Integrating professional identities: an ethnographic study of psychoanalytic child psychotherapy in a children’s social care setting

ABSTRACT

The importance of child and adolescent mental health services (CAMHS) collaborating with other agencies is of paramount concern for children with complex difficulties, including children in care. However, there is a lack of research exploring the role of child and adolescent psychoanalytic psychotherapists in multi-disciplinary and multi-agency work surrounding these children. Aims: to develop a theory of how child and adolescent psychoanalytic psychotherapists function within a social care setting, including how they position themselves in a multi-disciplinary and multi-agency environment. Methods: an ethnographic case study design, consisting of participant observation supplemented by interviews. Findings: grounded theory analysis identified that the child psychotherapists balanced three elements of their professional identity: discipline-specific identity; CAMHS team member identity; child’s care network member professional identity. To be effective in their role, the child psychotherapists needed to integrate the elements of their professional identity. The findings have implications for understanding the contribution of child psychotherapists in this field, particularly how to integrate into multi-disciplinary and multi-agency settings, whilst retaining their distinctive professional identity.

KEYWORDS:

• Psychoanalytic child psychotherapy
• children in care
• multi-disciplinary
• multi-agency
• professional identity

Introduction

Multi-agency working within children’s services has been a central feature of UK policy for several decades and is now recognised as the most efficient way of delivering services (e.g. Department of Health, 1998, Department for Education & Skills, 2003). Its’ importance has been particularly recognised for vulnerable children, including those in the care system (Biehal et al., 1995; MacAlister, 2022). It has been argued that children in care have different treatment needs to those offered by generic mental health services (DeJong, 2010); this is reflected in the development of specialist CAMH services to address these children’s needs (Callaghan et al., 2004). Potential benefits of specialist services include targeted interventions adapted to meet the child’s needs and strengthened communication between agencies (Golding, 2010). Having co-located services has also been identified as a facilitator to effective multi-agency working within children’s services generally (Atkinson et al., 2007).

Children in care often have large professional networks surrounding them, meaning there are numerous professionals who must communicate effectively. Thus, it is common for ‘fault lines’ to appear (Conway, 2009, p. 24). Problems include different professional roles, ‘languages’ and cultures, and opposing targets (Callaghan et al., 2004; Golding, 2010; Kelly et al., 2003). Street and Davis (2002) outline tensions that can occur when CAMHS and social services do not collaborate around these children. These include the perception from CAMHS that mental health support is best offered at times of stability, which may feel frustrating for social care. Furthermore, CAMHS professionals may feel that problems are being situated within the child, when they perceive the problem to be amongst the network.

Psychoanalytic theory has sometimes been used to try and explain the unconscious dynamics that can occur within networks around children in care, potentially leading to communication breakdowns, hindering professionals’ thinking capacities, and impacting on the child’s care (Emanuel, 2002; Sprince, 2000). Whilst this approach offers a framework for understanding barriers to multi-agency working, no research has explored how child and adolescent psychoanalytic psychotherapists (hereafter referred to as ‘child psychotherapists’) position themselves in a multi-agency setting, and their role in multi-agency collaboration around children in care. Child psychotherapists have traditionally provided both services and therapy for children with complex difficulties (Robinson et al., 2017, 2019), yet research is lacking on this discipline’s contribution to collaborative working practices.

There is also a lack of research concerning the role of child psychotherapists within multi-disciplinary CAMH services, despite most UK child psychotherapists working in CAMHS. Multi-disciplinary working has been a core feature since CAMHS’ introduction, ensuring children and young people access the most appropriate service for their needs, as well as enabling a mix of theoretical frameworks within teams (Health Advisory Service, 1995). However, within mental health services there has arguably been an increasing policy shift towards ‘creeping genericism’; the intention being to create more flexibility, so that different professionals can manage various responsibilities (Hill-Smith et al., 2012). This role blurring has been viewed as a potential corrosion of professional identity (Frost et al., 2005).

Given the above literature, there is a need to establish what individual disciplines contribute to collaborative working practices, especially for children with complex needs including those in the care system. More specifically, there is a need to understand how child psychotherapists can integrate themselves into multi-disciplinary teams whilst retaining their distinct professional identity. Finally, to explore what child psychotherapy can contribute via consultation with other agencies, to provide high quality services that support these children’s emotional needs.

This study explores this through an ethnographic case study of child psychotherapists in a specialist CAMH service. The overarching aim was to develop a theory of how child psychotherapists function within a multi-disciplinary CAMHS team, in a children’s social care setting, including: the distinct role of child psychotherapists in this setting; and how they position themselves in a multi-disciplinary and multi-agency setting.

Methodology

Research design

This was an ethnographic study, making use of observational methods (Brewer, 2000). Ethnography was chosen to conduct in-depth research that captured the complexities of providing child psychotherapy in a children’s social care environment, from the perspectives of different participants (Hammersley & Atkinson, 2007). This is aligned with the ‘thick description’ of ethnographic research (Geertz, 1973), whereby the researcher’s description of the culture under study goes beyond the ‘facts’, and includes context, analysis, and interpretation as a means of understanding the behaviours observed. Thus, allowing the researcher to move beyond merely describing the system, but also explaining why it functions as it does (Murphy, 2021). Participant observation as the main method allowed access to behaviours that participants were not consciously aware of, and observation of interactions that occurred between participants in the setting.

