Defining youth-centred practice in mental health care

Abstract

Background

Like many other nations, the rates of mental illness among children and youth have risen. Youth and emerging adults (YEA) between the ages of 16 and 25, in particular, have the highest rate of mental health disorders of any age group leading clinicians and researchers to ponder new and innovative ways to treat mental ill health (1–2). Youth centred practices (YCP) have emerged as possible new approaches in youth mental health care to better treat YEA living with mental illness, but also to empower this population to take control of their wellbeing. Despite the growing use of the term ‘youth-centred,’ there is little consensus on what this looks like in mental health care for youth. Using research coming out of MINDS of London-Middlesex, we explore how mental health professionals, including clinicians, researchers, administrative staff, and trainees, understand the term YCP and how they implement youth-centredness in practice.

Methods

Using a Youth Participatory Action Research framework as a guide, MINDS’ researchers worked alongside YEA research assistants in all phases of research. Participants were selected from a pool of known practitioners and mental health programs utilizing YCP, as identified by YEA research assistants. Qualitative focus group and interviews, developed using an appreciative inquiry approach, were conducted with 13 mental health care professionals, staff, and trainees to ascertain how they understand and practice YCP. Researchers conducted a codebook thematic analysis of the data: five themes and fourteen subthemes were identified.

Results

Our analysis identified five main themes: (1) Acknowledging YCP’s Role in Supporting YEA Mental Health; (2) Developing Authentic and Meaningful Relationships Between YEA and Care Providers; (3) Collaboration in Care: Engaging YEA as Active Agents in their Treatment; (4) Creation and Maintenance of Accessible Service to Facilitate YEA Engagement; and (5) Moving Beyond Tacit Knowledge to YCP as a Trainable Construct. Underlying each of these key components of YCP was a thread of recognition that systems of care for YEA must be responsive to the unique needs of those the system intends to serve. This process is seen as dynamic and fluid; often representative of societal change and growth, the specific needs of YEA will remain in flux and YCP approaches require continued reflexivity.

Conclusions

When YCPs are used in mental health care, YEA and their lived experiences are respected by trusted adults on their care team. At the core, YCPs are collaborative. There is a shift from the dynamic of “practitioner as expert” to one that provides YEA a sense of agency and autonomy to make informed decisions regarding their care.

Background

In Canada, youth and emerging adults (YEA) between 15 and 25 have the highest rate of mental health disorders of any age group (1–2). Not only does 70% of mental health problems occur during childhood and adolescence, but mental illness also remains the second most common cause of death in this age cohort (1, 3–4). Adolescence and early adulthood represent a time of considerable neurological and psychological development, as greater independence and its associated responsibilities manifest in considerable social adjustment [5–7]. This development, along with environmental factors, can result in increased personal stress and a greater susceptibility of developing psychological ramifications and provide a fertile environment for the initial emergence of a variety of forms of mental ill-health (8–9). The COVID-19 pandemic exacerbated mental health challenges for YEA, with and without prior mental health diagnoses, leading to increased rates of social isolation, anxiety, and depression [10].

While YEA represent the biggest age demographic accessing mental health services in Canada, there remain several factors and barriers that can challenge or limit appropriate access to care for YEA living with mental ill health (2, 11–12). For example, YEA often report navigating the system to be difficult; they are unaware of where to go for help, what types of services are available, or how they are able to access them. Administrative requirements and red tape to be navigated for admission to certain programs leads to inaccessibility– particularly for those who are without a general practitioner. Concurrently, wait times for those were able to successfully navigate the system are often measured in months, if not years, and there are few, if any, interim supports provided for those needing specialized care. Many of these interim supports are uninsured (e.g., private counselling) and also have wait lists (for a detailed overview of barriers, see 12).

A common challenge for YEA accessing mental health care is the transition from child to adult services that often occurs at or around the age of 18 [13]. This transition for youth is often fraught with significant upheaval, including a possible change in setting and practitioners that can lead to a gap in services [14]. YEA entering the ‘adult’ system may experience a change in the level of support and autonomy they may or may not be ready for depending on their developmental, rather than chronological age [15]. To combat the struggles in this transition of care, some communities have developed programming and care that supports youth and early adults beyond the age of 18. Integrated youth health care sites have also been established in Canada and abroad as ‘one-stop shops’ for youth to address a variety of needs, including mental health and addictions [16–18]. Although there is considerable variance among these types of programs both nationally and internationally, a common attribute many of these models have is the application of “youth-friendly” approaches [18]. The adoption of youth-friendly practices, as it relates to mental health care, refers to the provision of healthcare services that are accessible, acceptable, and appropriate for young people [19]. These types of practices acknowledge that YEA have unique needs and concerns and that the healthcare environment must not only accommodate these needs, but make YEA feel comfortable seeking and receiving mental healthcare [11]. Youth-friendly practices, like traditional forms of healthcare, ensure confidentiality and privacy, but also aim to uphold non-judgmental attitudes and include young people in decision-making about their own health [16–18]. Overall, youth-friendly practices aim to provide mental healthcare that is more appealing and responsive to the needs of YEA.

Like youth-friendly practices, youth-centred practices aim to improve mental healthcare services for YEA. Youth-centred practices (YCP) go beyond making mental healthcare services friendly and accessible and emphasize the active engagement and participation of YEA in all aspects of their healthcare needs, including the design, delivery, and evaluation of the services they use [20]. YCP draws on the work of positive youth development theory and practices (PYD). PYD realizes that youth are better able to thrive and contribute to the social world when they have material resources and meaningful and supportive relationships [21]. Using the theory of PYD, being youth-centred means working with youth as collaborators or partners in decisions that impact youth rather than developing strategies for youth (21–22).

Broadly, YCP is a form of person-centred care that is specifically focused on the unique needs of YEA. Person-centred care approaches focus on the person as opposed to their condition or illness, and promote dignity, respect and compassion [23]. Historically, young people (including those in the youth care system or in transition to the adult care system) have not been viewed as agents of change in their own care. Their capacity to be involved in decision-making due to age and severity of symptoms has been questioned [24] and practitioners are often balancing the perspectives of parents/caregivers who are often still heavily involved in the provision of care [25]. Instead of practitioners and other adult allies deciding what constitutes a youth-friendly and accommodating approach, YCP acknowledge YEA as the experts in their own lives and advocate for their involvement in decision making processes that affect their health and well-being. By considering YEA as experts in their own lives, practitioners utilizing YCP can promote the empowerment of youth to take control of their healthcare goals and decisions [22]. Specifically, these practices require a deep understanding of the unique needs of YEA and encourage agency among YEA, building their voices into healthcare policies and practices [26].

