Exploring engagement and the usefulness of The AIM Cards with

130 Pages·2016·3.64 MB·English

Exploring engagement and the usefulness of The AIM Cards with
'hard to reach' adolescents; hearing views and experiences from
young people and clinicians.
Jo Carlile

D.Clin.Psy Thesis (Volume 1) 2016
University College London
UCL Doctorate in Clinical Psychology

Thesis declaration form

I confirm that the work presented in this thesis is my own. Where information has been derived from
other sources, I confirm that this has been indicated in the thesis.

Signature:

Name: Jo Carlile

Date: 10th June 2016

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Overview

Part one of this volume presents a review of the literature exploring what maximises engagement
amongst hard-to-reach young people. It considers what is meant by the term engagement, what
facilitates engagement when supporting hard-to-reach young people and what are the barriers to
engagement. It discusses findings in relation to psychological theory and clinical implications derived
from the empirical data.

Part two comprises of a qualitative empirical paper which captures practice-based evidence by
exploring clinician and young people's experiences of an assessment and engagement tool, known as
the AMBIT AIM Cards. Thematic Analysis is used to synthesise reports and develop overarching
themes relating to the use of The AIM Cards and experiences of engagement. It presents the first
empirical findings regarding the use of these cards and discusses their use in supporting both
assessment and engagement.

Part three is a critical appraisal of conducting the research project. It is a personal reflection of the
research journey, from setting up and designing the project through to data collection, analysis and
write up. It considers design and implementation challenges and includes personal learning
experiences.

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Table of Contents
Acknowledgements

Part 1 Literature Review........................................................................................................7
Abstract......................................................................................................................................8
Introduction................................................................................................................................9
Method.....................................................................................................................................11
Results......................................................................................................................................14
Discussion................................................................................................................................29
References................................................................................................................................35

Part 2 Empirical Paper..........................................................................................................39
Abstract....................................................................................................................................40
Introduction..............................................................................................................................41
Method.....................................................................................................................................46
Results......................................................................................................................................51
Discussion................................................................................................................................66
References................................................................................................................................74

Part 3 Critical Appraisal.......................................................................................................79
Introduction..............................................................................................................................80
Stage 1: Capturing 'Real Life' Research...................................................................................80
Stage 2: Data Collection...........................................................................................................84
Stage 3: Data Transcription and Analysis................................................................................86
Personal Reflections and Future Directions.............................................................................87
References................................................................................................................................89

Appendix.................................................................................................................................93
A. Letter of Ethical Approval...................................................................................................94
B. Participant Information Forms.............................................................................................98
C. Participant Consent Forms.................................................................................................110
D. Semi Structured Interview Guides.....................................................................................113
E. The AMBIT AIM Cards.....................................................................................................118
F. Section of Coded Transcript...............................................................................................124
G. Example of Coding Analysis.............................................................................................127

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Tables and Figures
Literature Review
Figure 1. Flow chart of identifying papers.............................................................................................13
Table 1. Reviewed studies.....................................................................................................................15

Empirical Paper
Table 1. Main themes and sub-themes related to engagement, reported by clinicians.........................52
Table 2. Main themes and sub-themes related to the use of The AIM Cards, reported by
clinicians.....55
Table 3. Main themes and sub-themes related to engagement, reported by young people...................59
Table 4. Main themes and sub-themes related to the use of The AIM Cards, reported by young
people.....................................................................................................................................................63
Figure 1. A model to engage hard-to-reach young people.....................................................................67
Figure 2. AIM Cards usefulness model.................................................................................................69

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Acknowledgements
Firstly I would like to thank Dr Stephen Butler who turned my idea into a research reality. His
support and expert guidance through the entire process has been vital to the completion of this thesis.
Secondly I would like to make a special mention to Professor Peter Fuggle. His ability to help
problem solve and consider the wider system context has been a valuable insight, helping me along
the way, particularly through times of difficult data collection! Thirdly and most importantly I want to
thank the clinicians and young people who agreed to speak with me. If they had not given up their
time there would not have been a project and so I am forever grateful for their contributions. I was
genuinely moved by their honesty and bravery in being able to share not only their opinions but also
personal experiences.
Finally I want to thank Neil Jolliffe whose commitment to this thesis has matched my own,
sacrificing a lot in order to prioritise its completion.

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Part 1
Literature Review

What maximises engagement with 'hard to reach' adolescents in
mental health services?

