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\title{Youth Offending Teams: A Grounded Theory of the Barriers and Facilitators to Young People Seeking Help from Mental Health Services}
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\begin{document}

             \author[1]{Alexander R  Hassett}

             \affil[1]{  Canterbury Christ Church University, UK}

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\date{\small \em Received: 7 December 2017 Accepted: 31 December 2017 Published: 15 January 2018}

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\begin{abstract}
        


Young people within the youth justice system experience three times higher rates of mental health problems than the general youth population yet are one of the least likely groups to seek help. Very little theory or research is available within this population to explain these high rates of unmet need. The study aimed to develop a theory about the barriers and facilitators that Youth Offending Team workers experience when supporting young people to access mental health services. Eleven semi-structured interviews were conducted with participants; eight Youth Offending Team workers, two young people and a mental health worker. Interviews were audio-recorded and transcribed verbatim before being analysed using ?"grounded theory?". This method was chosen to allow the in depth exploration of participants experiences and the development of theory within an under researched area. Youth Offending Team workers appeared to play a crucial role in supporting a young person?s help seeking from mental health services. A preliminary model was developed which demonstrated the complex relationships between six identified factors which influenced this role. Youth Offending Team workers would benefit from more support, training and recognition of the key role they play in supporting young people to become ready for a referral to mental health services. Mental health services could be well placed to provide this. Clinical implications are discussed. Further research is needed to develop our understanding of what influenced the help seeking of this vulnerable population.

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\let\tabcellsep& 	 	 		 
\section[{Introduction}]{Introduction}\par
Author ?: Salomons Centre for Applied Psychology, School of O emotional and attentional disorders \hyperref[b28]{(NACRO, 2007)}. Despite high rate of distress, YP within the YJS are one of the least likely groups to seek help for their mental health needs  {\ref (CAMHS Review, 2008)}. 
\section[{a) Definition of help seeking}]{a) Definition of help seeking}\par
The World Health Organisation study of adolescent help seeking \hyperref[b2]{(Barker, 2007}) defined help seeking as:\par
"Any action or activity carried out by an adolescent who perceives herself/himself as needing personal, psychological, affective assistance or health or social services, with the purpose of meeting this need in a positive way" (p.2).\par
Rickwood, Dean, Wilson, and Ciarrochi (2005) emphasised the need for social interaction with another person in order to obtain support, advice, information or treatment. 
\section[{b) Patterns of help seeking in children within the youth justice system}]{b) Patterns of help seeking in children within the youth justice system}\par
Severity of mental health symptoms and level of functional impairment do not appear to predict professional mental health help seeking (Wahlin \& Dean, 2012; Lopez-Williams, Stoep, \hyperref[b25]{Kuo, \& Stewart, 2006)}. Instead, a range of other factors appear to have an influence. Those aged between 16-18 years old are at particularly high risk of non-help seeking \hyperref[b5]{(Campbell, 2013)}. In the UK and North America, demographic factors such as being male, from an ethnic minority, having low socio-economic status or low education level, are further risk factors for non-engagement in mental health services \hyperref[b11]{(Feitsma, 2010;}\hyperref[b25]{Lopez-Williams et al., 2006)}.\par
Youth Offending Teams (YOTs) were established as a result of the implementation of the Crime and Disorder Act (1998), with the aim of moving away from punishment towards addressing factors that led to YP offending \hyperref[b22]{(King, Brown, Petch,\& Wright, 2012)}. To improve access to health services for this population, YOT teams have at least one health professional who can conduct assessments and interventions and support referrals to specialist mental health services. However, despite having a legal obligation to attend a YOT, many YP do not fully engage with services that these teams offer \hyperref[b22]{(King et al., 2012;}\hyperref[b29]{Naylor, Lincoln, \& Goddard, 2008)}. 
\section[{c) Risks of non-help seeking}]{c) Risks of non-help seeking}\par
Unmet mental health needs in adolescence predict chronic disorders in adulthood (The Mental Health Act Foundation, 2007) and are associated with poor quality of life, social-isolation, poor physical health, early death and suicide (O'Connor, Martin, Weeks, \& Ong, 2014; \hyperref[b32]{Rickwood et al., 2005)}. For YP within the YJS, disengagement or discontinuity of forensic outpatient care has also been associated with reoffending and (re)conviction \hyperref[b11]{(Feitsma, 2010)}.\par
Non-attendance at CAMHS appointments has also been described as having an impact on the cost effectiveness of services by wasting time and resources that could have been utilised by clients more likely to take up or continue with interventions \hyperref[b11]{(Feitsma, 2010;} {\ref Dalton, Mjor, \& Sharkey, 1998)}. 