MINDS of London-Middlesex

The Mental health INcubator for Disruptive Solutions (MINDS) of London-Middlesex, is the first Social Innovation Lab in Canada dedicated to addressing the complex mental health system challenges facing YEA through the strategic development and evaluation of high-potential solutions tempered by the principles of youth-participatory action research (YPAR; see [27] for an overview of YPAR in the MINDS’ lab; [28–29]). Consistent with YPAR practices, YEA with lived experience of mental illness are employed as researchers and co-facilitators in all MINDS’ activities. YEA work within the MINDS’ lab across the lifespan of all projects– from initial inception, co-design of innovative solutions to mental health and addiction challenges faced by YEA, development of research protocols and engagement with research practices, through to manuscript preparation. Social innovation is based on processes of systems and design thinking tools to harness various sources of knowledge and expertise– with an emphasis on lived experience– to understand and work toward solving highly complex problems that have not been adequately addressed by more conventional or traditional approaches (30–31). The MINDS lab begins with the premise that the approaches and structures currently in place to prevent, identify, and treat mental ill-health are not nearly sufficient and beg re-examination.

As part of the social innovation process, MINDS engaged in a series of sensemaking activities including interviews with YEA who had lived experience in the mental health care system and the caregivers, to better understand the complex problem of mental ill-health from the perspective of the user. Sensemaking activities seek to explore or “make sense” of the current state of a system using various modalities, of which interviews is one [32]. Initial interviews identified multifarious gaps in the mental healthcare system, but among the most often cited was the interpersonal experience YEA had with their health care providers [30]. Many YEA reported feeling that their voice was unheard, their opinions and needs were disregarded in favour of the clinicians’ and care team’s push to discharge, and that the care providers themselves were disingenuous. Conversely however, YEA and their caregivers repeatedly identified that when a Child and Youth Care (CYC) worker was included in their care team, they felt that they had an ally in their mental health care journey, who genuinely and authentically cared for them. This connection and relationship with CYCs was highlighted as contributing positively to their mental health.

The importance of CYC workers on youth care teams aligns with extant research on models of engagement that combine youth decision-making and caring adults that promote lasting positive effects on mental wellbeing. YEA thrive when they are listened to, respected as contributors, and engaged meaningfully by the people and institutions in their world [21, 33–36]. This type of connection and relationship references a “youth-centred” approach to care, or (YCP), that is contingent upon actively involving YEA in decision making surrounding their care. This type of involvement is traditionally measured as either: a) the direct engagement of YEA by a service provider; or b) an open communication framework in which the voice of YEAs holds power within the organization structure (or a combination of the two; 38). Active involvement of YEA in their care, and the development and maintenance of strong and supportive relationships between care providers and YEA, has consistently been linked to better service outcomes. In part, this involves “de-labelling” of YEA and treating them as a whole person as opposed to the singularity of their experience as patient or case number [21, 37]. There are limits to the impact of strong and supportive relationships that cannot “compensate for lack of material resources” but they “have the potential to open up new networks and to provide opportunities for emotional connection and attachment; factors that reflect positive outcomes in adulthood” [21, p. 161].

Although there is a general understanding of what it means to be youth-centred in practice, there is currently no formal training for care providers to develop this effective and impactful approach to care. The goal of the present work is to translate the tacit knowledge of experienced mental health care providers identified in initial sensemaking activities as embodying and embracing a youth-centred approach to care into an operationalized definition of what constitutes YCP from a mental health perspective. Through our initial sensemaking activities with experienced mental health care providers, we aim to identify what it means to embody and embrace a youth-centred approach to care and develop an operationalized definition of what constitutes YCP from a mental health perspective.

Methods

Study design and recruitment

The present study employed a mixed methods design utilizing a Youth-Participatory Action Research (YPAR) framework to guide development and an Appreciative Inquiry approach to inform and direct qualitative evaluations of YCP in practice. As described above, YEA with lived experience of mental illness are employed as researchers and co-facilitators of all MINDS’ activities. The participation of YEA in sensemaking activities at MINDS ensures our practices align with the theoretical underpinnings of the YPAR approach by promoting social equality and amplifying the voices of YEA in work that directly impacts them. Indeed, sensemaking activities with YEA were used to identify that participant sample for the study (described below). YEA were further involved in the design, data collection, and evaluation of the study and resulting data. Appreciative Inquiry as a process is used to examine, identify, and further develop practices and policies by shifting focus away from identifying problems and instead highlighting strength. This approach was used to informed the interview process through the use of questions and open-ended dialogue intended to uncover existing strengths, advantages, and opportunities in YCP, by tapping into the implicit and/or non-formalized aspects of care participants provide (for an overview see [38–40]).

Data were collected from: (1) mental health care professionals (including community- and hospital-based clinicians); (2) clinical support staff; and (3) CYC workers and CYC trainees. Individuals were eligible to participate in the study if they were: (1) working with YEA as a clinician or clinical support staff in an identified community- or hospital-based mental health care program; (2) CYC workers or CYC trainees; (3) based in the City of London or surrounding Middlesex county, Ontario, Canada; and (4) able to provide informed consent. Using a purposive snowball sampling method, YEA and their caregivers engaged in sensemaking activities nominated and identified mental health care professionals, clinical support staff, CYC workers, and CYC trainees working within community- and hospital-based programs or treatment services that were deemed to be engaged in YCP– i.e., they were described as being particularly “youth-friendly” and as having a positive impact on the YEA’s experience and journey in the mental health care system. Five potential participants representing one individual mental health care worker and four identified organizations were approached to discuss potential participation in this study via email. Organization representatives subsequently connected research team members with an additional twenty-three participants via email. Interested individuals were provided with information outlining the purposes and details of the study. Individual interviews or focus groups with individuals from within the same program were conducted after obtaining informed consent. Participants were recruited into the study until thematic saturation was reached based on recurring discussions and consensus among the research team.

Ethical considerations

Written informed consent was obtained from all participants after they were given time to review the Letter of Consent and have any questions or concerns addressed. This study was approved by Western University’s Office of Human Research Ethics and Lawson Health Research Institute (HSREB #112741, ReDA #5294). Research conducted in accordance with the Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans.

Data collection

Interviews were conducted either individually [1] or as focus groups (3; 2–5 participants per focus group) for individuals from the same community- or hospital-based mental health care program/training as available. Individual interviews lasted 60 min and focus groups lasted 120 min. Interviews were conducted in the community- or hospital-based setting of the mental health care program/training. Interviews were conducted in a semi-structured open style intended to facilitate the transfer of tacit knowledge and encouraging participants to share all aspects of YCP from their perspective. Specific topics of interest were covered in the interview including participant’s personal and professional understanding and experience with YCP; what a youth-centred approach to care entailed; where and how they gained knowledge of YCP; and how YCP was embedded into their own professional care, as well as the mental health care program/training they were a part of.

