Our Keyworkers are an important part of a young person’s support network, working to avoid hospital admission and helping them to live the life theychoose. Some of the young people we support have given permission to share their stories of how our Keyworkers have built a trusted relationship withthem and supported them along a journey of change.
A young autistic person has been having support from a Keyworker for the past three months. They have been having significant difficulties successfully accessing medical help for their mental health and have spent time in and out of hospital settings.
The Keyworker has spent time getting to know the young person, at their own pace which allowed them to start to trust their keyworker and to speak about their experiences growing up and the trauma related to this. By actively listening and validating the impact that these experiences have had on the young person, they were able to start to think about how they can move forward. The young person had support to express their thoughts and feelings. They have expressed that they now understand the importance of their experiences and how their insights could help others. This has led to the individual developing a report, highlighting the challenges Autistic people face, especially trying to get help with their mental health in hospital settings.
This is a powerful document that they haven’t shared with professionals yet but want to do so with the support of their Keyworker. It will, hopefully, impact on the future experiences of others and drive change in their care and treatment.
Sally is a 15-year-old girl (pronouns she/her) who lives at home with her mum, dad, older sister and younger brother. Sally enjoys academic studies and will do exam papers ‘for fun’. She is a very accomplished Cello player and enjoys art.
In year 8 she started to struggle socially with friendships, although academically always achieving high standards in top sets. Sally found it difficult to spend time with her ‘old friends’ who she had known for a long time. She started to experience heart palpitations, and this was followed up with medical investigations with ECG and assessments, however it was concluded that Sally was having panic attacks.
In summer 2023 Sally’s mood and presentation to others changed noticeably and she was low in mood with no motivation for anything. She disengaged with most things, was self-harming and felt she couldn’t attend school.
In January 2024, the community mental health team supported Sally, and she was diagnosed with Autism. In March she stated she had plans to end her own life. There were concerns of a burn and shewas admitted to hospital. While in hospital she stopped eating, and she was supported by the eating disorder team.
Polly is a 16-year-old girl who currently lives away from her family in a care setting. She is passionate and bubbly, though she does express that she has overwhelmingly low days. Her mental health is becoming a concern to her and those around her, particularly because she has self-injurious behaviours. Polly is open about her worries and things she would like to improve. Family and friends are incredibly important to Polly, but she often feels a sense of responsibility for the adults in her life and takes on a care giving role to younger family members.
A referral was made to our service through the CETR process. During the CETR, it was deemed that Polly’s actions were down to anger from trauma and loss. They made the decision that it was the right time for a Keyworker to start supporting. Once Polly was matched with a keyworker, they spent time learning about ‘who is Polly’ and stepping away from the documents that were written about her. It was clear that Polly was passionate about her family, incredibly funny and lovely to be around. She was clear about what she wanted, what she was willing to do and what she was not willing to do.
Sally is a 15-year-old girl (pronouns she/her) who lives at home with her mum, dad, older sister and younger brother. Sally enjoys academic studies and will do exam papers ‘for fun’. She is a veryaccomplished Cello player and enjoys art.
In year 8 she started to struggle socially with friendships, although academically always achieving high standards in top sets. Sally found it difficult to spend time with her ‘old friends’ who she hadknown for a long time. She started to experience heart palpitations, and this was followed up with medical investigations with ECG and assessments, however it was concluded that Sally was havingpanic attacks.
In summer 2023 Sally’s mood and presentation to others changed noticeably and she was low in mood with no motivation for anything. She disengaged with most things, was self-harming and felt shecouldn’t attend school.
In January 2024, the community mental health team supported Sally, and she was diagnosed with Autism. In March she stated she had plans to end her own life. There were concerns of a burn and shewas admitted to hospital. While in hospital she stopped eating, and she was supported by the eating disorder team. In Sally’s room parents found a diary and drawings that she had done saying shedoesn’t fit in, doesn’t understand other people’s humour and doesn’t like her reflection in a mirror.
