‘I had my guard up for a long time and that probably didn’t help’: Exploring care leavers’ experiences of the barriers to accessing mental health support during adolescence using photo-elicitation and Interpretative Phenomenological Analysis

Abstract

Children in care are more likely to experience significant mental health difficulties and consequently poorer long-term outcomes. However, they are less likely to receive professional mental health support than children living with their birth parents. Exploration of the barriers to accessing support from the perspective of care-experienced young people is limited within the literature; the present study aimed to bridge this gap. Six care leavers aged 18–25 years old engaged in a photo-elicitation-based interview that explored their experiences of the barriers to accessing professional mental health support during adolescence. Data were analysed using Interpretative Phenomenological Analysis (IPA), and five group experiential themes and 10 subthemes were identified. The group themes were ‘A lost cause’, ‘Alone no matter what’, ‘Don’t talk about mental health problems’, ‘Misunderstood’ and ‘Nobody helped us’. The clinical implications are discussed, as well as recommendations for future research.

Plain Language Summary

Children in care are more likely to experience mental health difficulties and longer-term problems than children who are not in care. Despite this, they are less likely to receive professional mental health support. There is limited research exploring what stops young people in care from accessing mental health support when they need it, especially hearing from the young people themselves. This study aimed to bridge this gap. Six care leavers aged 18–25 years old agreed to take part in interviews about their experiences and were asked to present photographs that represented the barriers they encountered to accessing mental health support while in care. They were interviewed about these photographs and the data were analysed. Five main themes and 10 subthemes were identified. The main themes were: ‘A lost cause’, ‘Alone no matter what’, ‘Don’t talk about mental health problems’, ‘Misunderstood’ and ‘Nobody helped us’. The findings indicated that young people in care experience a range of barriers to accessing support; these focus around other people’s misunderstandings of their difficulties, problems trusting others and services being inadequate in meeting their complex needs. There is a need for more trauma-informed services as well as additional training for professionals and carers about mental health presentations associated with past trauma. Further research around successful experiences of accessing services and the role of informal support would be beneficial.

Keywords

Foster care looked after children mental health support barriers to services care leavers photo-elicitation

Introduction

Adolescence is a unique developmental phase characterised by a multitude of changes and is a period associated with an increased risk of mental health difficulties (Blakemore, 2019). Whilst early intervention for mental health difficulties is recognised as essential for improving long-term outcomes (Colizzi et al., 2020), many young people do not receive support from mental health services (Copeland et al., 2015). One subgroup known to have a higher prevalence of mental health difficulties (Wang et al., 2019) but who are less likely to access professional support is young people in care (Kerker and Dore, 2006). Understanding the barriers is crucial to increasing access to services and engagement in intervention for mental health difficulties.

The number of young people in care in England continues to rise. Most young people are placed in care in England due to early childhood adversity. In 2021, 85% of children were placed in care due to neglect, abuse, absent parenting or family dysfunction (Department for Education [DfE], 2021). The high prevalence of adverse childhood experiences (ACEs) (Simkiss, 2019) means it is unsurprising that the rates of psychological difficulties are higher amongst young people in care than the general population (Wang et al., 2019). Research estimates that around 50% of young people in care have a mental health problem (Beagley et al., 2014; Oakley et al., 2018), and a review exploring suicide found that young people in care were over three times more likely to attempt suicide than children who have not been in care (Evans et al., 2017).

Unresolved mental health difficulties during childhood increase the risk of mental health problems during adulthood (Copeland et al., 2015) and this is exacerbated for those who have experienced trauma (Duffy et al., 2018). Consequently, early intervention is essential in effectively managing psychological difficulties and preventing severe and enduring mental health problems in care-experienced individuals (Jackson Foster et al., 2015).

Whilst it is recognised that all children and young people should have access to mental health support when needed (Care Quality Commission, 2017), engagement in mental health services amongst young people in care remains disproportionately low (Kerker and Dore, 2006) and barriers to accessing support for young people in care are evident (Hunter, 2018).

Research examining foster carers’ perceptions of the barriers to young people accessing support has identified a range of potential barriers, including long waiting times (Fergeus et al., 2019; Hiller et al., 2020; Stanley, 2007; York and Jones, 2017), poor foster carer awareness of available mental health support (Fergeus et al., 2019) and challenges presented to engagement by discontinuity of care due to transitions (Hiller et al., 2020; York and Jones 2017). York and Jones (2017) identified that foster carers were satisfied with the referral process to mental health services but perceived it to be the responsibility of care agencies to manage the referral. Uncertainty about who is accountable for signposting young people to mental health services may partly explain literature highlighting that care-experienced individuals do not feel that others listen to them or act on their concerns (Flemming et al., 2005).

