about missing out on education. The risks of becoming increasingly caught up in antisocial and offending behaviour, drug and alcohol misuse or suffering with more severe and enduring mental health needs are all greatly enhanced through exclusion. But it is often the experience of the loss of trust by the young person that will be the biggest price to pay. This loss of trust of services through stigmatisation and marginalisation will impact on any future willingness and capacity to access support further down the line – when it is often the law that is called upon to intervene.

Connecting – Connected; a relational approach

In light of this all too familiar pathway, I have spent much of my time seeking wider options for young people to be able to connect with support and feel that they have some sense of agency and ownership of their opportunity for change.


My medical training and psychiatry experience has contributed to my work and the role that I offer within my team. However, I am more aware that it has been my training and involvement with Cognitive Analytic Therapy (CAT) over the last ten years, and my role as a Voluntary Youth Sector lead for over twenty years that has given me the confidence to feel able to propose and develop the projects that have evolved over the last few years.


Perhaps I should start with CAT as this offers a theory of the relational development of self and reflects on our development as a dialogue between other to self, self to other and self to self. This developmental model offers a framework for young people to think about their capacity to negotiate within themselves and with others whilst seeking a way of being and belonging that is meaningful and authentic. As noted by Steve Potter, ‘A relational approach to mental health is ever more pressing: as the extent, mix and severity of distress, the awareness of and sense of entitlement to psychological help increases and the cost pressures on the tax payer pull us towards smarter more joined up ways of working. Regardless of the type of treatment, intervention or care, and, regardless of the profession of the provider, the quality of the helping relationship is going to determine outcome in the face of this complexity.’


CAT’s strength lies in offering an approach that pulls all these themes together. It enables a more integrated and client-centred way of working. It has a focus on the interpersonal process, and a collaborative exploration promoting a sense of agency and integration through the use of tools such as maps, letters and other creative outlets. In this way CAT provides a model that can be both meaningful and accessible to the young person and their family, whilst holding in mind a framework of the relational development of self.

A sense of belonging and a relational view of identity

When working with young people, the core questions are frequently about ‘belonging’. The adolescent desires to know where and how they fit in. This drives the need for peer recognition and endorsement. When the young person presents to services, these key concerns about belonging are often exacerbated by traumatic experiences in earlier life. They make the ground upon which they stand even more fragile and contribute to feeling uncontained.


This struggle with a sense of belonging, and even existence, reminds me of working with a young person who was seeking the ‘perfect suicide’. Meeting with Amy wasn’t easy – she was reluctant to engage and doubtful that a therapist could offer her anything useful. However, exploring her symptoms and actions led to questions about a diagnosis of Bipolar which was enough to tweak her curiosity. By the time she started attending for regular appointments at the clinic, she was fully involved – to the outer world she presented a sense of capability and being in control, with the receptionist referring to her as the ‘head girl’. But getting to clinic had been hard and had required consistency and patience from me and colleagues through an outreach approach.


Since losing her father as a child, Amy had taken on the role of looking after her mother at the expense of not feeling parented herself. By the time she reached her teenage years, it was clear that she was becoming increasingly overwhelmed by her sense of ‘duty’ and started to find herself bouncing between poles – from a place where she felt in control and seeking to be the perfect high achiever in all that she did (the Head Girl), through to a place where she felt unsafe, insecure and everything was ‘fuzzy’. It was in this later place that she found herself attacking herself and thinking about life not being worth living. And it was this thought that she would carry with her to contemplate the perfect suicide – finding a way to leave, without having an impact on those around her. For Amy, the perfect suicide was a ‘non-relational’ suicide, one where she is no longer entangled in or by the lives of those around her. It was a perfectly controlling way of ending the yoyo between being on top or fuzzy? Working with this longing to escape from relationships and the painful meanings they provoke needs a versatile framework that can help find a way to separate her relationship with her-self from her relationships with others without the result of her taking her own life.


Working through CAT with Amy allowed the flexibility: to think about the symptomatology and possibilities of diagnosis, and not ignore the potential risks. It also enabled an exploration of some of her more fundamental queries and questions. As the therapeutic relationship developed, the chance to think about being and belonging, of loss and longing, became easier and more relevant to the work. The need for ‘a perfect suicide’ dissipated as the therapeutic relationship became increasingly secure, and the space felt safe enough to test out her thoughts, ideas and experiences without fear of being judged, criticized or simply ‘not fulfilling one’s duty’. As the therapeutic space became a place for learning to negotiate, Amy started to allow herself to learn how to look after herself, parent herself and become her own therapist. By being in dialogue in therapy, she could begin to be in a relationship with herself. Amy started to think about herself more in the context of relationships – thinking about ‘self to self ’, ‘self to other’ and also beginning to allow ‘other to self ’ in ways which felt negotiable, compassionate and not frightening.