Qualitative analysis

All interviews were conducted and transcribed by the research team. Prior to engaging in an in-depth analysis of the interviews, the research team met to disclose their own personal biases that may be brought into the analysis of the project so that they may be challenged by other researchers during coding and thematic extraction. Interview transcripts were read in-depth by researchers to facilitate deep immersion in the content of the interviews. Using Codebook Thematic Analysis researchers individually revisited each interview and began to identify potential codes. Researchers subsequently came together to discuss the themes that they noted as emerging and identify appropriate codes (i.e., label, description, what identifies that code, and examples from transcripts). This information was used to develop ain in-depth coding tree and codebook, after which all interviews were coded.1 Themes were finalized through the final coding of the interviews and in-depth discussion between the reseachers. MINDS’ YEA research assistants with lived experience in the mental health and addiction care system (as current or past patients) were intimately involved in this process, providing key insights into analysis and interpretation of the data. The initial coding tree consisted of seventeen main domains: treating YEA as individuals, actively listening to YEA, meaningful engagement, working with YEA, modelling behaviour, setting boundaries, meeting expectations, empowering YEA to make their own decisions, exercising freedom, YEA as experts in their own experience, meeting YEA where they are, recognizing barriers to care, individualized care, training in YCP, reflection, adaptation in practice, and community engagement. Researchers discussed the coded data to define and refine the five themes subsequently identified (see Table 1 for a list of all themes and associated codes). Following the discussion between the authors, consensus of thematic saturation was reached.

Table 1.

Themes and associated Codes– YCP thematic analysis

Theme	Associated Codes
Acknowledging YCP’s Role in Supporting YEA Mental Health	i. ii. iii.	Treating YEA as individuals Training in YCP Community engagement
Developing Authentic and Meaningful Relationships Between YEA and Care Providers	i. ii. iii. iv.	Actively listening to YEA Meaningful engagement Working with YEA Meeting expectations
Collaboration in Care: Engaging YEA as Active Agents in their Treatment	i. ii. iii. iv.	Empowering YEA to make their own decisions Exercising freedom YEA as experts in their own experience Individualized care
Creation and Maintenance of Accessible Service to Facilitate YEA Engagement	i. ii.	Meeting YEA where they are Recognizing barriers to care
Moving Beyond Tacit Knowledge to YCP as a Trainable Construct	i. ii. iii. iv.	Modelling behaviour Setting boundaries Reflection Adaptation in practice

Results

Sample characteristics

We interviewed a total of 13 participants. All participants were community- and hospital-based mental health care practitioners, staff, and trainees located in London, Ontario. Six participants held clinical roles (i.e., psychiatrist, psychologist, social worker), five were trainees, one was an administrative staff member, and one was a researcher involved in clinical interaction. Participants have been labelled in the text according to their most active roles as clinical practitioners (CR), trainees (TR), frontline staff (FR), and researchers (RR).

Qualitative exploration of youth-centred practice

Five main themes (14 subthemes) related to YCP were identified by the research team over the course of the analysis: (1) acknowledging YCP’s role in supporting YEA mental health; (2) developing authentic and meaningful relationships between YEA and care providers; (3) collaboration in care: engaging YEA as active agents in treatment; (4) creation and maintenance of accessible service to facilitate YEA engagement and (5) moving beyond tacit knowledge to YCP as a trainable construct. Key components of each theme are highlighted below and include salient and representative quotes2 from study participants. Participants real names have been replaced with pseudo-initials to protect confidentiality.

Acknowledging YCP’s role in supporting YEA mental health

YCP aims to understand, prioritize, adapt, and tailor care to the unique needs of YEA; enhancing their experience as they navigate the mental health care system. As this practice is not yet widespread, a push toward the inclusion of YCP framework in training is warranted.

Prioritizing youth

Youth-centred practitioners believe that central to YCP is prioritizing the youth– as an individual– above all else. However, the current system prioritizes numbers over individualized YEA care. As one participant states, “we prioritize helping the patients as opposed to getting people out the door which seems to be the modus operandi of some other institutions” (CR1).

Other interviewees further criticized the ‘one size fits all’ approach that undermines individualized care. A trainee noted “there is so much grey area in the field; we can’t be in black and white thinking. It’s that puzzle piece or cookie-cutter treatment that’s black and white… each child is not [a] cookie cutter shape” (TR1). Clinicians, they stressed, must be flexible (see III. Collaboration in Care: Engaging YEA as Active Agents in their Treatment).

Participants underscored that the understanding of ‘youth’ is ever-evolving, both socially and developmentally, requiring practitioners to remain agile and reflexive. One participant highlights,

To recognize that it’s evolving just like anything else, right? Because what might be seen as some of the core principles [today], five years from now could be [quite different]. Generations change and pretty soon what might have been built [as practice for a youth-centred organization] is going to be like looked back on, and in five or ten years [people are reflecting], ‘well that’s not necessarily relevant to the kinds of needs, or changing demographic’. [It’s about] staying agile; it’s staying on top of it; it’s staying aware; it’s recognizing that it grows, it changes and that we all have to reflect on that (CR2).

They also indicated that service providers should guide YEA toward continued positive progress through understanding and addressing each individual’s needs and bridging gaps in care. The overall impression is:

that most kids… do well if they can. So, if they can’t and they’re not doing well, it’s because they can’t. No one wants to be the bad kid. So, everything for me comes down to looking at their experience and figuring out what’s the lagging skill and it’s just all about skill development from there (TR2).

If YEA struggle, participants argued, it is rarely from a lack of effort but rather a lack of sufficient support. Systemic failings create significant barriers that are more readily attributable to difficulties that YEA face, rather than any limitations inherent in the YEA themselves. Compassionate, thoughtful, and autonomy-affirming care is seen as key to helping youth thrive.

Desire for formalized training and practice

All participants noted they practiced youth-centredness without formal training, instead relying on trial and error to refine their approaches underscored by a desire to continually reflect and adapt. Youth-centredness exists as tacit knowledge that only some have the opportunity to access.

One clinician, who works with YEA experiencing recent onset mood and/or anxiety disorders, expressed concern about recruiting new staff who embrace and embody the YCP mindset:

Where are we going to find the clinicians who are going to be able to work like this? There is so much of the training, not just of psychiatrists but of social workers and psychologists… that teach people the things you need to know to do good clinical work and to make your own clinical decisions with the patients instead of following some stupid formula that doesn’t necessarily apply to the individual sitting in front of you (CR1).

