Sally O'KEeffe

A growing proportion of children entering state care are born to mothers involved in recurrent care proceedings, a group often characterised by trauma, social disadvantage, and low trust in services. Although a range of interventions have been developed to prevent care entry and support reunification, there remains limited understanding of how and why these approaches operate within complex child protection systems.,This study reports a four-stage realist synthesis of 108 academic and grey literature sources to examine what works, for whom, and in what contexts to prevent care entry and enable reunification for mothers at risk of recurrent proceedings. Programme theory development was informed by three stakeholder advisory groups comprising mothers with experience of child removal, practitioners, and academic experts.,Findings show that outcomes are shaped not only by individual interventions, but by how these interact with the relational and organisational dynamics of child protection systems. Trauma is conceptualised as a relational and systemic force influencing interactions between mothers, practitioners, and multi-agency teams. Two key mechanisms underpin improved outcomes: (1) a relational bridge, wherein a trusted practitioner supports communication and shared understanding between mothers and professionals; and (2) a neutral outsider, who promotes fairness, redistributes power, and aligns multi-agency working around shared goals. Where these mechanisms are absent, interventions may either engage mothers without achieving credible risk reduction or manage risk in ways that undermine engagement.,The findings highlight the importance of designing child protection services that build trust, clarify roles, and support coordinated decision-making across agencies. By providing a practice-relevant explanatory framework, this study contributes to understanding how services can better prevent unnecessary care entry and support safe, sustainable reunification, with implications for improving outcomes for children and families.

Conducting mental health trials in busy EDs presents challenges, including record demand, bed shortages, 4-hour targets from arrival to discharge or admission, and staff shortages. This essay reflects on real-world challenges in a mental health trial involving people presenting to the ED with self-harm and/or suicidal thoughts and outlines lessons learned for future studies. No quantitative data will be reported. ASSURED is a randomised controlled clinical trial investigating the effectiveness of a brief psychological intervention for adults attending the ED with self-harm and/or suicidal thoughts. The original aims were to improve psychosocial assessments conducted by liaison psychiatry practitioners and to have the same practitioner deliver the intervention after discharge ensuring relational continuity. We worked with people with lived experience to address engagement challenges during mental health crises. 620 people across 14 EDs in England were recruited between 2022–2024. Although liaison psychiatry practitioners were trained to deliver the intervention, recruiting participants in crisis was difficult due to 4-hour targets and limited mental health research nurses. Delivering follow-up care post-discharge was challenging, as practitioners prioritised urgent assessments over delivering the follow-up intervention. However, it was feasible for researchers to recruit people within 1–2 weeks of ED attendance and for other mental health professionals to deliver the intervention. Flexibility in time and mode of delivery was paramount in participant engagement, which was mostly not achievable within liaison psychiatry roles. As many patients reattended the ED, experienced suicidal ideation or harmed themselves, supporting local clinical Principal Investigators to complete time-consuming paperwork in relation to these Serious/Adverse Events was helpful. ED liaison psychiatry teams face significant barriers to trial participation compared to other settings. Brief psychological interventions after ED attendance were more feasibly delivered by other practitioners such as assistant psychologists, and lived-experience advisors were central to ensuring sensitive engagement, approach and follow-up in research. Clinical Trial Number ISRCTN 13472559, Registered on 18 of November 2021.

