Introduction
Methods
Sample size justification
Participant selection
Data collection
Ethics
Interview guide
Participants’ demographics
Data analysis
Results
Phase one
Participant | Step 2: significant statements | Step 3: formulated meanings | Step 4: themes |
---|---|---|---|
Clinician | (1) “It's really hard to kind of provide a generic kind of template around that, because you do it—like you've generally reviewed the notes and you're tailoring the conversation to what the assessment was, so it's hard to say, oh yes, I'd do this and then I'd do that.” | (1) Follow-up interventions need to be responsive/tailored to the individual, as opposed to a one-size-fits-all approach | (1) Person-focused: The intervention needs a strong person-centred focus |
(2) “It's a bit kind of like, yeah, just building a banter with them and a therapeutic rapport and then albeit briefly, then being able to dive into those harder questions.” | (2) A genuine, empathic, and rapport rapport-building intervention must be prioritised over a 'tick the box' approach | (2) Phone call dynamics: Ensuring a genuine and empathic call is of primary importance | |
(3) “I feel it would be helpful, but there would need to be a purpose of the call, like rather than, oh how are you feeling today, yeah, still suicidal, oh that's shit. Like more of a have you called your GP like you said you would, have you followed like we tell the parents to remove access, have you done this with the parents, like more of a call to follow through and have you put into place what we discussed.” | (3) The intervention purpose must be clear and aim to meet the expectations and wants/needs of the individual | (3) Phone call purpose: The purpose of the call to each person must be clear | |
Young person | (1) “I think it depends on the circumstances." | ||
(2) “The person is still human. Just because they have a mental illness doesn’t mean they're any less mentally capable than anyone else. In my experience, when I've ever talked to someone over a phone I feel like they're reading from a script and I'm talking to someone that's robotic, and I totally lose all connection. It's, like, okay, let's wrap this up, I've got things to do.” | |||
(3) “I think psychoeducation is a big part of it. I know for my parents they didn’t really understand what I was going through. To them when I was really young it was like, this is just attention or this is just—why didn’t you talk to us about this sooner? Just not really getting it. If someone had taken the time to sit down with them and say, do you actually get how we got to this point—because they didn’t see the signs leading up to the attempt so they were just like, oh, this just happened. If someone had sat down with them and said, did you notice this, this and this? Because that was what that was, and this is what is happening with your child. They might have understood a bit better and been more caring about it.” | |||
Parent/carer | (1) “Generally, yes, but that should be stated at—while you're in the ED. I've asked my daughters about this and they said that they would like to know in advance to have the right to say yes, they want someone or no, they don't.” | ||
(2) “They don't want that specific have you decided to take anymore? Have you—not that they would ask that but they don't want that specific to—they feel like they're more confronted if they have to answer those questions. They just want to round it out, which my son still gets when he goes to his clinicians…” | |||
(3) “I agree. It's terribly important to follow-up but as kids get older you really have to take in their thinking about it all. As a parent when we needed to follow-up with a youngster, like 12, that was my lifeline, having someone call me. It was very important to me.” |
Clinician | Young person | Parent/carer |
---|---|---|
Person-centred focus | ||
“I think you kind of gauge that case by case when you go down and you actually talk to parents, like…” | “I think it depends on the circumstances. Going back a few steps, if you've identified with the young person that there's no risky stuff going on that their family is putting them at risk or is damaging their mental health then I think that's a good idea. But I think also realising that's a different kind of clinical discussion you're having than the discussion with the young person themselves” | “Generally, yes, but that should be stated at—while you're in the ED. I've asked my daughters about this and they said that they would like to know in advance to have the right to say yes, they want someone or no, they don't.” |
“It's really hard to kind of provide a generic kind of template around that, because you do it—like you've generally reviewed the notes and you're tailoring the conversation to what the assessment was, so it's hard to say, oh yes, I'd do this and then I'd do that.” | “I would say definitely contacting the young person first is going to be important, because imagine if you're the young person and your family is contacted before you about this, and you're told by your mother or your father, they just called me about this. You weren’t told about this. You weren’t asked any questions directly.” | “It would be helpful also if they could specify some sort of timeframe of when they're going to…” |