Likewise, a clinician with a career dedicated to youth mental health explains, “there [were] very few people that actually worked there as clinicians that had any kind of formalized training or demonstration of passion for working with youth” (CR2).

Although participants developed individual YCP methods, they desired formal education and practical training to establish a flexible, adaptable framework for youth-centredness in care. In their view, such training would strengthen organizational structures to better support youth and the professionals serving them.

Developing authentic and meaningful relationships between YEA and care providers

Strong, trusting relationships between YEA and their care providers– includingall staff YEA interact with– are essential to YCP. By genuinely connecting with YEA as individuals rather than reducing them to a list of symptoms, practitioners establish bi-directional trust, laying the foundation for effective care.

Humanity

Participants repeatedly emphasized that meaningful relationships are a cornerstone of YCP. A community worker and college instructor reflected, “… anytime I am engaging in youth-centred work I first have to start by forming some kind of connection, relationship and learning who this person is, who this youth is opposed to this youth” (CR3). Beyond simply connecting, providers must treat each relationship as unique and individualized. Community workers described their connections with YEA as “… strong and supportive”, characterized by “authenticity, genuineness; [the] two key elements of… a therapeutic relationship” (CR3). The importance of these relationships is heavily featured in a local CYC college curriculum. One course instructor stated “…we spend a lot of time on… the therapeutic relationship and building a relationship individually with each youth that we work with” (CR3).

Rather than relying solely on case files, workers stressed the need “[to get to] know the youth one-on-one. People are different in a relational context… so, I wanted to set the precedence that you’re not a file to me you’re a human being…” (TR3). This approach does not dismiss clinical and community care standards, but instead challenges the detachment often associated with file-based approaches; exploring youth as complex individuals and not as a series of check boxes. This can be a difficult process that requires an ‘unlearning’ on the part of the service provider. One community practitioner stated, “it takes self-reflection– and particularly on the part of the adult– because… it can be quite superficial… without having… examined your own assumptions” (CR2). In this way, practitioners can “shift the lens and the approach from a case number and a diagnosis, to a person and an experience” (TR3), fostering deeper engagement.

Something as simple as personal, real-time communication such as moving away from automated systems, to having staff personally responding to YEA via phone or text messages goes a long way in making youth feel valued. Other organizations that use text messaging as a form of communication often

… claim to be texting, and will send you text reminders, but even in those cases, it’s like an automated system… I think the game-changer for us is that it’s a real person that is texting with you… We’re actually sitting and responding to people and so that’s a huge component of youth-friendliness here too (RR1).

This simple, but meaningful, human touch reinforces YCP, fostering trust and accessibility.

Trust

Trust is a crucial element of relationship-building. According to one clinician “…so much of psychotherapy is building the alliance, figuring out how to build trust” (CR1). Establishing true trust requires intentional engagement– practitioners must actively create opportunities for connection:

to make that time, you have to be purposeful about your direct engagement because it might not happen otherwise… you have to be intentional about making time for those connections… just listen and learn a little bit more about what the kids are saying (CR4).

A key factor in fostering trust is ensuring youth feel validated and understood. One practitioner emphasized the impact of demonstrating “I see you; I hear you, you matter… you are special, you matter, you are very important” (CR4). Although some of the steps toward building trust are rather simple, the actual building of trust can be a lengthy process, particularly with YEA who may initially appear uncooperative. By treating YEA as social agents of change rather than simply as passive recipients, providers strengthen relationships. One child and youth care trainee mentioned the significance of consistency in development of relationship, demonstrating the belief to YEA that

… you are a human being, and you’re able to make mistakes or treat people; however, you want to treat them. But I am going to be here for you regardless of you treating me as an actual human being versus a piece of dirt on the floor. I am going to be here. And by showing up and building that trust that I’m not going anywhere, you can’t scare me was really prolific in the relationships that I built (TR3).

One common fear among youth in treatment is that they might ‘age out’ of services. A local clinic works to alleviate this anxiety,

[youth will say] “Oh, I am approaching age 25 are you guys going to kick me out?” and I’m glad they’ve given me the opportunity to clarify that for them. But it’s… sad because it’s indicative of the state of affairs everywhere else, right? You get eight sessions, and you’re gone. You turn eighteen, and you’re gone. Being able to assure youth that they will not be dismissed went a long way in gaining their trust… reminding them that we are going to be here for as long as they need us…as long as it’s working still, and we are getting somewhere. I think that’s reassuring for them (RR1).

The most direct way to build trust is through honesty. Managing expectations about treatment is essential:

not over-promising because I’m not going to fix anyone… it’s just not even relevant to the conversation, although some people come here with the expectation that they are going to come here and the doctors going to fix them that’s just not how it works (CR1).

By setting clear, realistic expectaction at the outset, providers ensure youth understand what care entails, and where and what boundaries exist.

Openness/therapeutic alliance

Authenticity is essential in building connections with youth. One CYC their role as one of engaged listening, “it’s an investigation but not an intrusive one, it’s a curiosity and a real intention to be present, to be there with that person but to also not be in the way, not make it about you” (CR4). Rather than making assumptions about youth and their needs, service providers should create space for youth to express themselves; “It’s not for [service providers] to make assumptions but to be able to have [youth] initiate that conversation and initiate those expressions of needs and not [for service providers to be] rescuing” (CR3). Balancing professionalism with authenticity is key to open dialogue,

[…] sometimes you have to step out of that professional barrier to relate to a prickly child to be like, ‘yo, man, I completely get it’; and you just have to work with that disclosure as carefully and still remain professional, but also, people don’t want to talk to textbooks… They want someone who has been experiencing what they have or something close to what they have, for someone to say you’re not the only one (TR3).

Without an authentic persona, service providers struggle to build the trust necessary for an effective therapeutic alliance, and this alliance is essential for positive outcomes:

You can’t go through a counselling relationship if you don’t have that connection with that counsellor, and it’s similar with our work, we have to have that respect and recognize that we may be triggering that client by our appearance, by our mannerisms and we need to let the client direct that (CR3).

Collaboration in care: engaging YEA as active agents in their treatment

Effective care planning for YEA requires a collaborative approach. YCP requires actively involving YEA to foster autonomy and avoid a prescriptive hierarchy that may overlook YEA’s personal experiences.

Youth engagement in care planning

To encourage autonomy and facilitate adherence to treatment programs, all participants stressed that YEA need to be active participants in their care. Practitioners note that they are “not pulling the wagon” but rather,

helping that youth get to the place they need to go by giving them the tools and the strategies to be able to get there. Because it’s not going to have any lasting impact if you are doing all the work for them even though that can sometimes be easier and quicker to get from A to B. They need to be doing that work to feel invested in that journey and to feel the importance of that journey. [It is the job of the practitioner to provide] support. […] Youth-centredness is being that collaborative support in [the EA’s] journey. Not doing all the tasks along the way (CR3).