Living with uncertainty, managing ambiguity

Today young people face so many dilemmas in shaping a relationship with themselves and the world. Do they explore the past or shut off from it? Do they conform and fit in but lose part of their spontaneity or do they take risks but feel exposed to scrutiny? Some young people appear to have a greater acceptance of uncertainty, and ambiguity that might not have been experienced or tolerated by previous generations in relation to work and identity.


The rise in mental health need amongst young people may link in part to the underlying sense of uncertainty that exists in the world around them. Previous generations might have had collective fears of world war three and the impact of the cold war but individually young people often expressed fears and anxieties about spiders or friends. Now fears are reported to be far more about failure and debt, bullying and safety, as well as wider environmental concerns such as climate change. We appear to have generated a dynamic for young people where they have greater level of responsibility but with the least amount of accountability than at any other time. It feels as though this gap (between how young people are expected to manage without the guidance and tools to manage), under- pins many of the concerns that young people express when seeking help.


For change to be possible and meaningful, there needs to be not only a relationship that allows the building of trust, but also promotes agency and is empowering. Young people need to believe that they have some sense of control over mental health work and that it is not about doing to, but rather about being with and alongside. It involves being empowering and enabling, rather than fostering hope whilst maintaining dependence.


The uncertainty described, especially regarding identity, feels open to a far wider exploration than I would suggest has previously been considered. Sexual identity, gender and sexual orientation seem far more open for discussion and consideration within some peer groups with a greater tolerance and acceptance of uncertainty.


I am very aware that many young people from LGBTQ communities will present to CYP mental health services with severe levels of distress, with marked risk of harm to self and suicide needing to be acknowledged and addressed. But I am also struck by how many young people I meet with currently who are far more willing to explore these areas of identity and belonging within a much more fluid and flexible framework – with the anxieties of any uncertainty perhaps being held more by their parents than themselves and their peers. To reflect on ‘gender fluidity’ or ‘pansex- uality’ would have been relatively unknown at the start of my practice in mental health, and yet I find this is becoming increasingly the norm in today’s consultations. As CAT offers such an openly accessible way of thinking about self, and how one’s sexual and identity development is so relationally dependent, then I feel that this dialogue sits comfortably within the therapeutic space – being picked up and worked with if required, but not necessarily needing to be the sole focus of the work.


The case of Polly perhaps best exemplifies this aspect of the journey through therapy. Having presented at the age of 15 through emergency services and an admission to a pediatric ward following a very serious suicide attempt, Polly was determined to engage in therapeutic work that aimed to address her uncertainty about her sense of self – especially in relation to her gender identity.


The work with Polly seemed to go through three distinct phases. The first was a balance between managing risk and clarifying the scope of the work. Given the severity of her attempt to end her life, my hope had been to recruit the parents (separated and estranged) to this work, but it became increasingly clear that this would not happen. This helped me understand how difficult it was for Polly to feel able to belong, and to feel connected. This initial phase focused a lot on the extreme responses and reactions of the world around Polly, as well as trying to gain some understanding of her world within. Many of these initial discussions were about needing to address concerns about gender identity through hormones and re-assignment. Polly would present at these initial sessions filled with thoughts, ideas and questions about how to embark upon this transformative journey, and yet the early mapping allowed for her to see that this quest regarding identity might also underpin wider questions about herself, and her relationships with the world around her.


As the therapeutic relationship developed, and became more focused on trust and allowing for negotiation, the dialogue shifted into a more relational and interpersonal understanding of being and belonging. We moved away from needing to focus solely on whether her own identity needed to be challenged or questioned, and more into an area of being able to negotiate with her peers, and with herself, about connecting and feeling connected. Her episodes of crisis and times of feeling over- whelmed became increasingly seen through a shift in gaze, as she started to consider the impact of relationships on her overall sense of wellbeing. Maps reflected patterns and procedures that started to integrate different parts of herself as she began to test out and prove to herself that her sense of self could also be defined by others as much as by herself. A crushing rejection by a partner a few months into the work outlined the relational impact with and of others, whilst reminding myself to be alert to the potential risks.