Phone call dynamics | ||
“It's a bit kind of like, yeah, just building a banter with them and a therapeutic rapport and then albeit briefly, then being able to dive into those harder questions.” | “Yeah. When they're, like, so when I saw you we talked about this, and I was, like, you remember who I am. That's nice. I'm a human. As opposed to, blah, blah, blah.” | “Often in a crisis, you don't think of everything that needs to be said and that there is follow-up emergency stuff that really unanswered questions that needs to be addressed.” |
“I guess a conversation directly around risk or if they were in hospital previously [around] risk taking their life and how, where are they feeling now … yeah.” | “I feel like it's got to do as well with connection. For me, if don’t have a connection with someone, I'm not going to tell them anything. But if I can at least trust them a little bit and build a little bit of rapport, I'm going to be a lot more open. Maybe just try and build that rapport, talk about something other than the visits. Like, have you seen a movie today? What have you, I don’t know, eaten? | “…should have a checklist that they go through themselves and they can point out on each—the person who rings up can also have that same checklist and they can refer different questions to A, B, whatever and say this is happening. What do you think I should do? Should I go and see someone? Should I just leave it and wait and see?” |
Phone call purpose | ||
“I feel it would be helpful, but there would need to be a purpose of the call, like rather than, oh how are you feeling today, yeah, still suicidal, oh that's shit. Like more of a have you called your GP like you said you would, have you followed like we tell the parents to remove access, have you done this with the parents, like more of a call to follow through and have you put into place what we discussed.” | “I think psychoeducation is a big part of it. I know for my parents they didn’t really understand what I was going through… They might have understood a bit better and been more caring about it.” | “Often in a crisis, you don't think of everything that needs to be said and that there is follow-up emergency stuff that really unanswered questions that needs to be addressed.” |
“We're just trying to make sure that they know how to access support, counselling if they need it, so what our number is, if this happens again how to proactively get help when they need it.” | “How they're going. Check in on them.” |
Person-centred focus
Phone-call dynamics
Phone-call purpose
Statement of phenomenon (step 6)
Phase two
Theme | Description | Key quotes |
---|---|---|
What works | ||
Structure | Participants discussed importance of a comprehensive, structured, and reliable phone call that provided assessment (where possible) of key outcomes and risk factors (e.g., mood) as well as supporting the young person and the carers with problem-solving techniques or advice and being able to facilitate appointments with community services | “But I also like how it goes over the mood stuff and suicide risk assessment with the safety planning and then…” [Clinician—Assertive Model] |
“I feel it's nice to go, hey, have you made it to your appointment? Okay, let's troubleshoot what happened, what stopped you from going. Let's sort that out. But again it does have that thing about, what if there's an insurmountable barrier stopping you from taking care of yourself. But I like that it's, we're going to—not just, have you been? What's happening there? How do we sort it out so that you can go?” [Young person—Assertive Model] | ||
“Or, you haven’t used your safety plan? Is that because you're fine or because it's not working for you? Do we need to change something about it?” [Young person—Assertive Model] | ||
“structure around questions or what we're checking on, like…” [Clinician—Assertive Model] | ||
Consistency | Participants and clinicians expressed desire for an intervention that was consistent, but able to be adapted as needed (i.e., tailored to the individual), and one that could be counted on was preferred (e.g., consistent clinician where possible) | “at the moment I think different clinicians have very different processes [unclear] so it provides consistency…” [Clinician—Assertive Model] |
“that reassurance that things are going to be okay and there is somewhere to go and someone to call…when things get tough again. So I think it's helpful in that sense.” [Clinician—Assertive Model] | ||
“I think clinicians want it, they want that level to be able to do appropriate follow-up like that, we want that sort of stock standard response, we want to be able to say yes, we're going to provide this.” [Clinician—Assertive Model] | ||
“This takes all that sort of unknown away and it's this [unclear] organisation that's there if you need us.” [Clinician—Caring Contacts] | ||
“The contact. The actual contact opens conversation” [Young person—Assertive Model] | ||