Another participant describes keeping youth engaged in their care:

Making sure that you are working alongside the youth. Not working for the youth. You are working in tandem with them to achieve their goals and consistently checking-in with them. Making sure that they are okay with the interventions, [that] their voice is being heard (TR4).

Collaboration in care planning ensures YEA have input, “When a youth is in care, they are expected to have an opportunity to have input on what their cares going to look like, what their goals are, [and] their future directions” (CR3). The rationale for this approach was summarised “if the client isn’t interested in that goal, it’s not going to be successful… if they don’t want to do that treatment it’s not going to work. It has to be what they want and what feels good for them” (TR1).

Sharing power

An key aspect of collaborative care is the reducing the inherent power imbalance in the adult-youth hierarchy by emphasizing shared power. Put succinctly, “that key in youth-centred practice is the youth-centred. Programming, planning, and interventions are consistently collaborative. Stripping down that adult hierarchy of: ‘I’m the practitioner, you’re the client, I am going to mandate what interventions happen’” (TR2; emphasis added) and instead placing it “on the youth, not on [service provider’s] ideas of what’s good for the youth, but what they would like to see in their own lives” (TR5). The acknowledgement and intentional dismantling of that hierarchy ensures that the needs and wants of YEA are observed and met. By involving YEA in the planning, implementation, and evaluation, their perspectives are recognized, leading to greater empowerment and innovative insight into existing problems. However, shared power does not mean unrestricted autonomy; YEA must still work within the necessary confines of the system. The goal is to balance decision-making with essential care guidelines. One community practitioner emphasizes the need for,

balance. But I think there also has to be youth and clinicians or adults or workers arriving at that together, right from the get-go… As a partnership and as new programs are being designed from the get-go or new interventions, and programs are being added into, that there’s actual autonomy… (CR2).

Clinicians must deliberately and consciously return power to youth; a process that requires a degree of self-awareness and unlearning:

one thing that I tried to consciously do is to keep giving that power back… - very consciously, and recognising when I might sort of be automatically making the decisions, and then kind of going, oh wait, wait, oh wait, that was not my place to do that. Even though I think this might be the right thing to do, that doesn’t necessarily mean that that was the right thing to do for the group that was involved (CR2).

Facilitating agency and choice

The forethought to present youth with choices throughout their care is a primary component in YCP. Youth must be recognized as having the right to make decisions– with guidance to facilitate informed choices. One practitioner highlights this need to for autonomy and,

recognizing that people have choices, and people are going to exercise their choices. We in fact want to promote young people to exercise their freedom to make choices because that is empowering them… How can we work with you to figure out what you want, and how can we get you there?… [The role of] a clinician is not to tell people what to do. [But] to provide them with options and to the best of my ability predict the potential outcomes of those choices… my job is to give people choices and to inform them about the consequences… I often say to people, ‘look, you’ve stopped your medication; I can’t make you take your medication. It’s your choice whether you want to take your medication or not. Let me tell you what might happen, and so you can have your eyes open for that possibility, in which case you might want to consider a different course of action’ (CR1).

The ability to make choices fosters a sense of control over their care, “and of ownership because a lot of the clients… have people who are making those decisions [for them]” (CR3). Presenting youth with the opportunity, information, and guidance to more thoughtful and informed choices in their care is,

hugely about empowering people and facilitating agency. That’s how people get better… people [can’t get] better without that. Young people are that age where they’re just developing [agency], that is so much more critical in what [service providers] do. [It] is integral in all communications: ‘You’re the agent. Here are some choices, what would you like to do? Here are some possible outcomes of those choices’ (CR1).

However, facilitating agency requires sensitivity to how YEA, particularly those who history of trauma, may react to choice. A trauma-informed approach helps elucidate what types of choices a youth may be ready to respond to:

One of the things I’ve learned from [working from a] trauma-informed [approach]… is sometimes too many choices is too much. But even limit it to three options that are viable, even that can be too much. [Individuals] who come from trauma are afraid to select anything… [so it’s important for them to be] “a participant in that choice process and allow[ing] them to see that it is safe. ‘So you’ve made this choice, and then look at what happened.’ And so not to just make the decision and then walk away and think we’ve done our job because we gave them a choice. We have to recognize the angst, the pain, the fear that can be wrapped up in making a decision for themselves when they have experienced that from a traumatic thing in their life. And that sometimes takes years to move through that” (CR4).

Creation and maintenance of accessible service to facilitate YEA engagement

Numerous barriers exist within the mental health care system; YCP stresses the need to eliminate obstacles that impacting the system as a whole, and specifically those that hinder YEA. Traditional forms of communication and sterile hospital-based environments often limit accessibility. Instead, flexible, youth-oriented approaches ensure services are relevant and usable.

Recognizing and removing barriers

Barriers to care exist in all settings; it is necessary to examine the unintended or overlooked barriers that inadvertently limit YEA’s access. One care provider stressed the importance of “being accessible in ways that are relevant to youth” (emphasis added); for example, using alternative forms of communication youth are willing to engage with such as “email or to text” (LH). Many YEA experience difficulty with standard approaches, as they are accustomed to digital communication. One practitioner reflected on this challenge:

it just became painfully obvious that requiring [youth] to make phone calls was never going to fly. Then it became obvious that emails weren’t going to fly… if you’re paying attention you’ll notice that certain things become unacceptable… and you just have to adjust… and say okay well apparently that mode of communication is out of bounds, now let’s try something else” (CR1).

The ability to pivot is key– “staying agile, it’s staying on top of it, it’s staying aware, it’s recognising that it grows, it changes…” (CR2). Without mindful awareness, barriers remain unrecognized and unaddressed.

Simultaneously, clear boundaries within services must be maintained, but in a way that acknowledges the circumstances and needs of YEA. Practitioners adhere to certain established structures: “the sessions begin at a certain time, the session ends at a certain time… and nobody else’s [the YEA’s] agency is going to change that” (CR1). This allows adult allies to remain “predictable to the patients and people know what to expect. There’s a structure that exists to ensure trustworthiness and safety and predictability” (CR1). However, within these boundaries, barriers that might otherwise prevent YEA from engaging are reconsidered. As one student reflected,

there are always going to be rules and structure and you don’t have to alter them you just have to help the [YEA] reach them in a different way. It’s levelling the playing field not lowering the bar… but you’re going to have to help them reach the bar in a different way (TR2).