\section[{d) Theoretical models of help seeking}]{d) Theoretical models of help seeking}\par
Although not extensive, a number of theoretical models have been developed to explain patterns of mental health service use in YP. The models range in focus from factors relating to the young person \hyperref[b3]{(Biddle, Donovan, Sharp, \& Gunnell, 2007)}, to more dynamic and social models of help seeking \hyperref[b32]{(Rickwood et al., 2005}; Costello, Pescosolido, Angold,\& Burns, 1998; \hyperref[b27]{Murray, 2005)}.\par
Rickwood et al.  {\ref (2005)} described a model in which a young person's help seeking process begins with the young person developing an awareness of their difficulties, then articulating it to others if there is an available source of help that the young person is willing to disclose to; a process whereby the "personal becomes increasingly interpersonal" (p.8).\par
Research exploring the experiences of YP within YOTs appear consistent with  {\ref Rickwood et al.'s (2005)} model. \hyperref[b40]{Walsh (2010)} found that YP were most likely to seek support from people they had long lasting relationships with. Barriers to developing relationships with people included issues with confidentiality, stigma and not feeling understood. \hyperref[b22]{King et al. (2012)} found that YP saw talking and help seeking as a beneficial coping strategy but were reluctant to talk about their feelings due to difficulties with trusting others.\par
Research with YP within the YJS more generally have found a number of other barriers that may impact on such a help seeking process including; previous trauma  {\ref (Paton, Crouch,\& Camic, 2008)}, negative experiences of services  {\ref (Vaswani, 2011)}, stigma \hyperref[b21]{(Howerton et al., 2007)} and low emotional competence \hyperref[b32]{(Rickwood et al., 2005)}. 
\section[{e) Social models of help seeking}]{e) Social models of help seeking}\par
A growing body of theory and research is moving away from a focus on YP towards exploring the influence of systemic and organisational factors on their help seeking processes. Costello et al.'s (1998) Revised Network Episode Model (RNEM), emphasises the influence of family beliefs and attitudes on YP's help seeking and the role that an adults' recognition of problems has on whether help is received or not. \hyperref[b27]{Murray (2005)} contributed to theoretical models by describing a process of 'problem legitimisation'; whereby adult help givers not only need to recognise, but need to legitimise distress as an issue for which the young person can seek help.\par
Recent research offers support to social theoretical models by demonstrating that factors associated with adults around a young person may actually have more influence on YP's help seeking than factors associated with YP themselves \hyperref[b37]{(Stiffman et al., 2001)}.\par
How and when other people influence YP within the YJS is not well understood \hyperref[b22]{(King et al., 2012)}. What is known is that many do not regularly attend school, have poor parental supervision and tend not to be registered with a GP \hyperref[b5]{(Campbell, 2013)}. Therefore, it is a requirement of youth offending professionals to have sufficient knowledge, training, and support to be able to support YP with mental health needs and their families (Youth Justice Board, 2008). They are expected to be sensitive to YP's barriers to accessing mental health services and to work to reduce negative perceptions of them  {\ref (Abram, 2007)}. However, available research has shown that YOT workers can feel unsure about how to assess and support a young person with mental health problems \hyperref[b25]{(Lopez-Williams et al., 2006)}. Staff vary in the perception of their role and responsibility for making referrals as well as in their confidence in their own skills and abilities to support the process and manage organisational barriers (Knowles, Townsend,\& Andersen, 2012). 
\section[{II. Rationale and Research Questions}]{II. Rationale and Research Questions}\par
Despite an increase in emphasis on supporting the mental health needs of YP within the YJS, there continues to be high levels of unmet need and very little research conducted to explore what may be influencing their help seeking for mental health problems \hyperref[b36]{(Stallard, Thomason,\& Churchyard, 2003;}\hyperref[b22]{King et al., 2012)}. In particular, there appears to be a lack of research in YOTs, where young people are least likely to engage with services \hyperref[b22]{(King et al., 2012)}.\par
Research suggests that factors related to both the young person and key adults around YP influence YP's help seeking. Therefore, the present study aimed to explore the process of help seeking in YP within YOT's by exploring the experiences and perspectives of both YP and YOT workers, to develop a better understanding of the factors which facilitate or create barriers to YP seeking help for mental health difficulties.\par
This study aimed to develop a grounded theory of YOT workers barriers and facilitators to supporting YP to access mental health services. Sub-questions included:\par
1. How do these factors influence the young person's help seeking process for mental health problems? 2. How do YOT workers overcome barriers to YP's help seeking?\par
III. 