Selecting the case

The setting was a looked after children’s (LAC) CAMH service, based within a social care office of a large city in England. Building on an earlier study of child psychotherapists’ work with children in care (Robinson et al., 2017), this service was purposively sampled: the child psychotherapists were based within social care, offering direct work and consultation, thus allowing the opportunity to understand how the teams worked alongside each other.

Ethical considerations

Ethical approval was provided by UCL ethics committee (Project ID: 8293/003), the Health Research Authority (IRAS: 227718) and the local authority. Informed consent was sought from the CAMHS and social care teams (further details of team characteristics can be found under the ‘Participants’ section). Although details of families were discussed during observations, participants were not asked to provide identifying details that would breach confidentiality. Therapy sessions with children were not observed. The local authority did not agree to foster carers being interviewed. No identifying details were recorded in observation notes and identifying details from audio recorded interviews were removed during transcription. The two child psychotherapists were assigned the pseudonyms Alice and Mia.

Participants

LAC CAMHS team

The team was made up of two child psychotherapists, a psychiatrist and a counselling psychologist. Their remit was to provide mental health services for children in care, and those transitioning to adoption, up to age 18. Services included: individual child therapy; consultation to the professional network; training with professionals/foster carers; therapeutic work to foster carers. The child psychotherapists reported a changing emphasis to their workload in recent years, with the local authority requesting more child therapeutic, and less consultation, work.

Child looked after and leaving care services

The service comprised: 1 Service Manager; 5 Deputy Service Managers; 17 social workers; 9 Personal Assistants (working with young people aged 18–25); and several other practitioners. Core duties included implementing and reviewing permanency and pathway plans for children in care and care leavers, undertaking statutory visits, promoting contact and ensuring developmental aspects were met. The local authority had encountered several changes over recent years impacting on its practice. One change was the embedding of systemic practice as a cultural norm across the whole organisation. Within this framework, problems were seen as arising from relationships between people, rather than situated within the person. Systematic practitioners had been recruited to work alongside and support staff in developing systemic skills.

Data collection

Table 1 summarises the data collection undertaken during the fieldwork period.

Table 1. Summary of data collection.

Data collection method	Number	Timescale
Participant observation and informal interviews	22 days	June–December 2019
Formal interviews: 2 child psychotherapists Social workers/Personal Assistants	3 8	Autumn 2019–Spring 2020 4 prior to observation period, 4 during observation period
Social work managers	2	November–December 2019

Participant observation and interviews

During the observation period, the first author (FR) observed the services the child psychotherapists provided to professionals. This comprised sitting in the office and observing their practice at their desks, and whilst conducting ‘informal’ consultations and interactions with social workers, such as in corridors or across desks. Furthermore, FR observed the weekly CAMHS team meetings, when the team came together to discuss high-risk cases and new referrals, and accompanied the child psychotherapists to external professionals’ meetings. 22 observation days were conducted between June and December 2019. Observations were recorded as field notes, organised as daily notes. A research diary documented feelings to participants and the setting. Following observations, the researcher often talked to participants about the observations and asked additional questions. These ‘informal’ interviews are typical of ethnographic research and were recorded as field notes. Alongside informal interviews, more formal interviews were conducted. Interviewees and interview questions were chosen to achieve theoretical saturation (see data analysis section).

Data analysis

Charmaz’s (2006, 2014) constructivist grounded theory was used. Constructivist grounded theory was chosen because it fits with the epistemological assumptions of ethnography, namely that knowledge is co-constructed intersubjectively through the interactions that people make within settings (Brewer, 2000), including the researchers’ interactions with participants in the environment. Coding was conducted using NVivo v.12 (QSR International, 2021). Coding comprised initial coding (assigning codes to each line of data); focused coding (synthesising portions of data in a more conceptual manner); memo-writing (jotting down ideas, comparisons and questions regarding focused codes); and development of categories (focused codes with higher conceptual meaning). Theoretical sampling began once tentative categories were developed. Memo-writing had identified gaps in understanding, which required further sampling. Through theoretical sampling, interviews were conducted with six members of the social care team and three with the two child psychotherapists. The categories were revised after each interview, with further interviews conducted until theoretical saturation was reached. The core category was developed after 22 observation days and informal interviews, plus 11 formal interviews. The two child psychotherapists were then re-interviewed twice to saturate the properties of categories. All data was recoded against the final categories. By the end of coding, no new focused codes were developed, suggesting the theory sufficiently accounted for the data, and theoretical saturation was reached.

In terms of credibility, multiple data collection methods were used, providing a multi-perspective account and data triangulation. Observations were conducted over several months and on different days, allowing a detailed insight into participants’ activities. The practice of reflexivity was adopted, meaning a transparent approach to how the researchers’ background impacted the research. Furthermore, a member-check (Charmaz, 2006) was conducted, allowing participants to feedback whether the theory resonated with them. In terms of transferability, the emerging theory was presented to a group of child psychotherapy trainees, working in different settings. The theory was also presented as a webinar to members of the regulatory body for UK child psychotherapists, allowing feedback from child psychotherapists in various settings.