And then finally, in the later stages of this work it felt possible to pull together a more ‘over-arching’ perspective – a view that allowed for negotiation with others and self that enabled Polly to just ‘be’ – and that some of her ‘unknowns’ or ‘uncertainties’ were OK, and didn’t need to result in her feeling distressed and overwhelmed. Dialogue about sexuality and identity returned, but in more reflective and exploratory sense – in a space where it was possible to be inquisitive and questioning, without needing a concrete answer. The capacity to live with ambiguity and uncertainty was available and allowed, and the sessions reflected this capacity for negotiation.

Enabling a Negotiating Voice

Hence, I am often asking myself what it is that CAT offers young people – what is it that they are getting from this type of approach. The process of facilitating an opportunity for change through understanding the past as well as present procedures is clearly the framework that we all work within – whether we stick to the 3 ‘Rs’ of Reformulation, Recognition and Revision or not. Likewise, I feel sure that we would all refer to the sense of collaboration and the need for working alongside as being very much at the core of our CAT practice – whether we do this through letters, maps or other tools. But I feel that this type of work often connects far more with some people as it enables the young person to develop the necessary negotiating skills – a ‘Negotiating Voice’ – that provides a dialogue with self and other and allows for a legitimation of the emerging self in this ever uncertain world.


I have found the use of the template map an invaluable tool in developing a therapeutic alliance and relationship with young people as it allows for a relatively clear understanding of what might feel very complex and overwhelming material. But it is also a map that enables young people to see the circularity of some of their patterns and procedures, as well as giving easy wins for thinking about from where their exits could emerge.


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Preventing the Flock of Seagulls effect

As CAT therapists we are privileged in being in dialogue with the legacy of radical educationalists and psychologists such as Lev Vygotsky whose work has helped inform CAT theory and understanding of self- development. His construct of the Zone of Proximal Development (ZPD) has been enormously helpful in thinking about learning, translating itself easily from the ‘teaching relationship’ to a therapeutic relationship that is enabling and empowering. But Vygotsky’s work also needs to help us think about the wider determinants of development and of where and how we practise as therapists/practitioners who seek to engage young people.


The ZPD allows us to think about working with young people where they ‘are at’ rather than where services would like them to ‘be at’. The number of young people who are willing or able to attend a clinic and engage with 8, 16 or 24 sessions of a formal therapy is always going to be small – and perhaps should always remain so. The transformation of services is, therefore, not simply about providing bigger budgets in order to offer more therapy and therapists.


If we are really seeking to explore how young people access support, and what type of support they would be willing to engage with, then we need young people to help and assist in the design and development of these services.


Perhaps driven by my involvement in the voluntary youth work sector I have increasingly considered the need for services for young people to be offered in more grounded and neutral settings – such as youth centres and community centres, rather than through clinics that are separated off and invite the risk of stigmatising and marginalisation. There will always need to be places where young people feel they can be helped and supported in a more private and confidential setting – but we need to allow young people to feel they can meet and build trust with professionals and staff in settings that lessen the barriers to those professional relationships being able to develop.


Having taken groups of young people away on residentials, camps and trips across Europe, and also been involved in running regular group sessions on a weekly basis, I am very aware of how important and powerful this work can be. It is in these settings that young people can test out and give informal voice to their ‘negotiating skills’ and build their resilience by being allowed to fail, and yet feel supported to get back on their feet. I am increasingly of the opinion that through youth work I feel I have probably done as much, if not more, for the emotional and relational wellbeing and mental health of some of the young people as I have through my role as CAMHS psychiatrist. I certainly have been able to work with some young people, far more intensively, helping them feel more connected and accepted by their peers, than is ever possible through a clinic.

Maintaining a focus on the 3 Rs

For a relational approach to mental health for young people, we need to focus on supportive and meaningful relationships around the young person. CAT enables a way of exploring a more integrated perspective of support (and of self) across agencies and services so that a young person will feel more empowered and take ownership of change in their life. But perhaps most importantly, CAT offers a theory and understanding of development that facilitates the testing out of the Negotiating Voice that is so crucial for transition into adulthood. It is a voice which the recovering young person finds in themselves often for the first time because they hear it from the teachers, mentors, peers and mental health professionals around them. CAT has evolved over time so that we can all comfortably reflect on the roles of Reformulation, Recognition and Revision – the 3 Rs of time limited therapy. What I am considering in this paper is a reappraisal of the 3Rs for CAT. A proposal that we should keep the 3 Rs – but this time the focus is on Relationships, Relationships and Relationships. 

Finding the middle ground

In other articles I have referred to the phrase I often use in therapy of finding ways of helping young people negotiate for themselves to be more ‘in the middle’ – a place that represents the more integrated sense of self, the compassionate heart of their Map, a place where positive self- to-self and self-to-other reciprocal roles and procedures can placed just as exits on an SDR (therapy map). This concept of being ‘in the middle’ seems helpful as an accessible means of describing and depicting therapeutic change for many young people who, at times, feel overwhelm- ed by some of the more formal therapeutic procedures.