Contained/finite | Satisfaction was expressed with models that were clear and contained (as opposed to ongoing with fuzzy boundaries). Comments showed preferences for a model that would have an endpoint and support the young person to progress back into community and family-led care | “This is good, it's contained, it's got clear guidelines [with the] 72 h. It's one phone call and these are the points that we're going to hit.” [Clinician—Assertive Model] |
“like it's got a finite amount of calls and it's spaced out enough that it's not a stalker-ish kind of setup” [Clinician—Assertive Model] | ||
“in terms of a system as well it's less work for us, because I think if we have all these [supportful] letters and postcards and text messages already set out, so then you can send it out …” [Clinician—Caring Contacts] | ||
“I think in terms of workload for us that is by far the easiest option.” [Clinician—Caring Contacts] | ||
What does not work | ||
Practicality | While the structure and content of the assertive model was appealing, and the empathic nature of caring contacts reassuring, there was doubt expressed around whether each model would be practical to implement. Clinicians’ comments centred on the extensive requirements and the concern around whether accurate assessment of outcomes could be made. Perceptions of the caring contacts model were positive, but agreement on the model losing authenticity over time and potentially confusing the follow-up services’ purpose (i.e., a key foundational requirement; see phase 1): | “In an acute team that's 24/7, I'd feel like we're still getting lost.” [Clinician—Assertive Model] |
“First of all, what if the young person has already used their 10 sessions for the year and it's September? Are you going to give them a weekly phone call until January? Because that seems like a really resource-heavy way of doing things, and I feel that's not going to happen in Q Health.” [Young person—Assertive Model] | ||
“on paper this is a really good idea but it has the capability to be really quickly, I'm going to say the word, delegitimised.” [Young person—Caring Contacts] | ||
“we don't want to be the ones that build the ongoing therapeutic relationship.” [Young person—Caring Contacts] | ||
Disempowering | Participants expressed concern around possibility of disempowering the young person and their family, particularly in response to the assertive model. Clinicians cautioned that there must be a clear separation from their services into the hands of the parents and guardians or community services (may be more difficult with more intensive interventions). Young people perceived structured, and highly detailed interventions as intense (may run the risk of taking control and autonomy away from the individual). Sentiment also verbalised by the carers and returns to the notion of a person-centred foundation | “… elements of it, but the onus has got to go back to the family too make their own follow-up.” [Clinician—Assertive] |
“Support them as much as you possibly can, I agree with you 100 per cent, but the onus has got to go back to the family at some point.” [Clinician—Assertive] | ||
“I think with this it’s 0 to 100 real quick. There’s no middle ground, and I think that is potentially a mistake.” [Young person—Assertive] | ||
“She has to be involved. You can’t do a safety—we can’t give her a safety plan.” [Parent/Guardian—Assertive] | ||
Call purpose | Clinicians expressed need for clear boundaries (assertive and caring contacts models) and the notion that calls should facilitate connection with community services (rather than continuing contact with the emergency response unit) | “Well state your purpose.” [Clinician—Assertive Model] |
“…what's the purpose of the call, yeah, are they always suicidal?” [Clinician—Assertive Model] | ||
“you're asking people to come in and build a relationship with that clinician rather than the community clinician.” [Clinician—Caring Contacts] | ||
“… we're a crisis team, it's just … people who are in there, then once we see them we need to move them on to someone else.” [Clinician—Caring Contacts] | ||
Helpful messages | Two primary themes emerged from suggestions which can be used as a template to generate messages. ‘Validating the person and their experience’ as well as ‘normalising the experience’ were broad focus areas along with ensuring the messages were ‘person-focused’. General suggestions on the type of message that could be sent (e.g., providing advice on who to speak with, what to do in risky situations, or how their discharge/safety plan is going) | “You did really good the other night chatting to us or calming down” [Clinician] |
“I can see a really resilient young person and you were really motivated to engage in therapy, that should be applauded, if you don't have hope for yourself, I have hope for you.” [Clinician] | ||
“I'll hold the hope for you.” [Clinician] | ||
“We know you've been discharged and you've been travelling quite well. If you have any concerns feel free to give us a call.” [Clinician] | ||
“A journey and having bumpy parts in the road or whatever” [Clinician] | ||
“I'm sorry that this sucks”[Young Person] | ||
“Out of suffering have emerged the strongest souls. The most massive characters are seared with scars” (Poetry quotation)[Young Person] |