However, very limited research to date has been undertaken seeking the perspectives of young people themselves (Powell et al., 2021). A literature review exploring research into young people in care’s general wellbeing found only three of the 39 studies included care-experienced perspectives (Smales et al., 2020). Of those studies that have examined barriers to accessing mental health services in care-experienced individuals, obstacles identified have included not feeling listened to (Blower et al., 2004; Flemming et al., 2005), feeling as though they do not fit in anywhere (Flemming et al., 2005), difficulties conceptualising their own mental health difficulties (Anderson et al., 2004; Coulter et al., 2022) and difficulties in trusting professionals alongside avoidance of talking about the past as a way of coping (Hiller et al., 2021).

There are limitations in relying solely on carers’ views to reflect the issues and experiences of adolescents, and research has found disparities in the perspectives of adolescents and caregivers when examining the barriers to young people’s mental health services (Schnyder et al., 2019). Research conducted to date with care-experienced young people and foster carers similarly shows differences in perceptions, with young people identifying more relational barriers to accessing mental health support in comparison to the systemic challenges emphasised by carers, and that may not be unique to this subgroup of young people.

The lack of inclusion of lived experiences from care-experienced individuals is not only a concern within research, but also in the development of services (Davies and Wright, 2008). This was echoed at the Care Experienced Conference in 2019, an event run by care-experienced individuals. Ten key messages were concluded, including ‘Mental health and well-being are our biggest worries and the most important and urgent things that have to improve’ (The Care Experienced Conference, 2019: 9) and ‘Having our say is essential’ (The Care Experienced Conference, 2019: 11).

Additionally, a 2021 report by the National Society for the Prevention of Cruelty to Children (NSPCC) concluded that care leavers and young people in care should be viewed as ‘experts’ of the care system and they should be included in the development of accessible services (NSPCC, 2021). Conversely, the lack of involvement in decision-making has been identified to negatively impact the wellbeing of care-experienced youths, supporting the need for collaboration in both care and service planning (Leeson, 2007).

A way to improve engagement with care-experienced individuals is the facilitation of methodological diversity (Holland, 2009); photo-elicitation is one example. Photo-elicitation is a method where photographs are used to aid interviews to gain deeper insights into experiences (Sibeoni et al., 2017). It helps to improve collaboration and reduce power imbalances (Bates et al., 2017) and has been successfully used with care-experienced participants in previous research (Curry and Abrams, 2015; Degener et al., 2020). Qualitative methods such as Interpretative Phenomenological Analysis (IPA) aim to ‘give voice’ to the experiences of participants (Larkin et al., 2006), and combining this with photo-elicitation can enhance self-reflection (Burton et al., 2017).

Method

The study aimed to address the following research question: ‘What are care leavers’ experiences of the barriers to accessing professional mental health support during adolescence?’ Full ethical approval was granted from Staffordshire University Ethics Committee.

Design

A retrospective qualitative design was used entailing an IPA approach; data were collected using semi-structured interviews alongside photo-elicitation. IPA focuses on capturing unique, lived experiences and the way in which these are interpreted by the participant (referred to as hermeneutics) (Smith et al., 2021). It has been identified as a methodology useful for exploring topics that are complex, ambiguous and emotive (Pietkiewicz and Smith, 2014).

Additionally, photo-elicitation was used to enrich the interview process due to its ability to reduce power imbalances (Bates et al., 2017), increase participant autonomy (van Auken et al., 2010) and create a ‘comfortable space for discussion’ (Epstein and Boisvert, 2006: 3).

Recruitment

Purposive sampling was used in which a research advert was shared on social media by charities and organisations working with care leavers; a snowball method was used. Following difficulties with recruitment, an incentive of a £15 Amazon voucher was offered to everyone who took part.

Participants

Care leavers were recruited for the study to obtain rich data of lived experiences. Participants were eligible if they self-identified as having experienced mental health difficulties during adolescence but did not engage in professional mental health support for this. Adolescence was defined as aged between 13–17 years old. Engagement in professional mental health support was defined as ongoing support (i.e., more than one session) from a mental health professional (e.g., psychologist, psychiatric nurse) through a service such as Child and Adolescent Mental Health Services (CAMHS) specifically for any mental health-related difficulty. The eligibility criteria required participants to have entered care before the age of 12 and to have remained in long-term care since then. This was to increase the homogeneity of the sample as children entering care between 13–17 years of age have different life experiences to those entering long-term care earlier (Clarke and Penington, 2021).

Six participants provided informed consent to take part in the study. All participants were White British and lived in England throughout their time in care, excluding one who had spent a period living in Wales. The mean age of participants was 21.8 years (range: 18–25 years). Table 1 provides an overview of participant characteristics.

Table 1.

Participant characteristics.

Lucy* is an 18-year-old female who entered care aged two. She had a total of nine different placements, with nine years in foster care and seven years in residential care. Lucy left care aged 18.

