Clara Faria: Welcome to Mind The Kids, a podcast series dedicated to exploring the latest advancements in child and adolescent mental health research and practice. I'm a junior doctor and a trainee child adolescent psychiatrist, and I'm passionate about understanding and addressing the diverse mental health challenges that young people face today. And in this series, I will be joined by renowned researchers and clinicians from around the world to discuss their cutting edge research, their innovative interventions and approaches, and best practices in child and adolescent mental health. So from eating disorders to anxiety disorders and from digital interventions to the community, we're going to delve into the complexities of mental health in different countries and different contexts. So through these conversations, we really want to highlight the importance of global collaboration, cultural sensitivity, and evidence-based approaches to improve mental health outcomes for young people. So whether you're a researcher, a clinician, or simply interested in mental health, hopefully this podcast series will have something to inspire you, educate you, and foster a deeper sense of understanding of the global landscape of chat and adolescent mental health. Just before we get started, I wanted to make you fully aware that in this podcast we are going to be talking about sensitive topics such as restrictive practices in the context of eating disorders and trauma. So today we have the pleasure of receiving Dr. Robyn McCarron: from the Cambridge and Peterborough Foundation Trust. Robyn is a consultant chat and adolescent psychiatrist at the Darwin Center for Young People here in Cambridge. We're going to talk about Robyn's work as a CAMHS inpatient consultant and also the fantastic work she's been doing piloting a new approach at the Darwin Center. Robyn, thank you so much for being here with us. Dr. Robyn McCarron: Thank you for the introduction, Clara. Clara Faria: Yes. So, well, there's lots I want to talk about, but I think before we go into the details of your fantastic word view and approach, I wanted to give a bit of context to our audience. So I wanted to start by asking you, like in your experience as a trainee and then as a consultant chart psychiatrist, what made you realize that our traditional models of care were not addressing all of young people's needs? Dr. Robyn McCarron: Gosh, that's a big question. I am a very new consultant really. So I completed my training in November. But prior to that, I had already done some acting up work and I'd already worked at the Darwin Center. And, been involved in seeing young people in the community in those different settings with different kind of needs. So coming to inpatient, I think it's fair to really kind of highlight that actually, there's probably more pediatric intensive care beds than there are general adolescent inpatient beds. So the children and young people that are needing inpatient care really are, the sickest and most complex young people that there are. And they are often likely to have quite a long relationship with different services and quite long-standing and complex needs. And they often come with a really broad range of perhaps developmental needs, social needs, trauma history, a lot of complexity. And I think that makes them incredibly vulnerable. And I consider myself to be someone who is interested in issues of social justice and intersectionality. And I think bringing that lens to it has been really important and kind of, you know, working on a very kind of values based approach to the work. I think that we see that you know, these children are really complicated and they're really challenging sometimes to treat and to work with. And, you know, there's ongoing stigma around mental health problems and there's ongoing discrimination against, you know, issues around social class, know, parental mental illness, drug and alcohol abuse. So what there is the risk of is actually that these young people who are in greatest need of help, you know, are felt to a kind of, you know, neglected further by the system. I think that there's that risk there that because they're really tricky and they might struggle to advocate for themselves that we might, you know, treat them in a way that is perhaps less focused on their rights and their longer term needs and also their development as young people. So I really kind of wanted to be able to think about all of those issues together. And I was very lucky in that I trained with a consultant colleague who previously worked here, who had done a lot of work already thinking about least restrictive practice and how we work with young people in a way that maximises their consent and their responsibility for their care and their ability to participate in decision making. And I think for me, one of the big things that I then have been looking to take forward is having that even sharper focus perhaps on reducing iatrogenic harm and thinking about that longer term trajectory of these young people. So being really mindful that the way in which we work with them and we help them to understand their difficulties and the experience that we give them of not just mental health support but of services and help in general is something that is going to empower them to use help in the future rather than kind of worsen the epistemic mistrust that many of these young people understandably have when they come in. Clara Faria: Yeah, 100%. When you mentioned a values-based approach, and I know one of the