Reflexivity (primary researcher)

During the study, I was acutely aware of my position as an academic researcher with a different professional background and ‘culture’ to the participants. This could be viewed as both a strength and limitation. It could mean that I was not as readily accepted as someone with clinical or social work experience; being an ‘outsider’ who comes from a detached, slightly protected, academic world compared to those on the frontline. This ‘outsider’ naivety may mean I asked questions an ‘insider’ would not ask, or concepts they take for granted (O’Reilly, 2009). Another potential benefit was that I did not foreclose my analysis early.

I also considered my own preconceptions, including my knowledge of psychoanalytic child psychotherapy. My background is in psychology and, prior to undertaking this research, I had only limited knowledge of psychoanalysis and child psychotherapy. My analysis may therefore have been shaped by my relatively ‘new’ understanding of psychoanalytic theories, however this was a strength in allowing me to ask the child psychotherapists’ detailed questions about their theoretical frameworks.

Whilst undertaking fieldwork, I engaged in several methods of developing reflexivity. I recorded reflections in a reflective diary. I also engaged in discussion with my supervisor (NM), who is both a researcher and child psychotherapist, which helped identify aspects of reflexivity relevant to the research, and potential impact on my interpretations. For example, as fieldwork progressed, I found that I was identifying with the CAMHS team during observations; shadowing their practice meant I found myself sometimes adopting their perspective as my own. Supervision allowed me to return to the field with this awareness, to ensure it did not detract from the views of other professionals, or my own views.

Findings

The core category, Integrating professional identities was developed because it was central to all other categories, explaining how the child psychotherapists positioned themselves within this setting. Analysis suggested the child psychotherapists managed multiple professional identities in this setting, which they needed to integrate, as all three served a purpose. The core category comprised several categories, detailed below.

Category 1: child psychotherapists’ multiple professional identities

This category describes the characteristics of each identity and explores instances in which the child psychotherapists adopted one as their ‘primary’ identity. The three professional identities are presented as sub-categories (Figure 1).

Figure 1. The child psychotherapists’ professional identities.

Sub-category 1: discipline-specific identity: child and adolescent psychoanalytic psychotherapist

The discipline-specific identity comprises instances whereby the child psychotherapists asserted their identity as a psychoanalytic psychotherapist. In interview, Mia reported that this identity was most evident in their therapy sessions, rather than interactions with professionals. She commented that had observations been conducted of therapy sessions, the differences between CAMHS disciplines would be apparent,

I think you would notice that when you’re working with somebody … the sort of questions you might ask, the way you might frame something … I think we would be more thinking of the underlying unconscious dynamics, or the kind of feelings that might be driving something. (Mia, interview 8 November 2019)

Despite this, during general office observations, the child psychotherapists asserted their discipline-specific identity outside the therapy setting. Having two child psychotherapists was perceived positively by both. Alice commented that it helped to ‘re-align’ her during case discussions; ‘Mia makes an observation and I feel my compass dial go back in the right direction’ (Alice, interview 27 March 2020). This metaphor described their sense of psychoanalytic thinking as a compass, perhaps useful for when they get ‘lost’ in multi-disciplinary case discussions.

Consultations with social workers were also informed by their theoretical framework, frequently around organisational defences against anxiety. An example is shown by field notes from a meeting between a newly formed social work team, working with unaccompanied asylum-seeking children (UASCs). The meeting’s aim was to identify support LAC CAMHS could offer to social workers,

Alice says she is thinking about how the social workers function and don’t replicate dynamics. She says they are listening to many traumatic stories and how do they keep listening without becoming defensive or splitting; she rephrases this, saying ‘without needing to protect yourself’. (Field notes 9 August 2019)

This demonstrates that the child psychotherapists’ theoretical framework informed their consultations, but they attempted to translate it into a ‘language’ that social workers could make sense of (although, sometimes slipping into psychoanalytic terminology, perhaps indicating occasional difficulties with translating). Field notes recorded that afterwards, the UASC Team Manager shared how she perceived social workers to protect themselves, for example focusing on performance-led aspects of tasks. She responded positively to the child psychotherapists’ suggestion of a space to think this through.

Sub-category 2: LAC CAMHS team member identity

Analysis suggested the child psychotherapists adopted an identity of ‘generic mental health clinician’ through their assertion as a LAC CAMHS team member. This appeared dominant in their interactions with social workers, including using the phrase ‘the CAMHS perspective’ often. The LAC CAMHS team were all employed on the same salary banding, following the loss of their Team Manager in a cost-saving exercise. This absence of hierarchy appeared important to the teams’ functioning; Alice described the team as ‘small’ and ‘tight’ (field notes 7 June 2019), with relationships built on friendship and camaraderie.

Conversations with the team suggested they positioned their identity by differentiating themselves from generic CAMHS. They perceived themselves as having more flexible working; describing how in generic CAMHS, clinicians have funding for a limited number of therapy sessions, whereas they could work with children for longer periods. They thought this flexibility suited children within their remit. Field notes recorded that Alice said ‘there is a point in treatment with children in care where you feel like you’re actually doing treatment – at first it can take a while to engage these children’ (field notes 18 July 2019). Flexibility thus meant they could firstly focus on developing the relationship with the child.