\section[{Method a) Design overview}]{Method a) Design overview}\par
A qualitative approach was chosen, to allow the depth exploration of participants' experiences. More specifically, a Grounded Theory methodology \hyperref[b39]{(Urquhart, 2013)} was chosen as available data for the general youth population, indicates a process of help seeking over time. Grounded Theory is particularly useful for an analysis of process \hyperref[b14]{(Glaser, 1978)} and it also allows for the exploration and development of theory in under researched and under theorised areas such as this one (Bistrang \& Charmaz, as cited in  {\ref Cooper, 2012)}.\par
Interviews were conducted using a semistructured interview schedule. This method gave a focus to the interviews whilst allowing participants the freedom to describe their subjective experiences and beliefs in their own language  {\ref (Cooper, 2012)}. This method, along with line by line analysis of the data, aimed to give a voice to those who use and work within youth offending services. 
\section[{b) Epistemological stance}]{b) Epistemological stance}\par
The researcher used a critical realist stance \hyperref[b39]{(Urquhart, 2013)} to the data collection and analysis. Within this, the researcher was viewed as a social being who had influence on the data collection and analysis. This influence was perceived as data to be constantly compared with participant data, and interwoven as part of the analysis \hyperref[b16]{(Glaser, 2002)}. 
\section[{c) Participants Inclusion and exclusion criteria:}]{c) Participants Inclusion and exclusion criteria:}\par
The YP recruited into the project needed to be aged between 16 and 18 and have been referred to mental health services (whether they engaged or not). Exclusion criteria included; risk of physical or verbal aggression to the researcher, high risk of distress or harm to the young person and a diagnosis of moderate or severe learning disability or autism. YOT workers needed to have experience of referring a young person on their caseload to a mental health service.\par
Both groups needed to be fluent in English. Recruitment: Participants were recruited from two YOT's. One was within the London area and the other within a semi-rural part of Southern England.\par
YOT teams were approached through a project supervisor or through direct contact with YOT management. The project researcher attended YOT team meetings and made direct email contact to a number of YOT workers. Inclusion and exclusion criteria, leaflets and information sheets for both YP and professionals were distributed within a variety of YOT's.\par
Sample: Eleven participants were recruited in total. This included, two YP (one male, one female, both aged 17), one mental health worker (MHW) (male) and eight YOT workers (female). It was unclear how many YP were asked to participate by YOT workers. YOT workers described many YP as not wishing to participate. The main barrier expressed, alongside other reasons for not taking part, was a reluctance to discuss their experiences to a stranger. In addition, four YP who were put forward were deemed inappropriate as they were not formally assessed to have had a mental health problem or their risk of distress was too high.Service structures between YOT teams differed in the profession of their MHW; a forensic psychologist and a social worker. 
\section[{d) Ethical considerations}]{d) Ethical considerations}\par
The Given the vulnerability of the project population, the researcher considered the main ethical issues carefully. These included; risk management, capacity to and informed consent, confidentiality and data protection. 
