The transition process between child and adolescent mental services and adult mental health services for patients with anorexia nervosa: a qualitative study of the parents' experiences.

BACKGROUND: Patients with Anorexia Nervosa (AN) often experience the transition between Child and Adolescent Mental Health Services (CAMHS) and Adult Mental Health Services (AMHS) as challenging. This period tends to have a negative influence on the continuity of care for the adolescents and represents a demanding and difficult period for the parents. To our knowledge, no previous study has explored the parents' experience with the transition from CAMHS to AMHS. Therefore, this qualitative study examines how parents experience the transition process from CAMHS to AMHS. METHODS: In collaboration with a service user with carer experience, qualitative interviews were conducted with 10 parents who had experienced the transition from CAMHS to AMHS, some from outpatient care and others from both in- and outpatient mental care units in Norway. All had some experience with specialized eating disorder units. The interviews were analyzed with a Systematic Text Condensation (STC) approach. Service users' perspectives were involved in all steps of the research process. RESULTS: Six categories represent the parents' experiences of the transition: (1) the discharge when the child turns 18 years old is sudden; (2) the lack of continuity is often followed by deterioration and relapses in the patient; (3) the lack of involvement and information causes distress; (4) knowledge - an important factor for developing a trusting relationship between parents` and clinicians`; (5) parents have overwhelming multifaceted responsibilities; and (6) parents need professional support. CONCLUSION: Improving the transition by including parents and adolescents and preparing them for the transition period could ease parental caregiving distress and improve adolescents' compliance with treatment. Clinicians should increase their focus on the important role of parents in the transition process. The system should implement routines and guidelines to offer caregivers support and guidance during the transition process.

Adolescents with anorexia nervosa (AN) who receive care from Child and Adolescent Mental Health Services (CAMHS) often need further treatment from Adult Mental Health Services (AHMS). This study explores the transition between CAMHS and AHMS for parents of adolescents with AN in a naturalistic public mental health-care setting. Our study identified six themes concerning the transition between CAMHS and AMHS, based on parents' experiences of the process and what they considered influenced the transition. In general, parents and patients are both unprepared for the sudden discharge from CAMHS when the patient turns 18 years old. The transition is often characterized by a lack of continuity, leading to deterioration and relapses among patients. The lack of involvement and information parents experience in the transition causes distress, and parents have overwhelming multifaceted responsibilities in the transition period. Parents view knowledge to be the key to a successful transition, and they are stressed and need support in the transition.

Mental health professionals' experiences transitioning patients with anorexia nervosa from child/adolescent to adult mental health services: a qualitative study.

BACKGROUND: The transition period between child and adolescent mental health services (CAMHS) and adult mental health services (AMHS) has been identified as an especially critical time for patients with anorexia nervosa. In the present study, to better facilitate patients' recovery process, we explored the experiences of professionals concerning the transition from CAMHS to AMHS. METHOD: A qualitative explorative study was carried out based on recorded interviews from one multi-step focus group and two individual interviews with eight experienced health care professionals. Together they had experience with treating patients with AN and the transition from CAMHS to AMHS, both from specialized eating disorder units, specialized mental health care units, and from a school nurse context. Service users with parents` perspectives and patients' perspectives were involved in all steps of the research process. RESULTS: Barriers experienced during the transition process were classified into four categories: (1) different treatment cultures that describe differences in how parents are included in CAMHS and AMHS; (2) mistrust between CAMHS and AMHS that can create a lack of collaboration and predictability for the patients' transition; (3) Clinicians` factors such as lack of professional self-confidence can influence continuity of care for patients; and (4) lack of trust between services and not enough focus on building a new alliance in AMHS negatively influences the transition. CONCLUSIONS: The present study revealed four important categories that professionals needs to consider when participating in the transition for patients with AN from CAMHS to AMHS. Awareness of these challenges might improve the transition process for patients with AN.

Experiences of patients with anorexia nervosa during the transition from child and adolescent mental health services to adult mental health services.