Background: Self-harm is a growing public health concern and the strongest predictor of suicide in young people (YP). The “Supporting Adolescents with Self-Harm” (SASH) intervention was developed with YP with lived experience and expert clinicians. It involves rapid follow-up after ED attendance and up to six intervention sessions. The intervention has three components: Therapeutic Assessment (TA) of self-harm; an enhanced safety plan (SP); and Solution-Focused Brief Therapy (SFBT). Depending on the YP’s preference, carers can join sessions. Carers can also receive two individual sessions. The clinical and cost-effectiveness of SASH is being evaluated in a randomised controlled trial across nine emergency departments in three NHS Trusts in London, England. A total of 154 YP were recruited between May 2023 and March 2025 and randomised on a 1:1 ratio to SASH alongside Treatment As Usual (TAU) or TAU. A logic model describes the SASH inputs, activities, mechanisms, outcomes and longer-term impacts. The aim of this paper is to (1) illustrate how TA, SP, and SFBT were implemented in practice by presenting intervention materials and session recordings for four YP cases and one carer case and (2) explore how the case study materials/recordings reflect the intervention mechanisms in the SASH logic model. Methods: Each case focused on a different component of the intervention. Intervention materials (TA self-harm diagram and completed SP) and recorded SFBT sessions with four YP and one carer were analysed using a descriptive case study approach. The TA diagram and SP were extracted from medical records. Audio/video recordings of intervention sessions were identified. Recordings of intervention sessions and qualitative interviews were transcribed. Quotes from qualitative interviews with the same participants were included where relevant. Results: Across the four YP cases, some core themes emerged. The role of friendships for young people, particularly at school, was important in both negative and positive ways. Experiencing difficulties with friends at school led to feelings of sadness and stress, which could become overwhelming, leading to thoughts of self-harm (“I just need to hurt myself”), triggering self-harm behaviour. YP described mood changes and signs that they were becoming stressed, which improved their self-awareness and understanding of the link between their feelings and self-harm behaviour. They reflected on what kept them feeling calm and overcoming their fear of burdening others by sharing how they were feeling, as this helped them not to self-harm. They also described difficult feelings stemming from a need to please everyone or needing validation from others. Overcoming these feelings led to less social anxiety and more confidence. This made it easier to go to school and to be more social with friends/student peers, which in turn improved their mood. Conclusions: These case studies demonstrate how YP improved their self-awareness and understanding of the link between feelings and self-harm behaviour and identified personal strategies for managing difficult feelings and situations. The carer case study demonstrates how sessions with carers can facilitate carers better supporting their YP’s mental health. Supporting YP and carers in this way has the potential to reduce the risk of future self-harm.

Introduction Self-harm is the strongest predictor of suicide in young people. Self-harm presentations to the emergency department (ED) are associated with repeat self-harm and suicide. Rapid follow-up contact after ED offers an opportunity to intervene before self-harm becomes an established coping strategy. Despite recent progress in self-harm treatment, currently, there are no evidence-based interventions to prevent future self-harm and suicide offered to young people after visits to the ED. Preliminary evidence suggests therapeutic assessment and rapid follow-up contacts may reduce self-harm and improve engagement in follow-up care. In this study, we assess the clinical and cost-effectiveness of a brief psychological intervention, supporting adolescents with self-harm (SASH), in addition to standard care in a randomised controlled trial, compared with standard care only. As per National Institute for Health and Care Excellence guidelines, standard care involves at least one follow-up by a mental health professional within 7 days of ED discharge. Methods and analysis The SASH intervention comprises up to six follow-up contacts with a mental health professional delivered over approximately 2 months for young people and their carers using a solution-focused approach, shortly after presenting to the ED. Participants are aged 12–18, presenting to the ED with self-harm or suicidal ideation (with self-harm in the past month), with capacity to consent. We aim to recruit 144 young people into the trial who will be randomised on a 1:1 basis to the SASH intervention or treatment as usual. Participants are assessed postintervention/standard care and at 6-month follow-up after randomisation. Self-reported self-harm is assessed via text message survey every 2 weeks during the 6-month follow-up period. The primary outcome is self-reported episodes of self-harm in the past month assessed at 6 months by summing three behavioural domains of the self-injurious thoughts and behaviours interview. We hypothesise that the therapeutic relationship with the mental health practitioner will mediate this relationship. Secondary outcomes include symptoms of depression and anxiety, frequency of reattendance at ED, death by suicide, school attendance, well-being and additional domains of self-harm-related behaviour and thoughts in the past month. The trial will also consider service use, costs to carer and carer health-related quality of life to evaluate the costs and cost-effectiveness of the intervention. Ethics and dissemination London-Riverside Nation Health Service REC (22/LO/0400) provided a favourable ethical opinion. Findings will be disseminated through social media, a website, scientific papers, conferences and reports, in collaboration with our Young Person’s Lived Experience Advisory Group. Trial registration number ISRCTN81846131. Protocol version 13.0, 30.06.2025.

The therapeutic alliance is a predictor of therapy outcome across treatments with adolescents, with ruptures and unresolved ruptures in the alliance being associated with treatment dropout. This study investigated the psychotherapeutic process in short-term psychoanalytic psychotherapy (STPP) with five adolescents with moderate/severe depression who had dropped out of STPP in a large randomized controlled trial and reported dissatisfaction with treatment. In each case, sessions were rated as featuring unresolved ruptures with the therapist. This study aimed to explore the processes characterising ruptures preceding dropout using the Adolescent Psychotherapy Q-set (APQ). Data were analysed using descriptive statistics of the APQ coding; a qualitative reading of the transcripts and clinical vignettes was used to illustrate how the APQ findings manifested in practice. Results revealed a weak alliance preceding the adolescent dropping out of therapy, with a mismatch between self-reliant and disengaged adolescents presenting with strong negative affects and therapists seeking to maintain an active exploration of the adolescents’ difficulties. Research and clinical implications are discussed.