\section[{e) Procedure}]{e) Procedure}\par
A flexible interview schedule was devised in accordance with the research questions. The length of interviews varied between 15 minutes and 65 minutes in duration. The comfort of the participants was of primary importance to the researcher \hyperref[b6]{(Charmaz, 2006)}. To ease participants into the interview process, the first questions were closed and information seeking. In accordance with grounded theory \hyperref[b6]{(Charmaz, 2006)}, intermediate questions aimed to be open ended to allow for exploration of participant experiences and the avoidance of the imposition of researchers' preconceived ideas. Prompts and clarifying questions were also offered throughout as ideas and issues emerged which allowed the researcher to pursue various leads and gather full and rich data. Final questions steered away from personal experiences to allow the interview to end in a normal conversational level \hyperref[b6]{(Charmaz, 2006)}, which was deemed particularly important for the young participants.\par
All interview questions were shared with two project supervisors and amendments were made accordingly. Interview questions for YP were scrutinised by YP within the youth club and amended by simplifying words, shortening some sentences and clarifying acronyms, improving their acceptability and validity. + 
\section[{f) Data analysis}]{f) Data analysis}\par
Grounded theory is an inductive method of data analysis and theory development which begins as soon as data has been collected \hyperref[b39]{(Urquhart, 2013)} and continues using a process of "constant comparison" which involved an iteration between the gathering and analysis of data. The process of analysis and theory development followed the practice described by \hyperref[b39]{Urquhart (2013)} which particularly emphasises the work of \hyperref[b14]{Glaser (1978}\hyperref[b15]{Glaser ( , 1992))}.\par
1. Interviews were audio-recorded and transcribed verbatim. The original recordings were occasionally referred back to which allowed the implicit meanings of the words in context to be analysed which may have been missed when reading the plain text (Urquhart, 2013). 2. Line by line open coding was conducted for the first seven interviews after which focused coding was used to analyse larger segments of data (sentences and paragraphs) \hyperref[b14]{(Glaser, 1978)}. NVIVO 9 was used to support the coding and analysis of the data. Invivo codes were used where possible to preserve participant's meanings and actions in the coding, increasing the "grounding" of the analysis in the data \hyperref[b6]{(Charmaz, 2006}). 3. Selective coding; whereby focused codes that were relevant to the research question were organised into more conceptual categories and sub categories. The process of "constant comparison" was employed between data and codes and codes and codes to begin to theorise about the processes in the data (Bistrang \& Charmaz, as cited in Cooper, 2012). 4. The interview schedule was reviewed at this point taking into consideration conceptual gaps and theoretical leads that were emerging in the data. Theoretical sampling also directed the recruitment of a mental health worker, which particularly allowed for the elaboration of the category "CAMHS facilitators". 5. Theoretical memo's \hyperref[b14]{(Glaser, 1978)} were written throughout data gathering and analysis and constantly compared with other data to aid the process of theory development and explore how issues within the research may have influenced this process. 6. Theoretical coding. As patterns were developed, the relationships between categories were developed into theoretical codes. The researcher referred to memo's, coding families and semantic relationships \hyperref[b14]{(Glaser, 1978}\hyperref[b17]{(Glaser, , 2005;;} {\ref Spradley, 1979)} and developed initial integrative diagrams (Strauss, 1987) to develop the theory. Theoretical sufficiency \hyperref[b10]{(Dey, 1999)} guided the end of recruitment whereby no further codes or categories in line with the research question were suggested by the data. 
\section[{g) Quality and validity}]{g) Quality and validity}\par
There are no agreed set criteria for the process and evaluation of qualitative research. However, flexible standards are available. The research used guidelines taken from \hyperref[b26]{Mays and Pope (2000)} and \hyperref[b41]{Yardley (2000)}. Reflexive processes: In keeping with a critical realist position, the researcher was aware that the collection and interpretation of evidence could not be conducted independently of the researcher \hyperref[b39]{(Urquhart, 2013)}. Therefore, the researcher engaged in a bracketing interview towards the beginning of the research process and kept a reflexive research diary. This process allowed for an honest examination of the influence of the researcher's own beliefs, actions, values, behaviour, motives and personal characteristics which could then be used within the analysis of the data \hyperref[b1]{(Ahern, 1999;}\hyperref[b16]{Glaser, 2002)}. Credibility checks: Sections of data were independently coded by one project supervisor and comparisons were discussed until they were agreed upon. The development of theoretical categories were also discussed with a project supervisor and with peers, until all parties were satisfied that the developing theory offered a "useful" model of help seeking that was "grounded" in the data, supporting its validity \hyperref[b6]{(Charmaz, 2006)}. Independent audit trail: A clear account of the data collection and analysis was recorded and included; coded transcripts, memo's, data analysis from open coding to theoretical coding and quotes corresponding to each focused code to demonstrate the fit between participant experiences and the researcher's interpretation of them \hyperref[b26]{(Mays \& Pope, 2000)}.\par
IV. 