values in your approach is not doing harm, avoiding heterogenic harm, which you just mentioned, and thinking about that and thinking recently. I don't know if you had a chance to see it, but there was just, there was a documentary out in the BBC about a mental health unit for children and young people. they interviewed lots of children and young people who had been inpatients in that unit and not to blame the unit, listening to those young people's testimonies and their experiences, think what is very clear is how traumatized they had been by the experience of inpatient care. And as you've said, young people who usually come to inpatient, young people who have previous trauma, previous experience of services. So I think your approach is really refreshing and really important in that sense, because it plugs into this gap of really important gap of how do we make services not yetrogenic and not like re-traumatizing for these young people. within this approach, are you focused in one specific type of disorder? Do you think there is a mental health condition that needs a more redesigning in how we think about inpatient care or do you think this approach can be applied to all mental health conditions essentially? Dr. Robyn McCarron: There's a few parts to that. So, I mean, think first of all, you know, I lean towards kind of Caspi's work thinking about actually, you know, there's this underlying P factor that is, you know, common across, you know, the many different ways that mental illness and psychological distress may present. So, you know, although our young people might have many different presentations and many different diagnostic labels that we can attach to them. There are many, commonalities on every level, know, from the SNP to the fMRI to, you know, all of those sorts of things that exist within that. And I suppose what our approach is trying to do is to see young people as that, young people. all of our policies and stuff refers to young people. And I think that's really important, kind of having that broad approach, especially in CAMHS, because we don't know how disorders will develop and the evidence around stability of diagnosis is, you know, there's different perspectives on that. And I think one of the things that we do see is that understandably, you know, services look to put young people in boxes. So, you know, there might be a neurodevelopmental service or there might be a core service or there might be an eating disorder. And whilst that might enable us to give that high quality specialist care, the majority of young people aren't going to fit in nicely in one of those boxes. And what we do find, I think, especially for young people who've been treated for eating disorders, is that they might have received a lot of evidence-based eating disorder treatment, but that has either ignored or know kind of not met or even exacerbated some of the other needs that they might have around trauma or neurodiversity for example. I suppose our approach really takes a really holistic approach and provides that truly person-centered care in thinking how we address the different needs that a young person has, rather than trying to kind of put it in a specific box. And certainly, we've been taking more and more complex young people who have often had really long and traumatic inpatient admissions for eating disorders that involve lots of restrictive intervention and restraints and they also are often, you know, autistic young people. And what we need to be really careful of in CAMHS is being mindful that these are adolescents who, you know, by definition are working out who they are and who they're going to be in the world, you know. It's this time of identity crisis and reimagining and working it out. And if in that really critical time period, the information that we're giving them is that they are too difficult or they are too challenging, that they are too unwell, or they need all of this super special help all of the time, or actually the only way that they can be safe is to be restrained for feeding. That has a inevitable impact on their sense of identity and their sense of self in the world. And I think that that means that it's even more important that we're really mindful of the risk of iatrogenic harm in this period, because it's such a sensitive time period. If we think about, things like the risk of developing trauma, around how much you're able to escape, know, the amount of power that you have and those border protective factors. Young people are... generally less powerful than adults, aren't they? They're more at the mercy of people around them and systems. And I think that, yes, that might be necessary, but with that comes a lot of responsibility for being really clear about the evidence that we're using to treat them and also being really attuned to kind of our values and our ethics. And I think the importance of the value side of things is again, kind of even more so in CAMHS because there often isn't a brilliant evidence base for a lot of what we're doing because of the nature of complexity, the nature of research and how medications and treatments are often tested. There's always going to be less evidence for young people than there are for adults. And we're also obviously working with that developing disorder. So there's also more ambiguity. So it's not always clear what the evidence base would say, but I think if we can be really clear on the values with which we're approaching young people and how we're looking to work with them, then that provides a