Jake* is a 20-year-old male who first entered care aged five. He had two different foster placements and chose to leave care aged 17.

Megan* is a 21-year-old female who first entered care aged 11. She had two foster care placements and left care aged 18.

Olivia* is a 23-year-old female who entered care aged six. She initially lived in foster care, but, moved into kinship care aged eight with her paternal grandparents until she was 18 years old.

Tom* is a 24-year-old male who entered care aged seven. He was placed under a special guardianship order with his maternal grandparents until the age of 18.

Poppy* is a 25-year-old female who entered care aged six. She had three different placements in foster care. Her foster carers in her final placement agreed for her to remain in their care until she was 20.

Pseudonym

Procedure

A semi-structured interview schedule was developed in line with both an IPA framework and photo-elicitation methodology, based on the protocol described by Johnson and colleagues (2011) in which questions are designed to elicit rich data from visual stimuli.

Due to the Covid-19 pandemic (World Health Organization, 2020), interviews were offered remotely and all participants opted for video calls instead of telephone calls. The average number of photographs brought to the interviews by participants was four. Interviews lasted between 49 and 72 minutes (average duration 59 minutes) and were concluded with a verbal debrief to ensure participants were not experiencing any unreasonable emotional distress. No negative effects were reported, and all participants were sent a debrief form and signposting information about services to access additional mental health support.

Analysis

The analysis followed the steps for IPA as detailed in Smith, Flowers and Larkin (2021). This allowed for the development of Group Experiential Themes (GETs) and subthemes. As IPA is committed to double hermeneutics (Engward and Goldspink, 2020), reflexivity and transparency surrounding the researcher’s philosophical position is important (Berger, 2013). In this study, the researcher held a critical realist position: critical realism acknowledges that there is a reality, but this can exist independently from our observations. To mitigate bias and promote rigour, the researcher practised bracketing (Smith et al., 2021) through the use of a reflective diary and supervision. This was to prevent their own experiences of working in children’s services from impacting on the findings. Furthermore, trustworthiness and integrity within the data analysis process were promoted by regularly returning back to the original data set, using direct quotes and keeping data trails to evidence the process of analysis (Johnson et al., 2020).

Results

Analysis of the interview transcripts revealed five GETs and 10 subthemes. The GETs were as follows: ‘A lost cause’, ‘Alone no matter what’, ‘Don’t talk about mental health problems’, ‘Misunderstood’ and ‘Nobody helped us’. Each theme will be discussed in turn.

Theme 1: A Lost Cause

Three participants referred to themselves as a lost cause, a view held either internally by participants or externally by those around them. Disbelief in the possibility of change and recovery negatively impacted motivation to seek support. Tom described feeling unfixable and as though nothing could be done to help alleviate his difficulties (see Figure 1):

Figure 1.

Tom’s photograph.

So, like, I’m broken and everything around me just feels grey and pointless and miserable, like there’s no point in fixing the roof because everything else, everything else would still be grey.

Lucy and Megan were perceived by others as having deep-rooted and complex problems that could not be eradicated, therefore accessing support was deemed pointless:

I felt like social services kind of gave up a little bit. They were like, ‘Well, we know this child is going to break this placement down. So, what’s the point in even trying to get her into a mental health placement because we’re just going to be back in this situation?’ (Lucy)

[People think] That we’re difficult. Doomed for life. That we cause problems for other children. There’s lots [of perceptions]. Just being wrong in every single way. (Megan)

Theme 2: Alone No Matter What

All participants expressed feeling alone, and there was a sense that they were ‘stuck’ in this position of loneliness. Based on past caregiving experiences that involved neglect, participants felt both abandoned by others but also a need to keep others away to protect themselves. Therefore, the emphasis on self-protection meant that reaching out for support did not feel like an option, creating a sense of ‘stuckness’ in being alone.

A. Nobody Actually Cares

Participants felt unimportant and as though nobody truly cared about them. The sense that they lacked an unconditionally caring adult who was attuned to their needs was portrayed:

Nobody ever stopped for a moment and thought ‘OK, Poppy’s in care, her mum died, she’s always falling out with her friends, maybe mentally she’s not OK because that’s a lot to go through’. (Poppy)

Tom explained that he felt it was pointless speaking about his difficulties as he believed nobody would take an interest in them (see Figure 2):

Figure 2.

Tom’s photograph.

I just think there was no point because people wouldn’t want to know.

Participants also conveyed a feeling that they were not a priority and as though other people’s needs took precedence over theirs. For example, Megan spoke about her foster carer’s biological child being prioritised over her:

When I did agree [to go to therapy], my foster carer had young children, so it was like, ‘Well, you have to get yourself to therapy’ … My foster mum told me that if I ever self-harm, don’t do it around the kids. That was it.