\section[{Results}]{Results} 
\section[{a) Overview of the model}]{a) Overview of the model}\par
In total, 79 focused codes were created. These formed 24 subcategories, which in turn generated six categories; "beliefs about CAMHS", "the relationship between the YOT worker and young person", "preparing YP for CAMHS", "YOT worker role and responsibility", "CAMHS barriers" and "CAMHS facilitators". The barriers and facilitators described by participants, influenced if, when and how YOT workers referred YP to mental health services, and whether or not YOT workers believed that this would result in a successful referral.\par
Figure  {\ref 1} contains the categories and subcategories in a preliminary model. This model represents a process over time beginning from; YOT worker's initial assessment of need, to factors which influence where YOT workers direct YP for support, to a process whereby YOT workers utilise a range of strategies to prepare a YP for a referral to CAMHS, and finally to participants' experiences and perceptions of factors associated with CAMHS that may facilitate or create barriers to this process.\par
For a comprehensive description of how participants' data informed the analysis and the development of the model, the six categories and their sub categories are described in detail below along with quotations from the interviews. Not all relevant quotations could be included in the description but can be found, along with focused coding. b) Beliefs about CAMHS YOT workers held a range of beliefs about CAMHS. These beliefs interacted with their sense role and responsibility for the YP, as well their perception of the quality of their relationship. This influenced whether they supported a YP to accept a referral to CAMHS, did the work themselves, or they supported a referral to a non NHS mental health services.© 
\section[{Beliefs about the consequences of a referral to CAMHS:}]{Beliefs about the consequences of a referral to CAMHS:}\par
All participants felt that YP actively avoided being associated with mental health difficulties, labels or services for fear of being stigmatised;\par
"He wouldn't engage, because he felt that by engaging he would just be dismissed as mental" (YW1).\par
"oh people, teachers, everyone else is calling them mad, saying you're mental, but actually having to go to CAMHS, would just, confirm that" (YW2) "that's when the labels come in and that's when the YP start behaving even more like that" (YW4) Despite the fears and negative beliefs that appeared to be prevalent, all of the YOT workers described ways in which CAMHS could benefit YP;\par
"The YP I work with who work with CAMHS have found it really useful. And have built quite good working relationships with people they work with. And I think it brings, a whole new awareness I guess of themselves" (YW7).\par
The more negative the beliefs about CAMHS, the less likely the YOT worker's were to encourage YP to accept a referral. Relevance of mental health services to their needs: Many YOT workers felt that YP believed that mental health problems and service were for people with severe difficulties and were therefore unrelated to their needs; "I'm not lying, I'm not crazy, you know, I don't need so see a quack" (YW2). One young person, who said he had been having psychological therapy for depression, did not associate mental health problems with his own difficulties;\par
"Yeah, I'm, when it comes to mental health, I don't think I have very much to talk about on it, because, I am pretty sure I am sane" (YP 1). If YP did not perceive services as relevant to them, they were less likely to accept a referral. Influence of family and cultural beliefs about mental health services: All participants felt that the topic of mental health was "a bit of a taboo subject" (YW1). Many believed that because "mental is a negative word in society", and CAMHS has the word "mental" in it, that YP perceived CAMHS with the same negative stigma. In particular, engagement with mental health services was believed to be strongly influenced by the culture and beliefs of the YP's family;\par
"It very much depends on the family background" (YW2).\par
In general, YOT workers felt that parents had a negative view of CAMHS and that;\par
"You can't really make progress with the child if the parent is resistant or against it" (YW6) However, positive experiences of parental support were discussed, including by the young person whose mother had encouraged him to attend therapy; Knowledge and experience of CAMHS: Many YOT workers felt that many YP and families did not understand the purpose of CAMHS appointments and that they lacked enough knowledge needed to be able to clarify this for them;\par
" Without knowledge, YP and YOT workers were left to rely on assumptions based upon previous experiences or negative stigma which negatively influenced the likelihood that they would seek out a referral to CAMHS;\par
"when you get a young person referred to a service, they are coming with that baggage with whatever their experience of services has been in the past" (YW 3)\par
Interestingly, one YOT worker had worked closely with CAMHS in the past whilst another had increased their knowledge of mental health services during a previous career. They held more positive views and fewer fears about referring a young person to CAMHS; "So I spent a good two years going to CAMHS meeting monthly as my YP would go two or three times a week?I learnt through CAMHS, a sort of a bit about what they did....I do believe that it can do nothing g to them but benefit" (YW7) "I come from a counselling background anyway, so it always fascinates me going to the CAMHS appointments" (YW6).\par