The shared identity was also used by the team to process feelings surrounding these children, including feelings unconsciously communicated from professionals. In interview, the child psychotherapists commented that LAC CAMHS meetings enabled team members to hold disturbance and anxiety surrounding these children. Alice said she felt ‘full up’ (field notes 7 June 2019) before meetings and anxious if she could not attend.

Analysis suggested the child psychotherapists also identified with this identity as a strategy for managing anxiety, when working in a setting that created uncertainties for their role. The local authority’s embedding of a systemic practice culture had impacted on LAC CAMHS, including a change to their workload. In interview, the social care Service Manager explained that the systemic team were taking on more consultation work: ‘I think ultimately we would like them [LAC CAMHS] to be having that emphasis on the direct work … I think with the individuals that’s often the realm of the psychotherapists isn’t it?’ (Team Manager, interview 14 November 2019). This demonstrates the perception that child psychotherapy was suited to therapeutic aspects of practice as it was individual-facing, whereas systemic practice was outward-facing, therefore suited to consultation.

The child psychotherapists used the LAC CAMHS team identity to manage these uncertainties. Field notes recorded that while they experienced frustrations, these were explored in team meetings to help them not act defensively in practice. For example, there were instances of the LAC CAMHS team not being fully integrated into the setting in practice, despite being co-located with social care. The team had no administrative support, and although they had a dedicated room for therapy sessions, there were instances of the room being used by social workers even when it was blocked out for use by the CAMHS team. Alice reflected that she felt their experiences of being the ‘fostered’ team replicated the experiences of the children they worked with (field notes 21 June 2019). Exploring these feelings in LAC CAMHS team meetings allowed the team to identify their own feelings of blaming or splitting with other services. This identity also gave them a foundation to take a position within the network; there was a sense ‘the CAMHS perspective’ gave the team greater authority to argue their position, transcending individual perspectives.

Sub-category 3: child’s care network member professional identity

The child psychotherapists sometimes adopted a third identity, as a member of the child’s care network. They perceived that, when a network functions effectively around the child, all professionals share this common identity. From their perspective, an important function was enabling professionals to hold aspects of the child together. Alice said, ‘One idea is that the child’s experience is so fragmented, there’s not one person … holding it all. So that means the network has to do that, hold the child’ (Alice, interview 8 May 2020). Here Alice’s discipline-specific identity informed her understanding of her network member identity.

The child psychotherapists perceived that they shifted between an ‘inside/outside’ function, by ‘observing what’s going on in the network but recognising we are part of it’ (Alice, interview 8 May 2020). When they were ‘inside’ the network they were fully part of it as ‘stakeholders’ (Mia, interview 8 May 2020) in thinking about the child’s experience. Field notes recorded examples of the child psychotherapists positioning themselves as ‘in this together’ with social care; during a meeting a social worker said, ‘that’s the local authority’s job, people don’t like us’ and Alice responded with, ‘not just you, but us’ (field notes 14 June 2019). This impacted positively on the social worker as she said she was ‘sharing the emotional load’. The child psychotherapists recognised that, when adopting this identity, they could get enmeshed in dysfunctional network thinking. Mia said, ‘when you’re right in the network, it’s not like we’re always being so thoughtful about what’s going in, cos you’re in it. You have to be in it’ (interview 8 May 2020).

They reported attempting to pull themselves ‘outside’ the network, by observing processes occurring in networks. Alice said, ‘you have to be able to come outside of it and think what’s going on here, what am I doing, what are we doing? … you can’t always do it a lot of the time. It’s hard work’ (Alice, interview 8 May 2020). Here Alice uses her discipline-specific identity to pull herself outside the network. When she shifts into her child’s care network member professional identity, she used her psychoanalytic understanding of network dynamics, presenting this to professionals to unify them on the task.

This identity was also used to keep in mind other agencies’ perspectives. Both the LAC CAMHS and social care teams perceived co-located teams as facilitating their understanding of each other’s position. Mia thought that working directly with social workers meant a different way of working to generic CAMHS, in which all the ‘little decisions’ (Mia, interview 8 November 2019) could be thought through daily. However, there was a tension in this identity because LAC CAMHS and social care were separate services. At times of disagreement with social care, observations recorded the child psychotherapists sometimes reverted to the LAC CAMHS team member identity. Field notes from a meeting between Mia and a social care manager, in which they disagreed over sibling contact, recorded that Mia eventually said, ‘my clinical judgement is she is putting her child at risk. This is the CAMHS perspective’. Although at the time, the social care manager did not change her perspective, subsequently, LAC CAMHS agreed that Alice should offer to accompany the manager to visit the family. Field notes over several days recorded that subsequently, the two agencies collaborated positively.

Category 2: shifting between professional identities while engaging in their role

Category 2 describes the processes the child psychotherapists engaged in, which are presented as four sub-categories (see Figure 2). While engaging in these processes, the child psychotherapists shifted between their professional identities.

Figure 2. Processes the child psychotherapists engaged in.