B. My Guard Was Up

All participants shared their difficulties in trusting other people and perceiving others to have negative intentions. They discussed how previous ill-treatment had resulted in them protecting themselves by concealing their inner world due to fearing others’ intentions:

I had to try and, like, protect myself. So, like, anything people said, I just like thought they were criticising me, because that happened a lot, but maybe, like, sometimes they weren’t. I was just very guarded. (Jake)

Olivia explained how the mistreatment from her birth parents provided her with an understanding of what harm others were capable of and led her to believe that nobody could be trusted:

I never knew when people would turn on me, and I think that was just from the horrific experience we had during childhood. And it’s like if your own parents can do that to you, why would other people not?

Lucy described how experiencing multiple difficult life experiences in which she had not felt supported led to a cumulative effect of mistrust in others which prevented her from seeking support:

I had a particularly traumatic event at 16, which I didn’t openly talk about because I just was like, well, I can’t really say anything to anyone else because of how I’ve been treated all this time.

Theme 3: Don’T Talk About Mental Health Problems

This theme reflects how beliefs surrounding mental health impacted the participants’ ability to seek support for their difficulties. The stigma associated with mental health prevented support being accessed.

A. You’Ll Get Judged

The stigma surrounding mental health was discussed and participants spoke about the negative beliefs held by others about mental health that impacted either their ability to convey their difficulties or others’ ability to accept these:

Nobody knew I had issues. Or maybe they did and they just left it because it’s so badly frowned upon if you’re a care-experienced person who has mental health [problems]. (Poppy; see Figure 3)

Figure 3.

Poppy’s photograph.

Participants also spoke about judgements within their peer groups and the expectations of how they ‘should’ behave to avoid judgements:

You have to act hard. You have to be hard. You have to basically be the stereotypical definition of a man … So yeah, you have to be strong, you don’t show any weakness. (Tom)

Lucy felt societal pressures to conceal her difficulties due to the judgements associated with mental health and its perception as abnormal:

Like, I wasn’t normal as a person because I had all these issues, and it was kind of like I had to contain myself to societal norms, in order to be treated with respect by my peers.

B. Family Scripts

Participants spoke about the narratives held by their caregivers surrounding mental health which restricted their ability to understand mental health difficulties or seek appropriate support. Tom, Olivia and Jake felt that these scripts were a result of the age of their caregivers and that this prevented acceptance of mental health difficulties:

My grandparents, they’re old school, because they were born in the ’50s and grew up with, like, that sort of era where their view of mental health … basically it wasn’t a thing, it never existed. (Tom)

Megan spoke about the influence of religion on her foster carers’ beliefs about the necessary support for mental health difficulties:

She just thought religion was the answer and that she could pray and that was it, she had helped me. She didn’t seem to think there was anything else that was needed.

Olivia also described her grandparents as unaccepting of mental health difficulties and consequently a narrative emerged within her family that mental health was a ‘taboo’ subject that should not be talked about:

It’s just my grandparents were just not on board with it. It was, like, it was like a taboo subject, that’s what it was. Mental health in our household was a massive taboo.

C. It Always Comes Back To Bite You

Participants spoke about the negative consequences of divulging mental health difficulties. Tom and Megan shared relational experiences in which they were rejected for disclosing their difficulties:

I definitely felt like I would be pushed out of the group I hung around with if they knew I needed help. Well, to be fair, that’s sort of what happened. (Tom)

Megan and Lucy discussed the practical repercussions that they experienced, such as being rejected from academic establishments and also having police attend their home:

I had to have the police come into my foster home, search my room for blades, and then just leave. (Megan)

Olivia spoke of a feared consequence that prevented her from disclosing her difficulties:

I just always remember being told that, they won’t let you into uni if you suffer with bad mental health, like, if they find that out on your application there’s no way they will accept you, and I was like, ‘Oh I never knew that, OK, keep hush hush about that then’.

Theme 4: Misunderstood

Participants felt that their mental health difficulties were not understood, with others interpreting their presentations through lenses that did not accurately reflect their experiences. Additionally, they felt a sense of confusion surrounding their own internal experiences and a lack of self-awareness that these were mental health difficulties:

A. Just Naughty Children

Four participants felt that those around them interpreted their behaviour as disobedience and therefore mental health support was not advocated. Positioning their difficulties in this way also created a sense of emotional distance between participants and their carers due to the lack of shared understanding:

But I think [my carer] just saw me as naughty or being bad and that I was a problem she didn’t know what to do with. (Megan)

Lucy and Jake described a negative preconception that is held about looked after children being defiant and therefore this preventing mental health difficulties from being recognised:

You’re seen as troubled, seen as defiant, angry or all these, like all this negativity. (Lucy; see Figure 4)

Figure 4.