Many YOT workers had concerns themselves about discussing and referring YP to CAMHS as they too feared negative consequences associated with stigma;\par
"basically I think that was what lead to me going to therapy was, she (mother) found out about this project and then after I didn't get into that she decided, she talked to me about going to therapy" (YP1). c) The relationship between YOT workers and young people "It's all about the relationship" (YW6): All participants described how the relationship between a young person and a professional was a key to facilitating the strategies by which YOT workers supported YP to overcome stigma and become ready to talk about mental health; "I think once you have built that relationship, they are more likely to it?rather than you meet them for the first time and then say, you have got to do this, and you have to do that or I am referring you here" (YW3) However, if the YOT worker perceived their relationship with the YP to be good and held negative beliefs about CAMHS, they were less likely to encourage a referral to CAMHS and more likely to do the mental health work themselves. If a working relationship had not developed, they appeared to refer on despite any negative beliefs. Developing relationships with young people in YOTs: All YOT workers made reference to knowledge, skills and values that enabled YOT teams to effectively engage YP;\par
"Open and transparent, and "we really do want to help people, and if we can help we will. We haven't got a magic wand, but, you know, we're here. We're not here because we want to be mean and we don't like you, we're here because we want to help, and because we have a job to do. And if we can, we will". It's as simple as that really" (YW4) "There is only a few people who actually care about their job and the work that they are doing it for and the majority of them are doing it for the money and the image. And young people notice that more than older people, no one thinks us young people do" (YP2). "Fair, firm and realistic is my way of working" (YW2). "Getting to know them, gets you comfortable". (YP1). Partnership is key: Although YP were ordered by the court to work with YOT, all YOT workers and the MHW described how YP were more likely to engage in discussions about their mental health and a referral to mental health services, if they had been a part of the process of decision making;\par
"If you can bring them alongside, that is half the battle" (YW7) "You can't do any of this work without them" (YW5). "It's got to be their identified referral, not mine, really, that's how I see it" (MHW). This need to "bring alongside" (YW6) and develop collaborative relationships, appeared to drive the type of strategies used to support a young person to become "ready" for a referral to CAMHS and was also related to how YOT workers perceived their role and responsibility for YP. Using the relationship to build rapport with other professionals: All participants discussed the importance of introducing the young person to other professionals: The relationship between the YOT worker and the young person seemed to facilitate a faster engagement with the other worker. This seemed particularly important in overcoming any negative beliefs that a YP may have had about CAMHS;\par
"when they first come we will do a meeting with us all, like us, the young person and them?So it's like, they know us already, hopefully have a positive relationship and hopefully some of that will spill over to the other worker I guess" (YW3). 
\section[{d) YOT workers sense of role and responsibility}]{d) YOT workers sense of role and responsibility}\par
Ways in which YOT workers perceived and managed their role, seemed to influence the likelihood of them seeking advice from or making a referral to CAMHS, doing the work themselves or referring to other services. This was also associated with their relationship with the young person and their beliefs about CAMHS; Managing self -expectations: YOT workers varied in how responsible, either professionally or personally, they felt they were for YP's needs; "They have had a lot of underlying ADHD, welfare, all the ingredients for offending -all the underlying stuff and we are expected to address it all" (YW2) "I had to accept was that there was a limit to what I could do" (YW6)\par
If they felt that they were not expected or were unable to do the work themselves, they were more likely to refer onto specialist services;\par
"When you don't have time to do all of those things so then it's just about, signposting I guess to other agencies really" (YW3) YOT worker distress: Some YOT workers expressed distress from working closely with YP with mental health problems and looked to the expertise of CAMHS to help them to manage their own needs. "He'd tied a ligature around his neck? so just horrendous. So at that time I was like, I can't have any more like this" (YW6). "Just more training, kind of how to look after ourselves?especially lately we have had a lot of more the complex ones coming through" (YW1).\par
YOT worker confidence in mental health expertise: Many YOT workers wanted further mental health training to enable them to assess and intervene more effectively. Those with less confidence in their skills were more likely to refer onto specialist services;\par
" "Especially with people that we have known for a long time?they don't have to explain all of that to you, so sometimes you are probably, one of the better people to talk about that with" (YW3).\par
For many YOT worker's, if they were distressed or lacked confidence in their abilities, even if the relationship between them and the YP was good, they were still likely to refer onto CAMHS. However, if they held negative beliefs about CAMHS, then they were more likely to refer onto other non NHS mental health services. 