really good steering point for being able to use the evidence that there is and apply it to the situation. So for example, our values are around respect, safety and discovery. And thinking about that really broadly, so for safety, for example, we're not just thinking about physical safety, we're also thinking about psychological safety. And by coming back to those values and seeing actually does this plan that we're doing here align with that, I think that's really helpful for keeping us working within an ethical framework and also being able to communicate that decisions to young people when we're helping them to be involved in their care or make choices and similarly to their families. Clara Faria: 100%. And like you mentioned the safety aspect and you also mentioned, in the eating disorders case, we know that. You mentioned actually lots of interesting points, but just to make a link with two things you've just said, you said about the evidence-based incomes and how often times does evidence base is frail. And then you've also mentioned the fact that, young people with eating disorders, oftentimes they, Dr. Robyn McCarron: Thank you. Clara Faria: It's not always the case, they do have a very traumatic experience of inpatient CAMHS for many different reasons. As you said, sometimes services are structured to address just one part of the equation, but not the others. And I was just thinking that, especially for young people with longstanding eating disorders, there's been lots of research push and funding at the moment especially around early intervention in eating disorders. There is the freed model, which works well for people with early onset eating disorders, mostly in the community. But you're totally right when you say that. And this is something patients, advocacy groups are always talking about, especially for young people with longstanding eating disorders, which sometimes is the case. And oftentimes is the case of young people who need CAMHS there isn't such a strong evidence base actually, aren't that many interventions that we know are effective, like clear-cut effective for that population. And thinking about that and thinking about what the Royal College of Psychiatrists guidelines recommend, for example, it is a bit of a, it is a very tricky situation, right? So feeding under restraint, for example, we know that sometimes that is necessary for life-saving situations. And that's what the Royal College of Psychiatrists most recent guideline recommends. But then at the same time, we have a few audits here in the UK showing how many times feeding under restraint was used in invasion units. And that number is really scary. And it's like, makes you wonder, right? In that sense, your approach is really, really, really vigorating. And I was just wondering how certain practices, like for example, feeding under restraint when necessary fit with this value-based model you're implementing at Darwin. and how do you communicate that to a young person? Dr. Robyn McCarron: So, absolutely. So I mean, when part of some of the changes that we've made, we do a period of kind of contracting when young people are referred to us. I mean, that sounds like a big drawn out process. Sometimes it might be a couple of meetings. Sometimes it might just be a quick teams meeting with them. But the importance of that is about transparency and us being clear with them, you know, how we work, what it means to work in a least restrictive way, what they can expect from us, what we need to expect from them. And when we're working with these, you know, very high risk in people with eating disorders or disordered eating, we will be transparent with them that we will work with them and give hold as much risk as is possible for as long as possible. But when we feel that their life is in danger at that moment, because of a lack of nutrition, we will need to deliver nutrition without their consent. But we do that on a feed by feed basis. I think that, you know, so we would be assessing each feed and we work closely with our dieticians to think about, well, what's the minimum amount of nutrition that will kind of help maintain sort of all the capacity of plunge glycogen stores to hold things. So we would certainly never be, you know, feeding people under a strain multiple times a day or even, you know, kind of consecutive days because every single feed we're seeing as a life-saving intervention that carries with it a huge amount of psychological risk, not only for the young person but for the staff and for their relationship with us. you know, in that moment, there really has to be nothing else that can be done. And we'll be really transparent with young people and their families around that. We will have been really clear on giving them opportunities. We will explain, kind of using the MEAD guidelines, why it is that now we really do have to act. But we will...also kind of do that restorative work with them afterwards and give them a debrief around that and show after we've got to that point that actually we can still, we're still working with you, you know, so we're still going to give you all the opportunities again. sometimes young people might need to go through that cycle a few times, but, you know, I think that often, you know, maybe doing that once helps them actually see, no, we do mean it, we are going to work with you, this is not something that we take light heartedly. But it is problem, think, you know, nobody wants a child or a young person to die and eating disorders are, you know, have the