Lucy’s photograph.

Jake explained how other people’s beliefs influenced the way he saw himself and consequently led him to believe his difficulties were a result of being ‘bad’:

They said that when they started fostering, the village said they didn’t want any bad kids so I just thought I was a bad kid.

B. You’Re Fine

Four participants felt that others failed to recognise the extent of their struggles, either by not noticing or minimising them. They expressed a sense of disparity between their experiences of a turbulent internal world and others experiencing them as stable and without problems. This disempowered them and hindered their ability to express their difficulties:

Everyone around me just kept telling me I was fine and that my sisters are fine and even though you feel like you’re not fine, it’s hard to understand so you just go along with it. (Poppy; see Figure 5)

Figure 5.

Poppy’s photograph.

Tom shared that his difficulties went unnoticed and that although he felt something was ‘wrong’ with him, other people did not recognise this:

I think people couldn’t really see anything wrong with me.

Olivia explained that her grandparents dismissed the possibility of her experiencing emotional or psychological distress as they provided continued contact with her father and therefore presumed this was satisfactory in preventing mental health difficulties:

They were like, ‘Oh you’re still seeing your dad, like, so why would you be suffering emotionally because you’re still seeing one of your parents?’ And it was kind of like in their eyes, they think everything is, like, fine and dandy.

Lucy and Olivia also spoke of feeling that their academic achievements masked their mental health difficulties, describing a sense that others inaccurately viewed academic success as an indicator of mental wellbeing:

For me and a lot of young people, if they were, like, high achievers in class, like, doing really well in school, I kinda feel like we’re less likely to get the support because it’s seen as, well, while you’re doing really well, you’re coping really well. You know, you’re achieving all these grades. You’re doing all of this, all of that. You’re fine, there’s nothing wrong with you. (Lucy)

C. I Didn’T Understand It

Four participants recognised a lack of understanding surrounding their own emotional and psychological struggles during adolescence. They described feeling unaware of mental health as a concept and consequently lacked insight and understanding into their own struggles:

At the time, I still wasn’t sure what, like, mental health conditions really were. Because there was no formal education for it in high school. So I don’t think I actually knew at the time I was struggling with my mental health. (Tom)

Poppy described how her inability to make sense of her difficulties meant that she was unable to share this with others:

I didn’t really know what it was. I didn’t understand mental health at all back then. I didn’t know what I was going through so how could I tell anybody else?

Jake linked his misunderstanding of his difficulties with low mood to the misinterpretations made by others:

Like, people just think it’s laziness so I thought it was laziness, but now I realise that actually it’s because I’ve spent so long in survival mode and now I’m out of it. Now I can see things better.

Theme 5: Nobody Helped Us

Mental health support was difficult to access for all participants, with services and professionals described as unresponsive to requests for help or observations that when support was provided, it did not fit with participants’ needs. Participants felt let down by the services set up to support them.

A. They Didn’T Listen

All participants shared at least one occasion of professionals or services being unresponsive to their mental health needs and failing to advocate support for them. Participants felt as though their needs were ignored and requests made to professionals for mental health support went unheard:

I was shouting at them saying ‘I’ve been telling you for years. I need help. And you haven’t done it’. (Jake)

Olivia identified how the lack of response to requests for help impacted her attitudes about seeking help in the future:

Back then I saw social services as a barrier too. Because you’d go to them, but then they wouldn’t do anything. And you’d just think, well, what’s the point, I won’t bother asking again.

Participants also discussed service-level problems in regard to accessing support from CAMHS, for example, a lack of support due to staff shortages, long waiting lists and rejected referrals for reasons such as moving geographical location and having a diagnosis of borderline personality disorder (BPD):

I would just be told, ‘Oh no, you don’t need to speak to a mental health professional because this is just part of your BPD. Get over it’. (Lucy)

B. The Wrong Support

Conversely, participants shared different occasions of when support for mental health difficulties had been offered; however, they perceived this as ill-matched with their needs, leaving them feeling overlooked and misunderstood. Megan, Olivia and Lucy described feeling a disproportionate emphasis on their physical health whilst their emotional wellbeing was not considered:

I remember going to see a nurse at the doctors who weighed me and did my height and I went quite a few times for something to do with that, but nobody ever said how do I feel, like, emotionally, in my mind. (Poppy)

Megan described being offered therapy, but feeling patronised by the therapeutic approach offered and angry that she was not consulted in the decision-making around this. This deterred her from attending future appointments:

It was just so insulting. I was 15 and they wanted me to sit there and draw and talk about my feelings. Nobody asked me if that’s what I actually wanted and surely at 15 I can have some kind of a say if I think something might help me or not?