The hospital unit was 4 hours’ drive from Sally’s home; parents and family would visit every other day and even had ‘holidays’ local to the unit so that they could spend time with her. Sallys parents areboth from large families and they all spent time together, which was important for Sally. Sally went on regular ‘leave’ from the unit with her family.
Sallys parents (as under 18 years) gave consent to an introduction to the keyworker collaboration. Sally engaged well with the keyworker and she able to share her wishes and feelings. She requestedthat the keyworker advocated on her behalf when her assigned advocate was not available.
Sally had a care education treatment review (CETR) meeting which brought everyone together to consider a longer-term care plan, what was working well, what was not working so well and whatneeded to change / happen.
Sally’s parents were actively involved in the planning and attended their own training on understanding Autism and weekly meetings with Sally’s therapeutic team with and without Sally present asappropriate for the work.
To support a return home, Sally stayed in a unit near to her home (now only 30 minutes away from her family home).
Sally has been successfully discharged from the unit with a clear plan formed by everyone involved with her support and most importantly led by Sally and her parents.
She has settled at home well and is happier with herself. She has reconnected with ‘old friends’ and has started to show interest in returning to some form of education. The keyworker will continue tosupport Sally in what she feels her next step will be, including education and any other areas she feels she still needs support with. The keyworker was able to be part of Sally’s journey from hospitaladmission to returning home and then support in the community. Having this involvement meant that Sally was always being “heard” as the keyworker was able to ensure she was always the focus ofall care planning. Sally has consistent support from the keyworker which helped when she transitioned from one unit to another, from hospital to community and then when community servicesstepped back, this had the positive impact of potentially reducing Sally’s time in hospital and supporting to reduce risks and potential relapses when back home.
Polly is a 16-year-old girl who currently lives away from her family in a care setting. She is passionate and bubbly, though she does express that she has overwhelmingly low days.Her mental health is becoming a concern to her and those around her, particularly because she has self-injurious behaviours. Polly is open about her worries and things she wouldlike to improve. Family and friends are incredibly important to Polly, but she often feels a sense of responsibility for the adults in her life and takes on a care giving role to youngerfamily members.
A referral was made to our service through the CETR process. During the CETR, it was deemed that Polly’s actions were down to anger from trauma and loss. They made thedecision that it was the right time for a Keyworker to start supporting. Once Polly was matched with a keyworker, they spent time learning about ‘who is Polly’ and stepping awayfrom the documents that were written about her. It was clear that Polly was passionate about her family, incredibly funny and lovely to be around. She was clear about what shewanted, what she was willing to do and what she was not willing to do.
The keyworker saw Polly every week. Polly said she found it difficult communicating with all the professionals in her life. Together they thought of ways for her to do this comfortablyand as she enjoys writing and typing, they personalised a digital diary on a glitzy USB for her to write down her feelings, worries and achievements. Polly then started sharingWhatsApp messages and emails directly with her social worker.
Polly was unexpectedly moved from where she was living but because communication with her social worker had significantly improved and she had the constant of a Keyworkershe managed this transition well. During the settling period of her new home, Polly encountered some tricky relationships to navigate. This led to an increase in concern aboutbehaviours that were a risk to herself and others. The Keyworker helped the professionals involved to understand Pollys need to be able to build a relationship slowly. Theypracticed unconditional positive regard with every incident that occurred to help build Pollys trust. They started communicating electronically with her and passing notes under herdoor. With her love for writing, Polly reacted well to this and started to let staff know when she needed a little more support and became more receptive to their advice aroundphone usage, boundaries and relationships.
The Keyworker helped Polly to complete her Person-Centred Plan which gave people a much deeper understanding of who Polly is and what she wants for her future.
Polly now attends college 3 days a week, she has a stable and positive home environment, she can clearly communicate her needs and now understands how to make thisaccessible for her.