highest risk to life of any mental health problem. So that is the reality that we're working with. But we need to make sure that we're doing it as the code of practice says and the Mead Guidelines say, as that life-saving intervention. And if we're NG feeding young people under restraint at a normal weight for height for extended periods of time, I think we really don't justify that. And it's similar to any area of medicine. If we have a treatment that isn't working, what would we do? We would look back, we'd think, the treatment being delivered properly? Is it the right treatment? Are we treating the right condition here? We'd go back and rethink that, wouldn't we? But for some reason, we've got a bit stuck with young people with eating disorders. The sort of FJN approach, the Maudsley approach, all these evidence-based approaches really do work. They get kids better in the community and are really brilliant for the disorders that they're intended for. But what we see at this end is young people who... have a complex combination of difficulties or eating difficulties that are perhaps a result of trauma or related to their neurodiversity. So they're not that straightforward population in which there's the strong evidence base for. But it takes a lot of repeated cycles of doing the same things and harder before we're able to, you know, they come to us and we can say, actually, well, let's relook at this. I think we need to be more confident within CAMHS and it's understandable why we're not to be able to say that when an intervention isn't working, actually, we need to... Not blame the patient, not blame the family, which I'm not saying that we are doing, but we need to be able to go back and think, actually, is this the right thing that we're doing here? Rather than just say, okay, well, we're not managing in the community. You need to go into inpatient so they can do this even harder. And, well, it's still not working. So let's go on to NG force feeding restraint. You know, it's, it's, we need to be able to pause and look back and take that bigger picture and think again, what are we treating here? and how and I think, you know, eating disorders is a really clear example of that. But I think that applies to all sorts of things that we see. You know, the number of young people that come and they might have all these different diagnoses and they've not got better and they've had all these different medications, but actually, you know, they're still being abused at home or the social situation is such. I think the risk is always that we're going to pathologize the child because the child or young person is being brought to us as our patient. And as doctors, you know, we're kind of trained to look at the patient in front of you and treat what is there. But within CAMHS and actually all of mental health and probably all of all of medicine anyway. Sometimes what we need to do is take a step back and understand those difficulties or that pathology or those behaviours within that broader context in order to see actually who is our patient or what is our patient or where is the disorder because we can be too quick to place it within the child when actually you know, the way that the young person is behaving and responding and feeling in the world is actually totally appropriate. You know, normal emotions are reactive emotions. And if you are experiencing abuse and deprivation and all of this adversity, we wouldn't expect you to feel happy and function really well, would we? But yet we do because we then say that actually, you're the disordered one without changing any of the other stuff around. I know I've gone around it in lots and lots of different ways, but I think, you know, being really open to questioning what we're doing and why, and having that really holistic approach, understanding young people within that broader context, and yes, making diagnoses, if that's the appropriate thing to do, but also being open that actually, you know, those difficulties might not sit within the child. Clara Faria: Yeah. as you mentioned before, the P factor and also like how diagnostic stability in CAMHS is actually not that great and, and like how, even in adults, right. We, we look back, you know, at, sometimes at electronic health care records and we see like the trajectory of a patient, the diagnosis changes so many times. And, and, and as you said, it's especially with children and young people, it's not about the diagnosis most of the time, right? It's about the whole context. think that especially applies in inpatient. Yeah, I remember when I was like really early in my medical school journey and I've always been interested in psychiatry and I remember I was in a conference and I was watching this really interesting talk about eating disorders treatment and about how It was by a Stanford group and they were talking about how family therapy, the Mosley model was fantastic and phenomenal and how their outcomes for their outpatient eating disorder service was amazing. And I kept thinking to myself, but in order for family therapy to work, you actually require a functional family, like a functional environment for that child. We know that oftentimes when children are in inpatient camps, that social support structure doesn't exist. And then what do you do? Right? Like those approaches no longer work. And I wanted to ask you, Robyn, I think you do the most challenging work of all, because again, you work with young people who really need help and oftentimes who, have been through multiple