Lucy and Jake gave examples of where the type of support offered, for example financial support and support from the police, was not suitable to address their mental health needs. Lucy described how the police involvement led to further emotional distress:

I just kind of come back around to the fact that I’ve got six or seven male officers restraining me in cuffs because I’ve tried either to hurt myself or I tried to end my life and it’s, you know, it becomes quite distressing after a while. (see Figure 6)

Figure 6.

Lucy’s photograph.

Discussion

This study aimed to explore how care leavers make sense of the barriers to accessing professional mental health support during adolescence. Six participants were recruited and took part in semi-structured interviews used alongside photo-elicitation. Five GETs were identified: ‘A lost cause’, ‘Alone no matter what’, ‘Misunderstood’, ‘Don’t talk about mental health problems’ and ‘Nobody helped us’.

A Lost Cause

The findings reflected a sense of young people in care perceiving themselves as ‘a lost cause’. Participants perceived themselves as irrevocably damaged and beyond help, meaning that hope for change was absent and help was not sought. This may reflect internalised self-stigma or Internal Working Models (IWMs) (Bowlby, 1969) of self to emerge from early experiences, with shame and low self-worth common for young people in care (Joanna and Lelliott, 2003; Luke and Coyne, 2008).

Participants also perceived that others believed advocating for mental health support on their behalf was pointless because of the complex and long-standing difficulties associated with young people in care. This may be rooted in the stigma surrounding the negative outcomes linked to the care system (Calheiros et al., 2015; Rogers, 2017), meaning that professionals feel discouraged about the impact interventions can have. However, it may also be a sign of the deprivations that systems can perpetuate for young people in care (Emanuel, 2006; Henry, 1974; Sutton, 1991) where early relational experiences lead to the development of defences in young people that prevent use of support for emotional needs and where systems re-enact this neglect, i.e., failing to advocate for help-seeking or seeing support as pointless, as in this case.

This supports a need for interventions that instil hope in the future, such as through peer mentoring programmes (Mantovani et al., 2019; Taussig and Culhane, 2010) or life story work (National Institute of Health and Care Excellence [NICE], 2021). Provision of reflective practice groups for social workers may also be indicated to promote thoughtful professional practice (Lees and Cooper, 2019).

Alone No Matter What

Participants portrayed a sense of being trapped in their isolation; they felt abandoned by others but also had a need to protect themselves by concealing their inner world and not requesting or accepting support. This finding offers further support to the relationship between experiences of neglect and abuse and the development of disorganised attachment styles characterised by distrust in others (Cyr et al., 2010; Stronach et al., 2011), including care-experienced individuals’ difficulties in trusting professionals (Hiller et al., 2021).

Furthermore, concealment appeared to be a learnt coping strategy among participants, consistent with the IWM (Bowlby, 1969) to emerge from their past abusive and neglectful experiences and which acted as a framework for how they perceived subsequent relationships. Namely, past experiences may mean adults are perceived as rejecting, neglectful and untrustworthy; this may lead to predictions that seeking support will be unsuccessful or associated with feared implications and is therefore to be avoided for self protection. In the Dynamic Maturational Model of attachment (Crittenden, 2006), such presentations align with Type A profiles, where emotion is inhibited as a self-protective strategy and is a response to over-estimation of threat. However, the maintenance of such coping strategies in the context of new caregiving relationships means young people’s emotional needs continue to be neglected, known as ‘double deprivation’ (Henry, 1974).

Significant barriers to trust suggest a need for multi-level interventions that include teaching, training and consultation for carers and professionals to create a safe network of people around the young person. This may involve direct psychotherapy with the young person at a later stage, focused on the development of secure attachment relationships and understanding the child’s reliance on defensive, distrustful strategies to keep themselves safe. An example of this is the Dyadic Developmental Practice (DDP) model (Casswell et al., 2014). In terms of any direct work with young people, the emphasis on mistrust in the findings implicate the need for longer-term therapeutic interventions where attention to safety and trust in relationships is prioritised, consistent with recommendations for working with complex trauma-related difficulties (Ford and Cloitre, 2009; NICE, 2018).

Don’T Talk About Mental Health Problems

Beliefs around disclosing mental health difficulties were found to hinder access to services. Participants experienced their carer’s personal narratives as influential on their ability to access support and described narratives influenced by carer age, religious beliefs and family scripts (replication of the expectations, beliefs and behaviours held by previous generations; Byng‐Hall, 1985) surrounding help-seeking. This supports existing literature that recognises parental help-seeking attitudes have a strong influence on help-seeking for children (Bonfield et al., 2010).

Recognising the influence that family scripts have on gaining access to support reiterates the importance of collaborative care-planning with young people in care, as opposed to relying solely on carer insights.