Sub-category 1: ‘a reminder to focus on the child’: thinking about the child’s emotional and psychological life

A principal role of the child psychotherapists was to keep the child’s psychological life at the forefront of network thinking. Often this involved providing an understanding to social workers of what the child may be communicating through their behaviour and helping social workers to develop their understanding of this. Field notes from a consultation recorded that Alice talked about a child with a fear of flying, saying she thinks ‘what she really meant is that she has a fear of being dropped’ (field notes 9 August 2019), thus perceiving that the child’s outward communication indicated her, often unconscious, feelings. The child psychotherapists described wanting to develop connections between an internal and external world, which they thought was fundamental to working in this setting,

The thing with children in care is that there are so many external intrusions … we’re always working a bit on the inside and the outside. If we just went to meetings and talked about the internal world … it’s got to be in some way that relates to decisions being made. (Alice, interview 8 May 2020)

Therefore, whilst Alice’s theoretical framework informed her understanding of a child’s experiences (discipline-specific identity), she needed to make these translatable into the child’s external world (child’s care network member professional identity).

Keeping in mind the child’s experience, whilst juggling so many other tasks, could be difficult to maintain for social workers. High levels of staff turnover also made it difficult to hold the child’s experience. In interviews, social workers reported valuing the child psychotherapists’ presence as a ‘reminder’ to focus on the child, ‘I think with social workers you’ve got so many things to think about … and it is a bit of a reminder to think about what’s actually going on for them’ (SW4, interview 5 December 2019).

LAC CAMHS, in comparison to other agencies, often held the child’s history for long periods, using a ‘phase-in-phase-out’ approach rather than closing/reopening cases. Alice said she thought this way of working was different to social work, who often think in the ‘here and now’ (field notes 7 June 2019), focusing on forward planning. She felt that their way of working meant the child’s current presentation could be situated in terms of historical factors.

Sub-category 2: ‘sharing the emotional load’: attending to social workers’ feelings and anxieties

Field notes suggested the child psychotherapists perceived high levels of anxiety amongst professionals; framing this in terms of defences they felt professionals used to protect themselves from anxiety (discipline-specific identity). An example comes from field notes during a LAC CAMHS meeting. The team discussed their perception that Mia was ‘excluded’ from decision-making meetings:

Alice asks ‘what is [name of manager] “pushing out” by excluding Mia?’ Mia says she thinks she brings complexity and problems, rather than solutions. Alice suggests putting that to them in a non-challenging way, ‘I’m having this experience that I bring problems … ’ Alice suggests they present it as a network issue; ‘as a network we’re repeating things’. (Field notes 9 August 2019)

This demonstrates several facets of the child psychotherapists’ approach, encompassing all identities. Firstly, framing their understandings in terms of defences (discipline-specific identity). Secondly, vocalising this to the network, in a non-confrontational way. Thirdly, to present it as a network issue that includes the child psychotherapist in replicating unconscious dynamics (child’s care network member professional identity). Fourthly, to think through with the CAMHS team an issue impacting on the child’s wellbeing (LAC CAMHS team identity).

Field notes recorded that a common intervention by the child psychotherapists was encouraging social workers to ‘stand back’ from situations; to pause and prioritise reflection, even in a crisis, so that decisions are made in the best interests of the child. Instances of them offering thinking spaces to social care were often met welcomingly, however, on occasion, social workers seemed less receptive to them. During a meeting between Mia and a social care manager to discuss different perspectives over sibling contact, Mia offered space to think about preventing this happening in future (child’s care network member professional identity). The social care manager stated ‘we should have this reflection at a later stage’ (field notes 2 August 2019), potentially because she had many practical tasks to complete, therefore reflection was less of a priority. Other similar examples suggested a pattern of social workers being less receptive to the child psychotherapists’ interventions at times of crisis. Observations recorded that the child psychotherapists’ attempts to ‘slow things down’ could feel frustrating for social workers and that perhaps the child psychotherapists misjudged social cares’ priorities, needing to adapt interventions when reflection was less of a priority.

Despite this, social workers reported in interviews that they valued consultations with a child psychotherapist,

A consultation can feel like a supervision … but it’s more of a reflective form … the most common thing [Mia will] say … she’ll say ‘that’s right. … sometimes she’ll say ‘that’s right but’ … there’s that kind of verification that these things are authentic. (SW9, interview 8 November 2019)

Therefore, social workers appreciated the validation that their feelings were understandable (‘that’s right’), but also the challenge that child psychotherapists offered (‘but … ’).

Sub-category 3: ‘rocking the boat’: investigating and challenging thinking and decision-making

The child psychotherapists perceived that their role often entailed investigating social cares’ thinking, ‘often you find … it’s not that people have done lots of thinking … it’s because they’re under pressure … I think there’s something about trying to … enquire about, not in a kind of you’re wrong way, but a kind of what has led to this?’ (Alice, interview 27 March 2020)

This demonstrates Alice’s approach of taking a curious stance to exploring social cares’ decision-making, aiming to unpick underlying pressures. Field notes recorded that during consultations, the child psychotherapists could be ‘firm’ with social care, offering clear advice about their perspective. Field notes from a professionals meeting recorded:

[Social worker] says she is concerned the children won’t get support soon as their looked after child status may to be dropped. Alice says firmly this is a worrying situation and she doesn’t think services should discharge them. (Field notes 14 June 2019)

Here, Alice’s child’s care network member professional identity can be seen. Following this meeting, Alice discussed the case with her CAMHS colleagues, and field notes recorded she ‘thought I had made the social worker think and she could hear what I said’ (field notes 14 June 2019).