services and it didn't work. And thinking about, research and thinking about developing new treatments and new interventions. what do you think that could work when we think about like, besides this fantastic holistic approach that you already have, do you think there is a place for, new interventions or new trials looking more to the inpatient CAMH population, but also thinking about eating disorders and specifically looking at young people with long-standing eating disorders for whom maybe, know, freed or FT, it's not going to be so adequate. do you think, you know, how do you think research could innovate in that area? Dr. Robyn McCarron: So I think being driven by clinical practice is really important. think that we're working at this kind of level when we're talking about essentially treatment resistant eating difficulties and trauma and autism combined in people under the age of 18. We're talking a significant group, but it's a small group. And they're also going to be incredibly heterogeneous and have had all sorts of other things before. I think it's really difficult to kind of say do a clinical trial type model. In that, that's not to say that, you know, that can't happen. But I think, you know, learning from the cases and kind of analyzing actually what it is that has worked, I think that there are really common themes. So for example, you know, in the way that we're approaching young people with eating disorders, there's almost kind of four phases that come and go and you move in and out of them. But one of them is around contracting and agreeing how we're going to work together. And that's something that I've said we do at the start, but we will do multiple points. So, you know, when there's a crisis, will... we will be contract and when we come to kind of those different phases. So that's an ongoing piece of work working out our expectations of each other and what the goals are and how that's going to work. But I think one of the main aspects of how we're working this is around containment. So I think you know, when I was a trainee, I think someone told me that the job of the consultant psychiatrist is containment, it's containing all the anxiety and stuff in the system and in the family and in the young person. And I suppose when we're working with these young people, we find, of course, you know, the community teams are very anxious because the stakes are really high, they're very, very risky. And then you know, if they go into an acute hospital, the acute hospital, you know, feel very panicked and very concerned. And it's very easy in that those high levels of anxiety and genuine fear for a child's life that services disintegrate. And we start splitting and, you know, we just raise anxiety. And actually, what we then end up with is essentially that kind of position of paralysis, where no one's working together and nobody knows what to do. And that isn't a place in which a young person can kind of take responsibility. It's too much. a lot of our approach is around having the ability to contain those different systems. So lots of communication with acute hospitals. lots of communication with family, know, managing higher levels of risk with very clear plans and lots and lots of very close medical monitoring and reviews, but also trying to not just react to crises. So that, you know, when we do have a plan, we can give the young person time to work to it. Because, you know, if we put in place a plan that their brain is trying to process for a couple of days. And if it doesn't work on day one, we go and change it. They're never going to be able to work to that because they're always trying to process it. So trying to be as consistent and containing as possible to give the young person the space that they need in order to be able to buy into a plan and work on it. And then I think that work around individuation and identity, which is so important for... all young people, whether or not you're in a mental health hospital. But thinking, especially when you've had those experiences, what is a life worth living? I know in DBT, we talk about, you know, a life worth living. And if your entire adolescence has been being restrained in inpatient units, that's unimaginable and is terrifying. So I think a large part of an approach at the Darwin is about giving young people those life experiences and letting them see that this doesn't have to be their identity and this doesn't have to be their life. So supporting even young people when they're still very low weight to have a home leave and be at home and be with their families because often their experience will have been being in hospital. That's why you end up with those cycles of readmission, because when it comes to discharge, you're expecting them to be at home and manage all of those family dynamics. And actually that in itself is an enormous task. So really focusing on actually what it means to be out in the world, to try different things, to be in a family, to be going to education, all of those sorts of things. And supporting parents to also have trust in their young person to do that. So if we think at the FTAN model, know, many of these young people and their families have been kind of stuck in that phase one or phase two. You know, they're managing the crisis or their family supporting the young person to eat. And if that hasn't been working and if you've had all of these traumas in between and these long periods away from home, actually supporting young people and their families to move to that phase three, that