Furthermore, participants expressed fears around the consequences of sharing mental health difficulties. This finding is similar to that of Hiller and colleagues (2021), who found young people avoided discussing their experiences in an attempt to avoid uncomfortable feelings; however, the current study identified additional fears such as being rejected by peers, implications for access to higher education and prompting potential police involvement. This supports the need for open dialogue in schools and colleges and whole-school approaches to mental health education to model more open discussion among young people, improve knowledge, reduce stigma and misperceptions and enhance the likelihood of disclosure and help-seeking. Approaches such as Youth Mental Health First Aid training can additionally be offered to teach adults ways to support adolescent mental health and have been shown to improve knowledge, attitudes and helping behaviour (Kelly et al., 2011). Given that help-seeking in this study appeared to be influenced by adult narratives, education for professionals and carers seems an important element to be addressed in any intervention.

Misunderstood

Participants felt misunderstood and as though their mental health difficulties were perceived as ‘naughty’ behaviours, which prevented mental health support from being sought. This supports existing literature which highlights how complex trauma often presents as behavioural manifestations (Cook et al., 2005). Unless caregivers have an understanding of this, many young people in care are unfairly labelled as oppositional and defiant (Gibbons et al., 2019). This perspective is likely to prevent care and compassion and instead reinforces feelings of rejection, shame and low self-worth which are common for young people in care (Joanna and Lelliott, 2003; Luke and Coyne, 2008).

Inaccurately interpreting behaviours suggests that those working with young people in care may benefit from support aimed at increasing reflective functioning, ‘mind-mindedness’ or mentalisation. Collectively, these concepts refer to the ability to make sense of ourselves and others in terms of mental processes and subjective states, including the emotions, desires and thoughts underlying behaviour (Fishburn et al., 2017; Midgley et al., 2019). Increased mind-mindedness is associated with more sensitive and positive interactions (Kelly and Salmon, 2014) and an increased ability to recognise trauma symptoms (Colonnesi et al., 2022); this may enable young people in care to feel better understood whilst also empowering adults to recognise difficulties. Mentalisation-based interventions such as the Reflective Fostering programme have been developed and are currently being evaluated in terms of effectiveness for improving children’s emotional wellbeing and a range of secondary outcomes (see Midgley et al., 2021).

Furthermore, participants felt that their struggles were minimised as ‘normal’ behaviours. It has been argued that routine work with ‘disturbed’ children results in foster carers (Minnis and Del Priori, 2001) and professionals (Wilkinson and Bowyer, 2017) becoming habituated to common difficulties, meaning significant problems can go unnoticed. Participants felt that they did not receive professional support because their problems were misunderstood and downplayed. This supports arguments that mental health care for young people in care is primarily crisis-driven as opposed to focusing on early intervention (Smales et al., 2020) and reiterates the need for sensitive caregivers who can recognise more subtle difficulties.

Nobody Helped Us

Participants described both a lack of response to requests for support and ill-matched support being provided. Potentially, requests for support by young people may go unheard in part due to perceptions of whose responsibility it is to action them (York and Jones, 2017). Consistent with research capturing foster carers’ perspectives, systemic barriers were also reported by participants, including long waiting lists, staff turnover and referrals being rejected due to complex problems (Fergeus et al., 2019; Hiller et al., 2020; York and Jones 2017). This is also in line with recent literature identifying shortcomings in CAMHS relating to unclear pathways, inconsistent processes and lengthy waiting times (Smith et al., 2018). Additionally, young people in care are disproportionately rejected from CAMHS for reasons such as lack of stability and disengagement (Kirkman, 2019). Although there is a clear need for specialist provisions for young people in care, between 41–49% of local authorities do not have a specialist young people in care pathway in CAMHS. This means many children are referred to services not equipped to meet their complex needs (Golding, 2010).

Furthermore, participants described police involvement in response to disclosures of suicidal thoughts or self-harm, which they experienced as distressing. This suggests a need for carers and professionals to be trained in approaches such as Youth Mental Health First Aid to develop skills and confidence to identify mental health issues, offer first aid and provide appropriate signposting even in a crisis.

Whilst the focus of this study was on perceived barriers, it is noteworthy that participants discussed the usefulness of informal support such as attendance at youth groups and after school clubs. How this aided good mental health was unclear but hypothetically appears consistent with current guidance promoting the development of young people’s interests to develop their identity, build skills and promote friendships (NICE, 2021).

Practice Implications

Whilst the evidence base clearly recognises the importance of trauma-informed approaches for young people in care (Buckley et al., 2016; Golding, 2009), participants in this study highlight a gap between this and the care that is experienced by the young people themselves. The findings indicate that steps are needed to ensure trauma-informed practice is followed both within generic CAMHS and in specialist services for young people in care. It is important that commissioners are aware of the need for more specialist provisions specifically set up for young people in care, with policies based on NICE guidelines to help break down service-level barriers to accessing support (Fisher, 2015). Additionally, this study has revealed the valuable insights that can be gained from understanding the lived experiences of care leavers and supports a collaborative approach to service improvement.