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Abstract
Objective: Hard-to-reach adolescents are considered the most vulnerable, complex and at risk
adolescent clinical population. These young people present with complex needs such as substance
misuse, conduct problems, severe depression, anxiety and psychosis. Often intensive intervention and
support is vital for a good prognosis. However, engaging these young people is particularly
challenging for mental health services and often requires outreach service models. This review aims to
address the question of what maximises engagement amongst this population by reviewing studies of
service users experiences and engagement strategies employed by clinicians and services.
Method: Studies that explored the views of young people with complex needs and studies evaluating
service or clinician engagement strategies were included. Sixteen studies were identified including
five qualitative, one case study, three experimental and seven service evaluations.
Results: General themes across all the papers argue that the engagement process relies on a complex
interplay of individual, clinician and service level factors. Findings showed implementing engagement
strategies to be a central predictor for young people to access support and led to better outcomes,
however a clear definition of engagement is lacking in the literature.
Discussion: Findings are discussed within the context of attachment and ecological theory, and
clinical and research implications for supporting hard-to-reach young people that emerge from this
literature are provided.

Introduction
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This review will provide a brief overview of how engagement is defined in the literature and
discuss identified factors that influence engagement considering three levels; service user, clinician
and service context. These findings will then be discussed in light of their research and clinical
application. However, firstly when considering what maximises engagement amongst hard-to-reach
young people in mental health services, the most important thing to address is who are the hard-to-
reach?
Hard-to-reach young people are defined by Kessler et al. (2010) as young people with a
complex profile of mental health and social needs. They propose this client group present with severe
mental health problems and are the most vulnerable to high risk behaviour and poor outcomes. By
their very nature hard-to-reach young people are therefore a group who are difficult to engage but are
probably the most in need of support. According to their definition, typical presentations of hard-to-
reach young people would include; substance misuse, conduct problems, offending behaviour,
psychosis, severe mood disorders, self-harm and suicidal ideation. Co-morbidity amongst these young
people is high and there is often a wider context of familial dysfunction and lack of educational
attainment. The poor outcomes and high risk behaviour associated with this group provide rationale
for researching and identifying how best to support and engage them in order to create optimal
support frameworks to reduce risk and promote better long term outcomes.
Hard-to-reach young people are also a challenging group to research. Complex needs, chaotic
lifestyles and a reluctance to engage with services makes interviewing, data collecting and evaluations
difficult. Services which are designed to support this group are often small as most support is
intensive and expensive. Gathering large samples and implementing strict randomised control trials
are perhaps the most challenging as they require larger numbers and a requirement to strict adherence
to research procedures. However, engaging hard-to-reach young people in research is important if we
are to understand how to engage and support them effectively.
Broadly speaking the literature focusing on hard-to-reach young people is limited. Dembo et
al. (2011) argues that most research with hard-to-reach client groups has been with adults and very
little is known about younger populations. However, the small body of literature focusing on
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supporting hard-to-reach youth has identified the role that engagement plays on producing better
outcomes (Dembo et al., 2011; Meaden et al., 2004; Gillespe et al., 2004; Karver & Carporino, 2010).
Meaden et al. (2004) looked at the role engagement played with hard-to-reach young people
in reducing hospital admissions. They found engagement predicted fewer admissions; specifically
perceived usefulness of treatment on the part of the young person and client-therapist interaction,
although no specific definition of what this term means is given. Dembo et al. (2011) claims
identifying strategies that enhance engagement is vital for young people with substance misuse
(identified as a hard-to-reach group). They propose flexible working and brief interventions can
support high risk young people and families to engage with services. Karver and Carporino (2010)
reviewed the literature on building the therapeutic relationship amongst young people with
oppositional defiant disorder and found it to play a central role in facilitating engagement amongst
this challenging client group. Additionally, although engagement has played a central role in the
developing research within this field, there are differences among researchers in how they define
engagement. Staudt et al. (2012) asks for clear understanding and conceptualization of engagement.
They carried out interviews with clinicians who described engagement as a complex interaction that is
influenced by relational, clinical and organisational factors.
There are consistent views across the literature that hard-to-reach young people are a
complex group with multiple needs. They are at most risk for poorer outcomes, which also has
implications for becoming increasingly reliant on services throughout their adolescence and
potentially adulthood. They are a challenging group to support due to high dropout rates, chaotic
familial systems and multiple service involvement. As a result it is important to understand and
implement strategies and service structures that promote maximum engagement. This paper will
review the literature examining what maximises engagement amongst hard-to-reach adolescents being
supported by community mental health services. Following initial searches and identification of
relevant papers research questions will be developed.

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