developing independence and individuation is really tricky. It's often what hasn't been done and has led them stuck in this cycle of phase one and phase two. So that's really important as well to be doing explicitly with the family. So what does it mean to let your 16-year-old daughter go for a walk on her own when she spent the past few years in hospital? You know, these are really, really big tasks for families because understandably they're so frightened and they just want what's best for their child and their experience has been that that is services looking after them and trying to keep them safe in hospital. So it really is that really big learning curve as well. Yeah and I think with that it's quite nice that often we find that when young people have had that long experience of being in and out of different hospitals and they've come to us and they've done something different, we're often the ones that get sacked. So they will often you know go on leave and they'll you know they'll be on extended leave or something and they'll that is actually you know we don't we don't really need you anymore. And obviously we do that in a managed way. We're still having, you know, discharge panic and stuff like that. But yeah, it's really nice when they feel that actually they're ready to get on with their life now. Clara Faria: It seems like you have a really special service going on in Darwin. When I was doing the prep for this podcast, I found a video. It said that it was co-produced by a patient and it's a really sweet video of this young person like introducing the world to other people. I mean, the young person doesn't appear, but it shows the world around and it shows like the different environments. And yeah, and it seems that you're piloting a really special model in that unit. I suppose to wrap up the podcast, I wanted to ask you a question. Well, we have a very big audience of early career psychiatrists, not necessarily child psychiatrists, but like, yeah, we have a big early career audience. And I wanted to ask you what led you to go through chat and lesson psychiatry? Were you like a run through trainee from the start or it was something that you decided like throughout training and yeah, and like why inpatient as well? I think it's fantastic. when you spoke about, the challenge and like of, of containing anxiety and, I can imagine it like we know, you know, we know how like, the NHS works and the appetite for risk, especially when working with children is very small. So trying to reinforce least restrictive practices in inpatient settings must be real challenge. And yeah, it is fantastic that you're taking that on. Dr. Robyn McCarron: Well, I mean, and that's where you come back to the values because, we all, you know, work within NHS values, but often it's making sure that those values kind of match what's happening clinically. But to go back to your question about how and why, I mean, run through CAMHS didn't exist when I was starting out. So that was not an option. But I was always interested in psychiatry right from the beginning of medical school. And we all have our own stories, don't we, about why we get interested in certain things. But I think that the complexity and the legal and ethical aspects of it and the biopsychosocial approach really appealed to me. And I like children. I've got three of my own. And the way that they challenge your perception of the world constantly is so wondrous and magical that I think that they're such a wonderful group to work with. And I had never kind of thought that I would work in in impatient, I don't think until I did my first inpatient job. And when you work on an inpatient unit, you've got so many beds. So you've got that set number of young people. And yes, they might be the most complicated and the most unwell, but you've got a real opportunity to get to know them and to build those relationships with them and to really bring yourself into that work and do something meaningful with them in a way that is just so challenging in the community because of all of those additional pressures. So I have the absolute greatest respect for my community colleagues that are trying to manage and always waiting lists and all of that. I don't know, it's such an honor and a privilege to be able to really get to know with these these young people and find out actually how can we help you take that next step. That, you know, I wouldn't do anything different. It's you know, it's really hard. Sometimes it's really hard and it has a really big personal toll sometimes. But, you know, I feel just I love coming to work and, you know, my young people just amaze me all of the time because of their resilience and their, you know, just working out who they are. It's a real privilege to be able to watch young people who've gone through so much be able to piece together who they're going to be in this next step in their life. So yeah. Clara Faria: Oh, that's really beautiful, Robyn. And thank you so much for being here today and for sharing more about all the wonderful work you've been doing in the Darwin. And I couldn't agree more. Children are the best and they are so fun, so insightful. And as you said, they just challenge your perceptions all the time. And if you're listening and you're considering a career in CAHMS yeah, do CAHMS. CAHMS is the best. Yeah, thank you so much Robyn for being here today and for sharing so much with us about the approach you're piloting in Darwin and well, about all things cams related. And thank you so much for the listen.