\section[{Using the self to inform need for interventions:}]{Using the self to inform need for interventions:}\par
As well as using their relationship with a young person, a number of YOT workers described using empathy with YP to inform the most appropriate way to work with them, which at times, appeared to include avoiding a referral to mental health services; "I just think you have got an experienced bunch of social workers who know things when things aren't right" (MHW) "Because if someone's got my information, I like to know what they're going to do with it. Why should anyone be any different to me?" (YW4) 
\section[{e) Becoming ready to accept a referral}]{e) Becoming ready to accept a referral}\par
YOT workers all described a process whereby young people became "ready" to talk about mental health difficulties and to accept a referral to mental health services. YOT workers used a range of strategies to facilitate this process, which were commonly described as "stepping stones" (YW2) or "steps we can take to get them to engagement" (YW1). The strategies used appeared to be influenced by beliefs held about CAMHS, YOT workers sense of their role and responsibility for YP and the strength of the relationship between YOT workers and YP as described below; A tentative, gradual process over time: All participants described how YP needed to learn to talk about mental health problems before they were ready to accept a referral to mental health services; "It takes time, it's not just something you will say and they will say, oh yeah alright then" (YW4). "Once you learn to be able to talk to people, it is a lot easier to talk to them about it, it's a bit like training" (YP1).\par
YOT workers described needing to sensitively time discussions about mental health or a referral to services with YP;\par
"So if you just drop it in the conversation or drop it in to when they come to our meetings?so just lightly mention it every couple of weeks until, and you can do it more frequently, until they are ready to have a full conversation on it". (YW4) "You have to pick your moments?You don't offer it to them until you feel they are going to say yes" (YW7). If a trusting working relationship had developed, this process was made easier and the process moved more quickly "A door in without realising" (YW1): If YOT workers assessed YP as not being ready to explicitly discuss their difficulties as mental health problems, then they would conduct mental health assessments and interventions without letting the YP know and more likely to refer to non NHS mental health services which some felt would support YP to eventually accept a referral to CAMHS;\par
. "You are just doing it as part of your job, it's just YP then, they don't see it as mental health, it's just part of their normal YOT appointments and they feel comfortable with that and they are ok with that, you are doing it bit by bit?without them realising" (YW2) "Discretely doing it, it's kinda a bit more easier" (YW4) "we also use like another agency that is not CAMHS, it does more informal CAMHS type work?so sometimes what we do is refer to them, get them talking a little bit and then, then they may be willing to, so it's sort of a stepping stone" (YW3). Raising awareness of their difficulties: YOT workers talked about needing to support YP to become aware of having problems. To be able to do this, it was necessary at times for YOT workers to explore their difficulties without relating them to mental health;\par
" "So I think a lot of them would benefit from it, but it's about encouraging them to know that they'll benefit" (YW8). Working with negative assumptions: Throughout this whole process, YOT workers described how they were "trying to pull them out of the stigma of mental health" (YW6). Normalising, avoiding stigmatising language and explaining terminology, were key methods that supported the various strategies;\par
"Just saying mental health is a massive barrier. I think exploring that with them first. And that this is something that everyone might have an issue, that everyone has at different points in their life have different emotions and your mental health will go up and down. So normalising a bit" (YW3). "Labels...being statemented. I have to explain what that really means?'oh I am stupid' and it is not like that at all, but it's getting the support she needs" (YW6)\par
Again, if YOT workers held stigmatised views of mental health, wanted to avoid the possibility of reinforcing a YP's stigmatised views of themselves, or had not developed a working relationship, then they were more likely to avoid discussing mental health and more likely to refer to non-mental health services, like drug and alcohol services.\par
Most felt that increasing awareness of mental health in society would be key to facilitating YP's access to mental health services in the future;\par
"increasing their awareness of it, cos if they understand it then, the more easier for us, cos when they come to us, they haven't got a clue what it is, you know, it's what they assume, it's their assumptions" (YW1). 
\section[{f) CAMHS not engaging}]{f) CAMHS not engaging}\par
All YOT workers described beliefs and experiences of barriers that they faced at the point in which they referred a young person to CAMHS. These were barriers associated with CAMHS, rather than the YP themselves; CAMHS not being child centred: Five YOT workers described ways in which they believed CAMH's approach and protocols did not take YP's needs and perceptions into consideration; "If you asked YP to come up with a title for CAMHS, they wouldn't come up with that, definitely not" (YW1) "It's that the approach has been very clinical and it's not been very young person centred and it's so clinical, it's out of a text book, to the point that the young person is struggling" (YW6). "And CAMHS because they are so busy and high in demand, that they will offer one appointment and if the young person does not turn up then they are taken off the list" (YW5).\par
These barriers impacted on YOT workers efforts to support YP to 'become ready to talk about mental health' and eventually accept a referral to CAMHS. 