This is first accomplished by recognizing that,

a lot of it is just understanding the developmental stage of young people and recognizing that they are doing complicated adult things for this first time in their lives… and you can’t have the same expectations of [someone] whose been in the adult world for [a] decade (CR1);

it is also “having a level of patience for their age and just having to manage their calendars for this first time on their own and developing independence” (FR1). For instance, one frontline staff member highlights how effective self-referral can be for a YEA just embarking on adult life; jumping through the established hoops of the traditional medical system “can be a big door in the face before you even try to receive treatment” (FR2). Maintaining more traditional referral streams places the onus of finding a first line care provider who acknowledges their struggles and difficulties with the brevity they deserve,

It’s like you’re finally like ‘okay, I admit I need some help’ and then it could be really complicated with who to get a referral from and ‘who do I talk to?’ and ‘what is my doctor doesn’t believe me?’ (FR2).

Self-referral underscores autonomy and highlights an inherent level of trust from practitioners; implicitly acknowledging “it is as serious as you believe it is… we believe you, you don’t have to get a referral from a doctor for us to actually trust that you are not doing well” (FR2). Furthermore, YEA should not be unduly penalized for missed appointments. It is established “in most aspects of the healthcare system there is quite a substantial fee if you don’t show up for an appointment” (CR1) which disproportionately effect YEA due to financial constraints. Instead, the local community service “reduced [penalties for missed appointments] in recognition of the fact that these are young people who may be working minimum wage jobs and we reduce it even further if they are on social assistance… [or] if they are unemployed” (CR1). The purpose of these programs is to provide service to youth and applying additional barriers will only serve to drive youth away. On the other hand, removing barriers within the structure of reasonable boundaries reflective of the needs of YEA, provides needed space to not only get youth in the door, but to keep them coming back.

Physical space

Ensuring accessibility– beyond, but inclusive of, the traditionally understood and implemented physical accessibility (i.e., automatic doors, handicap parking, ramps, etc.)– includes physical space that is warm and welcoming:

when we made the transition from [the hospital] to this location, it made a huge difference to the people coming to see us. They really appreciated that it was a much more youth friendly place… it actually makes a huge difference being in a house on the community (CR1).

Developing a warm and welcoming environment also goes beyond just bricks and mortar; it is established by the consideration and awareness of the frontline staff who,

try to keep an eye on what the stress level is… I just try to make them feel comfortable, so if they need to come into [the conference room] if that’s an option before their appointment we do that. If I can get the clinician to take them a little bit early… I want to respect what they are asking of us and I think it makes them feel comfortable… I have to work at it, but I think about it so that what they are greeted with here is kindness… that’s what I can offer them (FR1).

Instead of leaving patients waiting to be called for their appointment after a brief and impersonal initial check-in, intentionally monitoring the needs and wants of the patients the moment they enter the space creates a more accepting environment.

Moving beyond Tacit knowledge to YCP as a trainable construct

Engaging in YCP is an evolving process, adapting to the shifting needs and expectations of YEA shift across time and context. Practitioners must remain reflexive to these changes, adjusting their approach as needed, weaving genuine care and compassion with professional boundaries and expectations. Modelling of this behaviour is an important component of ensuring YCP continues in all aspects of care.

Social emotional learning competencies

Respondents lamented that it can be easy to get caught up in the bureaucracy and politics of the organization they work for, that can create environments that interfere with compassionate care. One service provider articulated how these pressures can cause practitioners to lost sight of their core purpose,

we can get stuck in the roles and the policies and practices and the stress […] sometimes we lose track of why we are there… we get busy in every milieu of practice we work in… and not recognizing it’s about the care of that client (CR3).

Another described how prioritizing organizational administrivia over relational engagement can diminish the quality of care:

often where we look back and go, ‘okay, I had a good shift today because I finished all of the stuff I needed to do’ as opposed to ‘how did I utilize that environment to best leverage opportunity to connect and to learn about the children and the youth that we are serving’ (CR4).

Participants emphasized that YCP requires true self-reflection of service providers, ensuring their own emotions and perspectives do not unduly influence their interactions with YEA. While participants did not explicitly reference social-emotional learning competencies, they often described the need for self-awareness, emotional regulation, and relationship management. One respondent detailed the internal dialogue they use to remain self-aware: “What is influencing you? What are your biases? What are your preconceptions? What are your lived experiences? How does that impact positively or negatively in interactions with our clients?” (CR3)–continually reflecting in the moment as to how experiences and biases can shape interaction, collaboration, and treatment planning.

Extending beyond mere reflection, providers must engage in “self-regulation… emotional regulation” (CR4), and being intentional and aware of how their own emotional state can unduly create or exacerbate stress for those they are working with. Of note, “it’s the emotional climate that [is] created” from something as simple as “how [someone is] standing, talking, or looking [at others], or not” (CR4). By managing their own emotional responses, providers can provide more supportive environments. However, providers are not “robots”; it is profound when a provider is able to acknowledge their own humanity;

it’s okay to say ‘you’re right, I’m having a bit of a challenging day today… you noticed that maybe I was a little off today. Thank you for noticing’. It’s another opportunity to model that I’m going to do what I can to deal with these feelings that I’m having, because I’m a person just like you (CR4).

By modelling this response to emotional dysregulation, service providers can connect more meaningfully and respectfully with those they serve. This transparency allows YEA to see that emotions can be acknowledged, processed, and managed constructively.

Professional boundaries

Service providers must establish clear professional boundaries with those they serve. Although this may seem counterproductive, boundaries essential for developing a healthy dynamic. One practitioner stressed, “it’s about creating a space, intentionally and again… knowing that those boundaries are about me as a human being vis-a-vis you as a human being” (CR2). Boundaries protect both YEA and service providers; without them, lines between professional and personal relationships can blur– particularly as many practitioners genuinely care about the youth they work with. The depth of care can lead to over-involvement. A clinician stated “we are drawn to our field, we are very high empathy and often some lived experiences that really contribute to that care and that need to make a difference and sometimes we can get a little lost in that” (CR3). Maintaining clear distinctions prevents emotional exhaustion and allows practitioners to focus on guiding youth rather than taking on roles they are not equipped for. This is highlighted as

model[ing] what professional boundaries look like… we’re very empathetic; we want to support and help, but [sometimes] that’s not our role. We’ve got to stay in our lane and make sure we’re taking them to those resources that are there for them” (CR3).

Professional boundaries help to create a safe space for both parties preventing the confusion that can occur otherwise and provides YEA with a sense of realistic expectations of the relationship.