The child psychotherapists were prepared to challenge where they felt necessary; this primarily occurred when questioning social workers’ beliefs. Field notes during a consultation following an unexpected placement breakdown recorded:

The social worker describes the child as ‘resilient’. Mia replies ‘I don’t agree’. She thinks it is a defence, the child is scared of her feelings, so she clams up and says it’s all ok. Mia says she has a problem with the word resilience: ‘you can call it that in the short-term because it enables [child] to keep going, but it doesn’t let you get in touch with your feelings’. (Field notes 2 August 2019)

Here Mia adopts her discipline-specific identity to reframe the child’s behaviour. Field notes recorded that the social worker seemed unsure of what to say, and that Mia said ‘this can be a conversation for another time’, and after the meeting, said to me ‘when I heard him mention the word resilience I had to say something, then pulled myself up for being so frank’ (field notes 2 August 2019). This suggests that although they felt challenging was necessary, it was important to be careful about the timing of such interventions.

When challenging, the child psychotherapists utilised an approach in line with their discipline specific identity of encouraging reflection, thus alleviating anxiety. Field notes during a LAC CAMHS meeting recorded that Alice said she wanted to ‘induce anxiety so as to mobilise the network’ (field notes 5 July 2019). Challenging therefore frequently comprised an action-focused stance, aiming to create perceived appropriate anxiety.Social worker interviews demonstrated that the challenging was primarily received positively. One social worker commented that often the notion within the network is ‘don’t rock the boat’ (SW2, interview 14 November 2019); therefore, they welcomed the child psychotherapists’ different perspective. Despite this, challenging could also feel disconcerting, ‘I do trust them, their expertise, and the fact they will challenge something … it feels like “oh gosh we really have to take that into account”. I really struggled with that case because I still disagreed with them’ (SW21, interview 28 November 2019). This demonstrates that the social worker perceived the child psychotherapist as an expert, who it was alarming to disagree with; but also, she did not accept their opinion. On questioning her on how the tension was resolved, she commented that following several meetings, the final care plan is ‘the best one in that it’s somewhere in the middle’; suggesting negotiation was key to managing perspectives.

Sub-category 4: ‘getting them to formulate their own ideas about things’: facilitating a sense of agency in social workers

Analysis suggested the child psychotherapists engaged in this as a means of activating social workers to have ‘firm thoughts and their own mind’ (Alice, field notes 30 August 2019) on cases. This sub-category has overlaps with their role of challenging; the child psychotherapists perceived that challenging could lead to social workers having a more authoritative sense of professional identity. There were also distinct elements as follows.

This process primarily stemmed from the child psychotherapists’ belief that sometimes social workers lacked ‘ownership’ (Alice, field notes 9 August 2019) of their cases, being swayed by the opinions of network professionals. Their intervention often involved advising social workers to be firm in decision-making. This is demonstrated by field notes during a meeting between Alice and social care. Alice called the meeting following concerns that her perspective was overlooked:

They talk about the meeting that Alice feels her perspective was excluded from. [Social care manager] says she doesn’t want to have another meeting like that, there were too many opinions involved. Alice says ‘I don’t think you should – you should own it as the local authority. It’s your care plan’. Alice says ‘you two need to take ownership of this system’. (Field notes 9 August 2019)

Here Alice shifts between her child’s care network member professional identity, but also recognises the differences between agencies and aligns herself with LAC CAMHS. All parties left this meeting feeling buoyed up, with the social workers reporting they felt ‘ready to take on the network’ (SW2, field notes 9 August 2019), in what Alice hoped meant they made their opinions more known.

Observations suggested the child psychotherapists aimed to increase professional confidence by encouraging social workers to manage ‘safe’ risk. One social worker found this empowering,

I think there are so many professionals … that don’t allow you to live in uncertainty, they want you to get rid of it. Whereas having that reassurance [from the child psychotherapists] that it’s ok, we don’t know what will happen … it makes you go ok that’s alright. (SW2, interview 14 November 2019)

Social worker interviews also revealed that several were aware of the child psychotherapists’ attempts to facilitate a sense of agency. One commented that ‘pushing onto the therapist makes the young person feel like you can’t contain them’ (SW11, interview 14 November 2019), thereby recognising the need to apply the child psychotherapists’ advice to their practice, rather than deferring for therapy.

Category 3: having professional confidence in the child psychotherapist identity and role

The child psychotherapists’ professional confidence in their identity permeated all processes they engaged in. Analysis suggested a disparity between social workers’ perceptions of the child psychotherapists (as ‘experts’) versus how the child psychotherapists attempted to portray themselves (as having ‘professional confidence’ but not being ‘experts’).