Background: Patients presenting to emergency departments (EDs) following an episode of self-harm are at risk of future suicide. There are few evidence-based interventions for self-harm in the ED context in England. This study sought to assess the feasibility of a trial of a newly developed brief psychological intervention, the Assured approach. This approach consisted of an enhanced psychosocial assessment, collaborative safety planning and three rapid solution-focussed follow-up sessions. Phase 1 was a feasibility study, and phase 2 was an internal pilot trial of a cluster randomised controlled trial to assess whether progression to a full-scale trial was warranted. Methods: In phase 1, patients were recruited and allocated to a study arm, the Assured arm or treatment as usual, depending on the allocation of their assessing practitioner, in four EDs in England. They were invited to research assessments after consent and at 6 months. Phase 2 was the internal pilot of a cluster randomised controlled trial conducted in six EDs in England. Practitioners were randomised to deliver the Assured approach or treatment as usual. Patients were recruited and allocated to a study arm depending on the allocation of their assessing practitioner. They were invited to complete research assessments after consent and at 3, 9 and 18 months. Results: Sixty-one patients were recruited into the Assured (n = 46) and treatment as usual (n = 15) arms in phase 1. Findings showed we could recruit and follow up patients over a 6-month period. The research procedures were acceptable to patients and practitioners, and the intervention was delivered with acceptable fidelity to the intervention manual. Forty-seven patients were recruited into the phase 2 internal pilot trial, falling substantially short of our target of 491 in the stop-go criteria, indicating that the trial was not feasible in its current design. Conclusion: The feasibility study indicated that both the intervention and research processes were acceptable. However, the internal pilot trial revealed substantial challenges in recruiting patients and delivering the intervention in the ED context. Adaptations to the trial design and intervention are proposed to enable the Assured approach to be tested in a future trial, to improve care for this underserved population. Trial registration: ISRCTN16003313, 04/02/2020; ISRCTN13472559, 18/11/2021.

People presenting to Emergency Departments (EDs) in a self-harm/suicidal crisis in England receive a psychosocial assessment and care plan. We aimed to construct a typology of peoples’ perspectives on crisis care plans to explore the range of experiences of care plans. Thirty-two semi-structured interviews with people who presented to EDs following a self-harm/suicidal crisis in England were analysed using an ideal-type analysis. Cases were systematically compared to form clusters of cases with similar experiences of care plans. People’s perspectives on care plans fitted into three types: (1) personalised care plans (n = 13), consisting of advice or referrals perceived as helpful; (2) generic care plans (n = 13), consisting of generic advice that the person already knew about or had already tried; and (3) did not receive a care plan (n = 6) for those who reported not receiving a care plan, or who were only provided with emergency contacts. Care planning in the ED following a suicidal/self-harm crisis was perceived as supportive if it provided realistic and personalised advice, based on what had/had not worked previously. However, many people reported not receiving a helpful care plan, as it was ill-fitted to their needs or was not considered sufficient to keep them safe, which may mean that these patients are at increased risk of repeat self-harm.

Talking therapies are the first line of treatment for adolescent depression, yet dropout rates are high. Despite parents being considered primary stakeholders in a child’s mental health treatment, there is a lack of qualitative research on their perspectives on adolescent dropout. This study aimed to explore parents’ perspectives on why their adolescent children dropped out of therapy. Interviews with 12 parents whose adolescent children had dropped out of therapy were purposively selected from a larger dataset to explore their understanding of why their children had stopped going to therapy. Interviews were analyzed using thematic analysis and five key themes were identified: practical barriers to therapy; adolescent’s readiness to work with the therapist; relationship difficulties between adolescent and therapist; perceived helpfulness of the therapy; and parents being unaware of why their child ended therapy. Involving parents throughout the therapeutic process could be helpful as they are uniquely positioned to suggest how best to support their child. Services should provide information on the types of therapy, and different therapists, available to adolescents prior to treatment starting. Difficulties in the therapeutic relationship should be addressed in the moment to reduce rupture and, therefore, risk of drop out.