Maintaining professional communication

Effective communication is central to maintaining boundaries while engaging youth in meaningful ways. Practitioners emphasized meeting youth where they are, “communication is being respectful, being honest, us being authentic, being present”, and speaking at a level that is appropriate, doing away with “jargon”, and “ensuring that they recognize how we are saying it, the tone that we are saying it, the rate, the pace that we are saying it.” When, for example, “engaging with clients where English isn’t their first language, [taking the time] slow it down. And being mindful of some of the isms that we use” (CR3). Nonverbal communication is just as important as verbal. A strong working relationship includes, “demonstrating empathy, reading the non-verbal’s, being mindful of our non-verbal’s, eye-contact, respectful eye-contact, being present, being approachable, being clear, asking open-ended questions some of those really easy tangible things and how impactful they can be” (CR3).

The words practitioners choose also play a significant role in how youth respond. Something as seemingly innocuous as “throw[ing] in the word, ‘but’. It means I’ve just disregarded everything before the word but… Same with the word why. So, if you’re talking, and you say, ‘why did you do that?’ That immediately [leads the youth to feel] defensive.” They prescribe a simple solution: “take the but out, don’t use the word but. Just don’t say it. Continue your sentence and watch how that changes [the response you get]” (CR4).

An additional layer of tension can arise for service providers as they navigate a fitting balance of “proper vernacular” with more relaxed and youth-friendly slang. This tension is highlighted by workers who note

we expect this professional communication in your role as a professional and also recognize that there may be a time and a place where texting lingo is appropriate with the youth you are working with. Particularly if it’s an environment that is utilizing social media as a way of engagement” (CR4).

This is especially relevant in digital interaction, where youth are more comfortable with casual messaging. A formal and prescriptive text can make youth feel that they are texting an “automated system” and the importance of ensuring the YEA know “that it’s a real person that is texting with you… actually sitting and responding; that’s a huge component of youth-friendliness” (RR1).

Importance of modelling behaviour

Modelling appropriate behaviour is essential in training of practice that is youth-centred. Outside of formal training sessions, much of this learning happen implicitly, through observing and practicing interactions in real-time. One practitioner described it as developing, ”very specific skill sets… that become very natural… for engaging cooperation, for behaviours that are starting to escalate… Specific phrases to use… to acknowledge someone’s feelings but also manage some behaviour.” (CR4).

An emphasis is placed on shifting of perspective, to understand the impact of one’s own actions and reactions on the youth they serve. Individuals must take the time “to recognize the impact of their behaviour [from] both a professional and personal lens. It is also about evaluating the effectiveness of their efforts” so that they may be iterated upon and refined (CR4). Practitioners must constantly remind themselves “that it is not about me and what I know; it’s about [the youth] and what I don’t know, yet” (CR4). This perspective shift ensures that interactions remain focused on the needs of the youth rather than being driven by assumptions or agendas of the service providers.

Modeling behaviour should occur at every level of an organization, including administrative staff, who are often the firs point of contact. One clinician emphasizes the significance of these roles, “how important people who answer the phones, greet you at the door, really are. These people need to have clinical skills. They don’t need to have credentials, clinical licences necessarily. But they sure as hell have to have clinical skills” (CR1).

Discussion

The present work examined the various concepts, behaviours, and cognitions inherent within a youth-centred approach to care from mental health care practitioners, support staff, and trainees who work for community- or hospital-based programs, identified by YEA with lived experience, as engaging in Youth-Centred Practice (YCP). Qualitatively, appreciation for the work of YCP, naturally involves an explicit understanding that a youth-centred approach to care has significant positive implications for YEA who are seeking and using mental health care services. This ubiquitous thread, found in all interviews, is perhaps unsurprising, as it is well-established that YEA have better experiences of care and report better outcomes when they feel they are being listened to, respected, and involved in their treatment planning (20, 21–22, 26, 41). However, for a variety of reasons including lack of resources, limited time allotted, and clinical burnout, YEA are often left feeling unheard, and as though they are deemed less knowledgeable about their own experience than the individuals who are treating them. The results from the current paper add to a growing body of literature that highlights the importance of youth-centred approaches to care that increase patient retention, adherence to treatment protocols, and better short- and long-term outcomes [42–45].

Participants in the current study consistently highlight the importance of building strong and authentic relationships with the YEA they serve, as a key component of quality care. Our results suggest that the hallmark of these relationships is an underlying and genuine respect for YEA, displayed through trust, openness, and connection. Building of trust with YEA can take a significant amount of time, particularly when those YEA have experienced a breach of trust, or a discarding of their lived expertise in the past. Fostering trust requires care providers to remain steadfast in their dedication toward developing this relationship, while balancing the clinical needs of the YEA under their care. This can cause tension, as providers may at times need to make decisions surrounding care that the YEA is not in agreement with. Service providers who approach treatment planning with an intention of sharing power shift the naturally occurring power dynamic toward one of collaboration. Maintaining open and clear communication is key to navigating this more novel dynamic; providing an opportunity to continue cultivating an alliance with YEA, while also ensuring that they are active participants their care. Mental health care providers should present treatment options while being direct about the potential outcomes of each treatment scenario; thus, providing YEA with the information and guidance to develop an informed approach to their own care. YEA who are involved in their care planning and feel as though they are being listened to routinely report better clinical outcomes [21]. Establishing trust in relationships with care providers enables YEA to exert autonomy, which in turn helps them to establish their voice.

Although crucial, building authentic and meaningful relationships and collaboration in care, require that YEA are utilizing the services that are available to them; however, as authors, we would be remiss not to acknowledge that access to service is directly linked to social structures (organizational, societal, political, monetary) that either facilitate or obstruct YEA’s ability to engage [15]. Participants in the present study reflect that the willingness and ability of clinicians, support staff, planning committees, and so on, to recognize and remove barriers within their control that prevent YEA from accessing and engaging in care, is instrumental. For instance, as we continue into an increasingly digital age, participants report that there is clear desire from YEA to be able to communicate and access services in non-traditional ways (e.g., texting, or online booking systems, compared to speaking to someone on the phone). Other barriers to care may be more difficult to navigate and require larger structural changes. The current study illuminated the efficacy of locating mental health care programming outside of the hospital setting where possible. The clinical setting of a hospital can sometimes feel unwelcoming or overwhelming for some patients, whereas the integration of services into community space has been frequently associated with positive outcomes [16–18]. It is essential that organizational structures and conventional approaches be examined with a critical lens; and that they are challenged and disrupted when no longer serving the community for which they are intended.

Finally, formalized training that serves to impart the tacit knowledge of mental health care providers experienced in YCP, would allow for a broad framework to describe YCP and their application. Our research identified five key themes in YCP as it relates to youth mental healthcare, many of these constructs are present in some form in the extant literature regarding person-centred care, youth-friendly practices, and/or positive youth development [16–18, 20–23]. The work contained herein provides extension, deeper contextualization and understanding of how the individual components and processes relate to one another to form what we recognize as YCP. It provides an operational definition of the various components of YCP with provisions around incorporating those into daily practice. Importantly, this work notes that YCP is a teachable construct and provides directives to guide the development of YCP programming. The recognition that YCP is something that can be learned, may not seem particularly novel, but it represents the capacity for direct action and impact. MINDS’ researchers are in the process of refining these learnings into a training program. It is important to note that while the five themes identified in this body of work can help to provide training in YCP, these components of YCP should not become formulaic and should remain flexible, creative, and innovative.