Social worker interviews revealed they held LAC CAMHS’ views in high regard. There was a sense that CAMHS’ opinion was ‘weighted’ more than a social worker in certain environments, such as court. One social worker described this as a ‘professional pecking order’, commenting that adding LAC CAMHS’ perspective to a court report made him feel ‘powerful’ (SW11, interview 14 November 2019). Several social workers gave the impression of LAC CAMHS helping them with situations they felt unequipped for. One social worker admitted that when she booked a consultation, she hoped the clinician would ‘jump in and say let’s go visit them together … there’s anxiety around mental health, cos I’m not therapeutically trained’ (SW8, interview 28 November 2019). Another thought these feelings stemmed from social workers’ level of experience; those with professional confidence may approach consultation with their own views, ‘I just have to remember that whilst they’re so expert … they’re thinking very much about a child’s psychological needs … in social work you’ve got other factors to balance’ (SW21, interview 28 November 2019). This illustrates that social care and CAMHS had different responsibilities and CAMHS’ opinion only formed one part of social cares’ decision-making.

There was a sense viewing LAC CAMHS as ‘experts’ of the child’s psychological needs felt reassuring for social workers. They spoke about seeking validation; one social worker said ‘Alice will be like “yep that’s a really good way of thinking about it”. And I’m like oh wow. I am actually thinking about this in a proper way’ (SW2, interview 14 November 2019). In contrast, this view could engender fearful feelings when social workers disagreed with LAC CAMHS. One said it was ‘scary’ to disagree with an expert: ‘I really struggled with that case because I still disagreed with them. And then I found it very hard … to justify my disagreement … when they were bringing so much evidence’ (SW21, interview 28 November 2019).

Observations suggested the child psychotherapists did not intend to come across as experts, but instead had professional confidence in their opinions. This does not mean they did not experience dilemmas, but that their theoretical framework gave a basis for understanding behaviour. The child psychotherapists perceived that professional confidence enabled them to do applied work, distinct from child psychotherapy in generic CAMHS, largely based in the clinic. The child psychotherapists attended settings such as schools and foster carers’ homes for meetings and therapy sessions. They described being able to work in different contexts and speak to professionals and families in a relatable way,

We’re not purists in the sense that we’re working with a toy box with every child … but I think we have that setting in our head. A fundamental internal setting. Which is what allows us to move around and speak in different ways. (Alice, interview 27 March 2020)

Having professional confidence appeared to contribute to the child psychotherapists integrating their professional identities.

Discussion

This study aimed to explore how child and adolescent psychoanalytic psychotherapists function in a multi-disciplinary CAMHS team, in a children’s social care setting. The findings were presented as a grounded theory of Integrating Professional Identities. The main finding is that the child psychotherapists balanced three elements of their professional identity in this setting. Their role involved engaging in various processes, ultimately aiming to place the child’s psychological life, as they understood it, at the centre of social cares’ practice. They shifted between identities while engaging in these processes.

The discipline-specific identity was their core identity, most apparent in their interactions with the other child psychotherapist, and, from their perspective, therapy sessions. The LAC CAMHS team member identity was dominant in interactions with social workers, utilising ‘the CAMHS perspective’ to demonstrate a team viewpoint based on psychological understanding of the child, and to process feelings surrounding these children. The child psychotherapists perceived that the child’s experience could be held by professionals when the network adopted the child’s care network member professional identity.

The first process engaged in was thinking about the child’s psychological and emotional life, enabling connections between the internal and external world. Attending to social workers’ feelings and anxieties carried a reflective function; the child psychotherapists perceived their role as recognising where they felt anxiety was occurring within the system (and how it was managed) then inviting these anxieties to be thought about. They engaged in investigating, and challenging, thinking and decision-making to explore processes that led to decisions being made, including unpicking external pressures. Finally, they aimed to facilitate a sense of agency in social workers by encouraging them to take ownership of cases. Although these processes involved a thinking/reflective function, they were action-focused, in terms of altering decision-making.

Several hypotheses can be made about the intended consequences of these:

• The child’s emotional life is kept at the forefront of network thinking;

• The connection between a child’s past experiences and their current behaviour and responses to relationships is considered in network planning;

• Social workers become aware of ways they may protect themselves against painful feelings, and how, unless managed, this creates risks to the child, the worker and the organisation;

• Social workers can and should pause and ‘stand back’ from situations, even crisis situations;

• Social workers can connect with the child’s, and their own, feelings;

• Social workers have more professional confidence and can articulate their views.

There was a disparity between social workers’ perceptions of the child psychotherapists, as mental health experts, versus how the child psychotherapists attempted to portray themselves, as having professional confidence in the child psychotherapist role and identity.

The literature on professional identity formation was used to integrate the categories into a theoretical framework (‘theoretical coding’ in grounded theory; Charmaz, 2006). There is debate as to whether professional identity is ascribed by organisational structures, or whether it is shaped by individual agency (Brown, 2015). This has similarly been explored in the social work literature on how child protection social workers construct their professional identity within a socio-political climate of blame (Leigh, 2014). The child psychotherapists in this study appeared in the middle of this dualism; they accepted the identity offered by an organisation (theoretical affiliation), but also used their own agency to shape it. This allowed them to adapt to their working environment, by shifting between other identities, defined from interactions with other professionals; and thus, exhibiting several ‘possible selves’ (Leigh, 2014; Markus and Nurius, 1986).