Figure 6 Example of using a template map for a young person – with focus of how to be more ’in the middle’ at the centre of the diagram


Being ‘in the middle’ may sound as though this is a fudge – that it is some form of compromise, and a way of accommodating to adverse events or significant past difficulties. But what I hope the template illustrates is that this idea of being ‘in the middle’ is really about offering a space for a young person to test out their newly acquired negotiating skills, and seeing where they fit in with established patterns, procedures and the more established reciprocal roles. The space at the centre – in the middle of the template map – demonstrates the circulatory nature of some procedures and patterns, but also shows that the skills being developed and proposed for the middle can have a relationship with many of the surrounding reciprocal roles – being possible exits that need to be negotiated and trialed both within the therapeutic relationship and outside. Being in the middle legitimises the opportunity for developing the negotiating skills that will enable change.


For some young people, there can be a need to ‘find a balance’ of their needs and the demands and expectations placed upon them (by self or other) and for others, there is often a greater focus on learning how to care and look after yourself, how to parent yourself, and eventually, how to think about becoming your own therapist. Whichever approach is needed within the work, CAT offers a flexibility to test out a number of tasks, rather than needing to focus on one goal in isolation.


CAT has the capacity to facilitate a space for the young person to really discover and test out these negotiating skills (as shown by Amy’s case above) and become familiar with their own ‘negotiating voice’. Opportunities for change need the young person to have some understanding of their past, and how this becomes re-enacted in current relationships, but they also need to be able to develop a sense of trust in another – and often it is the therapeutic relationship that allows this to happen. But as noted previously, there also needs to be a sense of agency for the young person, and I am of the view that it is by enabling a young person to develop these skills and start to engage with their ‘negotiating voice’ which gives them the sense of empowerment to make things different.

A community based approach

A more relational approach to mental health for young people needs to be developed within a youth centre/community centre setting, with the role of the specialist being as much about offering guidance and support to the youth workers, as offering one-to-one support for the young person. The tools of making maps, exploring reciprocal roles, and generating a contextual reformulation can often be just as powerful when directed through others, enabling a relational understanding of emotional development and distress that can be more easily supported within the community. It has been possible to do this work with youth workers, gangs workers and football coaches in a variety of settings. All have helped to generate a better understanding of the difficulties facing the young person, or group of young people by maintaining the focus on the relationships rather than solely on the distress.


Other therapeutic models have also developed this type of approach with mentalisation-based therapy perhaps being the closest ally in this field. The AMBIT model has emerged to seek to work with young people where there are real difficulties with engagement – and the integrative application developed by MAC-UK are some of the best examples of how to put this work into practice. Likewise, the HYPE model developed by Chanen et al in Melbourne offers an assertive approach to community engagement and this being entirely focused around CAT as the tool for change. Both of these approaches offer valuable opportunities for thinking about how we might transform our services, as they fundament- ally seek to place the relationship at the centre of all that is offered – and instinctively allow for a relational approach to mental health.


But we need also to ensure that we are not overwhelming the young person who may be presenting with need. After all, it is seldom that a young person presents to a service with just one difficulty – they can find themselves being passed from service to service, from professional to professional, as each of their individual difficulties are identified. How many young people have a list of 4 or 5 professionals in their lives – all of whom need to complete their assessments, write their reports, clarify their risk assessments, even before they consider an intervention that might enable some change. Many young people will have social workers, mental health workers, drug and alcohol advisors, youth offending officers, teachers etc. – the list goes on and on – but how effective everyone feels in what is provided is often brought into question. One young person I worked with summed this experience up completely, being asked to meet with me, after a whole raft of professionals. Put simply he stated: yous lot is like a flock of f***in seagulls – you’re each coming in for your own little bit then p*** off’ (Figure 7).

A relational approach to the support for this young person – including their mental health needs – would allow for the specialists to focus on the keyworker – the individual with whom the young person is most engaged, or wants to work with – and it is the keyworker who will sustain the relationship with the young person. The focus is on the team around the keyworker – who all inform and help sustain the key relationship between keyworker and young person. It is through this approach that relationships are formed and sustained, trust is allowed to develop and the young person, in collaboration with their keyworker is enabled to start making steps towards change. This is a relational approach to development. It is what Vygotsky talked about when referring to the Zone of Proximal Development, and it is the core of a relational approach to mental health.

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