A lack of awareness and understanding of the impact of trauma among adults working with young people in care was suggested from the results. Whilst indirect interventions for young people in care have shifted from focusing on reducing challenging behaviour to better understanding the impact of trauma (Gibbons et al., 2019), participants still felt misunderstood and stigmatised because of their mental health difficulties. This indicates a need for further training around the impacts of trauma to increase professionals’ and carers’ abilities to recognise psychological difficulties and consequently seek support. It also highlights a broader need for a shift in the way current systems are set up to support the mental health needs of young people in care.

Furthermore, participants recognised a lack of understanding and insight into their own difficulties which supports previous research (Coulter et al., 2022). In light of the preference among participants for less formalised support, universal interventions such as whole-school mental health initiatives aimed at improving young people’s literacy around emotions and mental health may be beneficial. The lack of insight also reinforces the importance of attuned and sensitive caregivers who are able to infer a child’s internal world. This supports the need for interventions aimed at improving carers’ reflective functioning and mentalisation as well as using approaches that empower carers to be effective in supporting the child to develop their own understanding of their difficulties in an accepting and non-judgemental way.

Following on from this, this study identified the detrimental impacts of past trauma on current relationships and how this serves as a barrier to seeking support. Young people in care need to feel safe within relationships in order to share their internal world and request support (Fylkesnes et al., 2021), and so interventions effective in addressing attachment-related difficulties and improving the carer–child relationship are needed.

Finally, as future help-seeking behaviours are impacted by the quality of the outcome of past help-seeking (Johnson and Menna, 2017), it is extremely important that positive experiences of accessing support are facilitated from an early age. Additionally, consultation models are frequently used within care services (Dimaro et al., 2014) and it is therefore possible that adolescents are unaware of the indirect support. However, findings from this study suggest young people want to be more actively involved in treatment decisions.

Strengths And Limitations

This original and clinically relevant study provides valuable insights into the lived experiences of young people in care. These new understandings help to empower the care community by supporting practice development centred on their experiences and perspectives.

However, the retrospective nature of this study may mean that participants’ re-interpretations of past events were impacted by later knowledge and insights. This means that these findings may not accurately reflect their feelings during adolescence. Despite this, it can be argued that these retrospective accounts provide reflections of greater clarity and insight.

Future Research

Future research should continue to understand the experiences and perspectives of care-experienced individuals. Research exploring the perspectives of care leavers who have had successful encounters with CAMHS and other specialist services for young people in care may identify factors that facilitate engagement. Additionally, understanding the role of informal support would be beneficial.

Having said this, the recruitment of care leavers for this study proved particularly difficult, so recruiting through local authorities and care-leaving teams is recommended. The use of incentives is essential in recognising the valuable contributions of care-experienced individuals.

Interestingly, when asked about the experiences of engaging in this research, some participants commented that the photo element of the study elicited fears of ‘getting it wrong’. It also appeared to add an additional demand on participants that may have deterred some potential participants. Therefore, further research around the use of this novel methodology specifically with care leavers would be beneficial.

Conclusion

This research aimed to explore care leavers’ experiences of the barriers to accessing mental health support during adolescence. Participants’ mental health difficulties were commonly misunderstood or minimised by others. External beliefs surrounding mental health impacted participants’ willingness to seek support. Additionally, participants did not feel safe to disclose their difficulties and felt let down by professionals due to their unresponsiveness to requests for support or the support offered being poorly matched to their needs.

Services specific for young people in care are essential, and policies are needed to accommodate their complex needs. Therapeutic support should focus on improving understandings of trauma among carers and professionals so that mental health difficulties can be better understood. Mentalisation-based interventions aimed at improving the mind-mindedness of carers and professionals offer promise, as well as approaches aimed at improving the carer–child relationship to increase feelings of trust. Future research should continue to capture the voices of care-experienced individuals. Understanding care leavers’ past experiences of successful encounters with CAMHS as well as the role of informal support may provide further direction for service development.

Footnotes

Declaration Of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Dr Helena Young is a clinical psychologist in a Perinatal Mental Health Team and Maternal Mental Health Service at Derbyshire Healthcare NHS Foundation Trust, UK. When the research of the article was conducted, she was a trainee clinical psychologist at Staffordshire University, UK.

Dr Yvonne Melia is a clinical psychologist, Principal Lecturer in Clinical Psychology, Academic Director and Acting Programme Director of the Professional Doctorate in Clinical Psychology at the University of Staffordshire, UK.

Dr Laura Chance-Lawton is a consultant clinical psychologist and Clinical Lead of the CAMHS Eating Disorder Service at Leicestershire Partnership NHS Trust, UK.

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