The literature concerning collective versus individual professional identity is also pertinent. Wenger’s (1998) ‘communities of practice’ theory contends that identity is negotiated in individuals’ participation in communities, defining themselves in relation to ‘familiar’ and ‘unfamiliar’ based on group belonging. Within this context, the child psychotherapists arguably sought belonging to other ‘communities’ through their identities, using this to bring the ‘group’ (professional network) together on a shared task. In contrast to this theory, the child psychotherapists drew on their uniqueness as a psychoanalytic therapist to vocalise differences of perspective to other professionals.

The findings contribute to literature on multi-disciplinary and multi-agency working. ‘Role blurring’ has been identified as a consequence of genericism within multi-disciplinary services (Atkinson et al., 2007); in contrast, the child psychotherapists had a strong sense of their discipline-specific identity. They chose to identify with their CAMHS members as a means of promoting shared team identity. This contrasts with literature which argues that role blurring is initially perceived negatively by workers while adapting to a new professional identity (Frost et al., 2005). This lack of ambivalence towards ‘generic mental health clinician’ identity may stem from the specific CAMHS team, and such positive adoption may not be demonstrated by child psychotherapists in other settings.

In terms of multi-agency working, the setting exemplifies centre-based delivery; the two services were based together but functioned separately. In terms of facilitators to collaboration, the findings suggest that co-located services can foster ‘informal’ consultation, enabling ‘little decisions’ to be thought through daily. The child psychotherapists often used a process of ‘translation’; translating understandings in ways they perceived as accessible to social workers with different ‘languages’. It is conceivable that the social work team were positively disposed to psychoanalytic thinking, having two child psychotherapists employed in the service under the CAMHS umbrella, and perhaps this would not be the case for other social work teams.To ascertain whether the findings resonated with child psychotherapists outside the setting, an online webinar with 50 UK child psychotherapists (working in generic and specialist services) was conducted. Overall, the different identities resonated with participants, and balancing the child’s internal and external worlds. Several perceived the setting as ‘privileged’ compared to their workplaces: in this setting, child psychotherapy was valued by both teams; LAC CAMHS had flexibility to work with children for extended periods; and there were two child psychotherapists in the service. Several participants, operating as a lone child psychotherapist in their service, commented they found it difficult to hold onto their discipline-specific identity. Participants thought the smallness of the LAC CAMHS team was perhaps beneficial in reducing tensions between colleagues. Further research could explore practice in other settings, such as large, generic CAMHS.

The findings of this study have implications for how social care can make use of child psychotherapists’ conceptual knowledge, particularly connecting the child’s internal and external worlds. Their role of attending to social workers’ feelings was also valued by social workers. This suggests a role for child psychotherapists to facilitate reflective practice spaces and contrasts with the shifting focus they reported, with the local authority requesting more therapy.

The findings also have implications for child psychotherapists in this field. To facilitate effective collaboration with social care, they need to consider the timeliness of interventions. This study found that social workers may not be receptive to child psychotherapists’ interventions when there is a pressure to act, such as unexpected placement breakdowns. It may be that at these times social workers need to hold on to defences in order to keep practising, by focusing on practical tasks. For child psychotherapists working alongside social workers, the provision of sustained thinking spaces may be more pertinent to developing reflective practice skills. Potentially they can then apply principles of ‘thinking prior to action’ (Cregeen, 2008, p. 186) in crisis situations.

At a service delivery level, the CAMHS team used a ‘phase-in-phase-out’ approach rather than closing and reopening cases. This contrasts with typical mental health practice, which often recommend a specific number of sessions. Using a ‘phase-in-phase-out’ approach may benefit children in care, who may value the continuity of an ‘open door’ to return later. Furthermore, network professionals can access mental health services with a rich understanding of a child’s history, available for consultation even when therapy is not active. For the mental health service, using this approach may lead to less re-referrals. While this can only be said tentatively given this was a case study, future research could establish the feasibility and cost-effectiveness of using this approach more widely within targeted mental health services for children in care.

This is the first research study to explore how child psychotherapists function in a specialist CAMHS team, in a social care setting; demonstrating their discipline-specific contribution, and their role in multi-disciplinary and multi-agency collaboration around children in care. Once the therapist gains an understanding of how the child’s internal world has been influenced by their external world, the challenge is then not only to work with the child to arrive at some understanding of this, but also with the professional network involved in the child’s care. Once this is achieved and the child’s psychological life is at the forefront of network thinking, the best decisions will be made on behalf of the child. The second challenge is to form strong working relationships with allied professions including social care, and this involves mutual respect of professional roles and responsibilities while acknowledging the unique contribution of psychoanalytic thinking.

Acknowledgments

We would like to thank the CAMHS and social care teams who participated in this study. Particular thanks go to the two child psychotherapists who were so generous in allowing their practice to be observed.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This study was conducted as part of a PhD study, that was funded by a UCL Impact PhD studentship, with financial support from the Association of Child Psychotherapists.

Notes on contributors

Fiona Robinson

Fiona Robinson is a Research Fellow in the School of Health & Psychological Sciences at City, University of London, UK.

Nick Midgley

Nick Midgley is Professor of Psychological Therapies with Children and Young People in the Research Department of Clinical, Educational, and Health Psychology at University College London (UCL), UK. He is director of the Child Attachment and Psychological Therapies Research Unit (ChAPTRe) at the Anna Freud National Centre for Children and Families/UCL.