BACKGROUND: The transition between the Child and Adolescent Mental Health Services (CAMHS) and the Adult Mental Health Services (AMHS) is identified as an especially critical time for the continuity of care for patients with anorexia nervosa (AN). However, research on this topic is scarce. In the present study, we explore the patients' experiences of the transition between CAMHS and AMHS. METHODS: A qualitative explorative study was carried out based on recorded interviews from one multi-step focus group and six individual interviews with patients who experienced the transition from CAMHS to AHMS in Norway. This study is service user-initiated, meaning service users were involved in all steps of the research process. RESULTS: The adolescents' experiences are characterized by four overall themes regarding the transition process between CAMHS and AMHS: (1) "Being unprepared and alone in the transition process" describes how a lack of preparation for the transition between CAMHS and AMHS makes them feel alone and increases stress. (2) "It takes time to create a trusting relationship" describes how time influences patients' trust in therapists and motivation for treatment. (3) "We are not all the same" describes how adolescents develop differently but are not treated differently despite their diverse ability to be self-sufficient. (4) "How they see me and treat me affects my hope for the future" describes the interaction between adolescents and therapists. CONCLUSIONS: Acknowledging the patients' needs during the transition period and considering their readiness for the transition is important. Taking into account the four dimensions described in the present study might improve the transition process and enhance the patients' self-sufficiency and maturity.

Remote Care for Caregivers of People With Psychosis: Mixed Methods Pilot Study.

BACKGROUND: A reduced availability of resources has hampered the implementation of family work in psychosis. Web-based support programs have the potential to increase access to high-quality, standardized resources. This pilot study tested the Norwegian version of the Relatives Education and Coping Toolkit (REACT), a web-based United Kingdom National Health Service program in combination with phone-based support by trained family therapists. OBJECTIVE: We investigated how the program was perceived by its users and identified the facilitators and barriers to its clinical implementation. METHODS: Relatives of people with psychosis were offered access to REACT and to weekly family therapist support (with 1 of 2 trained family therapists) for 26 weeks. Level of distress and level of expressed emotion data were collected at baseline and after 26 weeks using the Family Questionnaire and the Relatives Stress Scale. Both family therapists and a subset of the relatives were interviewed about their experiences after completing the program. RESULTS: During the program, relatives (n=19) had a median of 8 (range 4-11) consultations with the family therapists. Postintervention, there was a significant reduction in stress and in expressed emotions in the relatives of people with psychosis. Interviews with the relatives (n=7) and the family therapists (n=2) indicated the following themes as important-the intervention turned knowledge into action; the intervention strengthened the feeling of being involved and taken seriously by the health services; and management support and the ability for self-referral were important, while lack of reimbursement and clinician resistance to technology were barriers to implementation. CONCLUSIONS: The service was found to offer a valued clinical benefit; however, strategies that aim to engage clinicians and increase organizational support toward new technology need to be developed.

How do adolescents with depression experience improvement in psychodynamic psychotherapy? A qualitative study.

BACKGROUND: There is emerging evidence for the effectiveness of psychodynamic psychotherapy for depressive disorders. However, we know less of how this relation-focused therapy mode is experienced and what the patients themselves identify as helpful. Hence, the purpose of this study is to explore adolescents' experiences of factors promoting improvement in psychodynamic therapy. METHODS: Eight female patients participating in a Norwegian study on psychodynamic therapy, the First Experimental Study of Transference Work - In Teenagers (FEST-IT), were included. The participants were offered a total number of 28 sessions. Semi-structured qualitative interviews about experiences with therapy were then conducted and analysed with systematic text condensation and hermeneutic interpretation. RESULTS: The analysis revealed four main themes. 'Exploring oneself' comprises autonomy and acknowledgment, openness, insight and acceptance of oneself. 'Therapist relation and characteristics' includes confidence and trust in and support from the therapist as well as having a trustworthy and experienced therapist. 'Focusing on everyday life' includes learning and practical orientation. 'Time factors' refers to duration and frequency. CONCLUSIONS: Together with a supportive and listening therapist, the adolescents improve by exploring themselves within the frames of a time-limited treatment period. Improvement seems to be experienced through better relations to oneself and to others and by finding one's place in the family, or at school. Adolescents value problem solving and help with concrete challenges. Hence, therapy should be tailored to the needs of adolescents with depression and incorporate the challenges they face in their everyday life. TRIAL REGISTRATION: ClinicalTrials.gov . Id: NCT01531101. Date of registry: 8 February 2012, retrospectively registered.

Participants' perceived benefits of family intervention following a first episode of psychosis: a qualitative study.

AIM: To explore the perceived benefits for patients and family members of psychoeducational family intervention following a first episode of psychosis. METHODS: A qualitative exploratory study using data from interviews with 12 patients and 14 family members who participated in a psychoeducational multi- or single-family treatment programme. Semi-structured interviews were digitally recorded and transcribed verbatim with slight modifications, after which they were analysed by systematic text condensation. RESULTS: Patients and family members reported benefits that could be classified in five categories: (i) developing insight and acceptance requires understanding of the fact that the patient has an illness, and recognizing the need for support; (ii) recognizing warning signs requires an understanding of early signs of deterioration in the patient; (iii) improving communication skills is linked to new understanding and better communication both within the family and in groups; (iv) Learning to plan and solve problems requires the ability to solve problems in new ways; (v) becoming more independent requires patients to take responsibility for their own life. CONCLUSION: The study suggests that developing insight and acceptance, learning about warning signs, improving communications skills, learning to plan and solve problems, and becoming more independent are perceived as benefits of a psychoeducational family intervention.