The adoption of a YCP should maintain diverse perspectives as YEA each have unique needs, preferences, and experiences and populations differ across cultures, regions, and contexts. Participants revealed that YCP ought to be ever evolving as new methods, goals, priorities, and services are adapted to best suit the needs of YEA. This means tailoring mental healthcare services to the specific needs and contexts of young people and reflecting both personally and socially to adapt to changing local and cultural contexts. Lastly, when adopting YCP, it is paramount that mental health professionals maintain a participatory approach that emphasizes the active involvement of YEA in decision-making processes. Inherently, this means that the definition and framework of YCP is collaborative. When mental health care professionals adopt YCP as a part of their practice, YEA can experience increased independence, efficacy, and resilience in their mental health care, as well as allow them to develop stronger and deeper quality relationships with their health care providers. Practitioners engaging in YCP should foster deeper connection with their clients and as a result create a more welcoming and open environment for youth experiencing mental health and addiction difficulties.

Importantly, research suggests that youth-centred approaches displayed at the organizational level directly impact the degree of youth-centred care that is provided by individual providers [20, 23]. Organizations wishing to embrace a youth-centred approach to care need to commit to meaningfully placing youth at the center and recognizing them as diverse and autonomous stakeholders [45]. Without the guidance and definitive support from leadership, service care providers may not take the initiative to engage, or understand the benefits of engaging in YCP, as the organization has not made it a priority. Clinical services providers, in particular, have limited time and resources allocated toward professional development– and a lack of support at the organization-level can lead to gaps in knowledge and understanding.

Limitations

This research aims to provide a framework for using YCP in a mental health setting servicing YEA. We provide an operational definition of the term YCP and outline how this might be achieved in practice using the practical experiences of clinicians and trainees working in the youth mental health field. Although this is the first known study to operationalize YCP for YEA accessing mental healthcare, there are some limitations to the research. First, our sample of practitioners, clinicians, and trainees is not random. Participants were selected based on nomination from YEA who have accessed mental health and addiction care services within the local community and snowball sampling. Participant selection thus did not include practitioners, clinicians, and trainees who self-nominated as engaging in YCP, which would have provided an additional perspective. Additionally, the sample is limited to one large Canadian city in Ontario. The location and size of a given locale might impact the ability of clinicians and practitioners to provide YCP. Smaller communities, including rural areas, may have differing abilities to provide YCP and this could impact perceptions of what it means to provide these types of services to YEA. Access to mental health services in rural communities is often marred with challenges such as clinician shortages and transportation issues.

The purview of this work was intended to provide a conceptualization and operationalization of what YCP is. The scope of this work thus, did not examine the various intersectionalities (e.g., race, gender, sexual orientation, class) of YEA and how that may necessitate adjustments in the implementation of YCP to reflect the unique needs of YEAs based on their identity/intersectionality. Future work should seek to engage in a sensemaking activities to better understand the impact of intersectionality on care provision for YEA of varied intersectionalities, and the way in which care providers are addressing that with YCP. YCP may provide a fruitful opportunity to begin dismantling of oppressive systems within mental health care, enduring YEAs are able to access services that tailored to their unique experiences.

Further, our sample only draws from those working in mental health programs and did not include other practitioners, like primary care physicians, nurse practitioners, and social workers, working in non-mental health care settings (e.g., family care settings) that support youth with a variety of healthcare concerns. Similarly, community mental health care providers not covered by OHIP (e.g., private counsellors or social workers) were not included in this research, though they may practice YCP.

Lastly, while the mental health professionals and trainees interviewed in this research study have a wealth of experience and knowledge, most do not provide services to YEA experiencing more severe forms of mental ill health, such as psychosis and schizophrenia. This population of YEA may have different needs and what it means to apply YCP might look different than what we have described. The next phase for MINDS of London-Middlesex (MINDS 2.0) research aims to remedy this limitation and seeks to make sense of complex mental health and addictions, not included in the current research.

Conclusions and future directions

This study provides valuable insight into the various aspects and components of a youth-centred approach to care and the importance of YCP for practitioners and YEA receiving care. The exploration of YCP through this study contributes to the definition and recognition of the concept of YCP. YCP is an approach to care that values and promotes YEA voice, autonomy, decision-making, and most importantly, the expertise in YEA’s own lived experience. Centering care planning around YEA agency and lived experience allows for the collaboration of youth with care providers to be a partnership of deep trust and mutual respect. YEA are thought to be more likely to flourish when practitioners engage in this approach to treatment and according to one clinician from this study this is relationship is not only rewarding for the youth, but also the practitioners “…young people get better. And it’s incredibly rewarding… they are in a development stage where they can just blossom into fantastic, wonderful human beings from having felt defeated and so undone by their mental health concerns” (CR1). Further work is required to expand our understanding of how intersectionality of YEA necessitates change in the provision of YCP, and how YCP can be used with YEA facing more complex mental health and addictions challenges– to ascertain not only what this might look like but how it might differ among different YEA populations. Researchers at the Mental health INcubator for Disruptive Solutions (MINDS) of London-Middlesex aim to research and develop innovative solutions for assisting YEA facing complex mental health and addiction challenges in the next phase of their research.

Abbreviations

CYC

Child and Youth Care

MINDS

Mental health INcubator of Disruptive Solutions

PYD

Positive Youth Development

YCP

Youth–Centred Practice

YEA

Youth and Emerging Adults

Author contributions

AC, EC, and AGM conceived of and designed the study. AC and EC collected data. AC and RH performed all data analysis with assistance from EC and JS. AC and RH wrote the paper with support from JS. RH and AC completed all revisions the the manuscript. All authors (with the exception of EC who passed before the manuscript was completed) read and approved the final manuscript.

Funding

Funding for this study was provided in part by: St. Joseph’s Health Care Foundation London, Frayme Learning Through Living, and the Social Sciences and Humanities Research Council Insight Grant.

Data availability

The datasets analysed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

Written informed consent was obtained from all participants after they were given time to review the Letter of Consent and have any questions or concerns addressed. This study was approved by Western University’s Office of Human Research Ethics and Lawson Health Research Institute (HSREB #112741, ReDA #5294).

Consent for publication

N/A.

Competing interests

The authors declare no competing interests.