Challenges for group leaders working with families dealing with early psychosis: a qualitative study.

BACKGROUND: Family work is one of the best researched psychosocial interventions for patients with chronic psychosis. However, family work is less studied for patients with a first episode psychosis and the studies have revealed contradicting results. To our knowledge, no previous studies have examined qualitatively group leaders' experiences with family work. In the present study we wanted to explore challenges faced by mental health professionals working as group leaders for family interventions with first episode psychosis patients. METHOD: A qualitative exploratory study was carried out based on digitally recorded in-depth interviews and a focus group interview with nine experienced mental health professionals. The interviews were transcribed in a slightly modified verbatim mode and analysed by systematic text condensation. RESULTS: Challenges faced by group leaders was classified into six categories: (1) Motivating patients to participate, encouraging potential participants was demanding and time-consuming; (2) Selecting participants by identifying those who can form a functional group and benefit from the intervention; (3) Choosing group format to determine whether a single or multi-family group is best for the participants; (4) Preserving patient independence, while also encouraging them to participate in the intervention; (5) Adherence to the protocol, while customizing adjustments as needed; (6) Fostering good problem-solving by creating a fertile learning environment and choosing the most appropriate problem to solve. CONCLUSIONS: Group leaders face challenges related to recruitment and selection of participants for family work, as well as in conducting sessions. Awareness of these challenges could help health professionals more specifically to tailor the intervention to the specific needs of patients and their families.

Patients' and family members' experiences of a psychoeducational family intervention after a first episode psychosis: a qualitative study.

The objective of this study is to explore patients' and family members' experiences of the different elements of a psychoeducational family intervention. A qualitative, explorative study was performed based on digitally recorded in-depth interviews with 12 patients and 14 family members. The interview data were transcribed in a slightly modified verbatim mode and analysed using systematic text condensation. Six themes that both patients and family members experienced as important in the family intervention were identified: alliance, support, anxiety and tension, knowledge and learning, time, and structure. A good relationship between the group leaders and participants was essential in preventing dropout. Meeting with other people in the same situation reduced feelings of shame and increased hope for the future. Hearing real life stories was experienced as being more important for gaining new knowledge about psychosis than lectures and workshops. However, many patients experienced anxiety and tension during the meetings. The group format could be demanding for patients immediately after a psychotic episode and for those still struggling with distressing psychotic symptoms. Group leaders need to recognise patients' levels of anxiety before, and during, the intervention, and consider the different needs of patients and family members in regards to when the intervention starts, the group format, and the patients' level of psychotic symptoms. The findings in the present study may help to tailor family work to better meet the needs of both patients and family members.

Does prescribed burning result in biotic homogenization of coastal heathlands?

Biotic homogenization due to replacement of native biodiversity by widespread generalist species has been demonstrated in a number of ecosystems and taxonomic groups worldwide, causing growing conservation concern. Human disturbance is a key driver of biotic homogenization, suggesting potential conservation challenges in seminatural ecosystems, where anthropogenic disturbances such as grazing and burning are necessary for maintaining ecological dynamics and functioning. We test whether prescribed burning results in biotic homogenization in the coastal heathlands of north-western Europe, a seminatural landscape where extensive grazing and burning has constituted the traditional land-use practice over the past 6000 years. We compare the beta-diversity before and after fire at three ecological scales: within local vegetation patches, between wet and dry heathland patches within landscapes, and along a 470 km bioclimatic gradient. Within local patches, we found no evidence of homogenization after fire; species richness increased, and the species that entered the burnt Calluna stands were not widespread specialists but native grasses and herbs characteristic of the heathland system. At the landscapes scale, we saw a weak homogenization as wet and dry heathland patches become more compositionally similar after fire. This was because of a decrease in habitat-specific species unique to either wet or dry habitats and postfire colonization by a set of heathland specialists that established in both habitat types. Along the bioclimatic gradient, species that increased after fire generally had more specific environmental requirements and narrower geographical distributions than the prefire flora, resulting in a biotic 'heterogenisation' after fire. Our study demonstrates that human disturbance does not necessarily cause biotic homogenization, but that continuation of traditional land-use practices can instead be crucial for the maintenance of the diversity and ecological function of a seminatural ecosystem. The species that established after prescribed burning were heathland specialists with relatively narrow geographical ranges.