\section[{CAMHS do not effectively engage YOT young people:}]{CAMHS do not effectively engage YOT young people:}\par
Most YOT workers described ways in which CAMHS did not take into consideration the specific needs of YP within YOTs. This risked disengagement which YOT workers associated with negative consequences;\par
"it is just the way that they're approached and worked with, um, fortunately, it is quite a generic system so you apply and they work in a way that is one size fits all, whereas, our YP have different needs and different ways of communicating, and I don't feel that...not tailor made for them" (YW6). "Some are being assessed by CAMHS but it is taking too long, so they have ended up in A\&E for self-harm and stuff like that" (MHW). Many YOT workers felt that CAMHS were not fulfilling their responsibilities to YP; "So I know they haven't got time to keep sending out loads of appointments?But maybe there should be more efforts made to build a relationship or pursue a relationship with the young person" (YW8).\par
It appeared that YOT workers had worked hard to support YP to get to a stage where they were ready to accept a referral to CAMHS and were therefore frustrated with what they perceived as CAMHS not fulfilling their responsibility to YP within YOTs. This reinforced negative beliefs about CAMHS which, depending on the YOT workers perception of their role and their relationship with the young person, increased the likelihood that they would refer to other services or do the work themselves. A lack of collaboration between YOT and CAMHS: YOT workers felt that YP perceived CAMHS as being both physically and clinically separate from YOT; "I think that's what it is, they see it like that's the ivory tower and everyone's, we have to go there, they never come to us" (YW4) "You know, different venue, different setting. Different kind of stuff" (YW1). YOT workers also perceived CAMHS as separate from them; "I mean I think it seems to be up there somewhere, doesn't it?" (YW2) YOT workers described having to "put a bit of pressure on to get in their quicker" (YWX) when making a referral to CAMHS. The MHW felt it was his "job to try and push it up" (MHW). Descriptions like these gave an impression of having to fight a resistance from CAMHS instead of experiencing collaboration and clear pathways between services.\par
g) Facilitators to a successful referral into CAMHS Positive experiences of collaboration: Although most YOT workers described a lack of collaboration between services, the development of close working relationships between YOT and CAMHS workers appeared particularly effective at facilitating referrals;\par
"I used to go on training courses with the organisations, then I could make referrals quite quickly afterwards, because they were already susceptive to the role I am in" (YW7).\par
Those with experience of collaborative working experiences were positive about the impact this had on YP;\par
"I've learnt a lot through the assessments of the young person, what the psychiatrist has been doing with them, what the worker's going to do with them, and then if we can all work together with the young person, that's got to be better for them than all working in different ways" (YW6). "CAMHS were fantastic, because we just liaised with them?so it was upsetting, but the support in the team was really good" (YW7) The key role of the MHW: The MHW within the YOT teams were viewed as having a key role in facilitating collaboration between services and providing effective mental health interventions and support to the YOT. Being based within the YOT service and getting to know the worker was seen key to their success; "And they (MHW) obviously know more about what they (CAMHS) can do and things, as we don't know so much, I mean I do know a bit, but when you have to ring somebody or you are trying to get hold of someone its difficult." (YW8) "They don't associate MHW with CAMHS, it's completely different?they would see them as part of YOT, even though they know what they do, but they would see them under the YOT umbrella, rather than the CAMHS umbrella" (YW7) "I think they just see (name), inside of them, that they are just another person, you know" (YW4).\par
However, YOT workers and the MHW felt that having one health worker in the team was not enough;\par
Priority for YOT young people: In both services, YOT workers described having priority access to CAMHS for YP. Both described using the MHW to facilitate this process and support YP in the interim; "so they don't have to go through the GP, the normal route, and wait 6 to 8 weeks, we can do it quite quicker" (YW2) "if there is likely to be CAMHS involvement, the MHW will quite often come and meet the young person. So that, it almost acts as an interim, so that it happens quicker" (YW3).\par
Faster access into CAMHS appeared to improve YOT workers beliefs and the likelihood of referring YP to CAMHS in the future.\par
V. 
\section[{Discussion}]{Discussion}\par
This study offers a preliminary model of the barriers and facilitators that YOT workers experience which appear to influence YP's help seeking from specialist mental health services. Below is an outline of the theory and a discussion of the model and what appear to be the key relationships between factors. This will be followed by a discussion about how these relate to and extend current help seeking theory and empirical research and clinical implications. 
\section[{a) Outline}]{a) Outline}\par
The findings demonstrate that a number of factors appear to influence YP's help seeking from mental health services such as CAMHS. It appeared that if YOT workers had confidence in their mental health skills or held more negative beliefs or fears about CAMHS, then they would be more likely to do the work themselves or refer to other services. Those who had less confidence, or more positive beliefs, or perceived there to be fewer barriers, would be more likely to refer to CAMHS.\par
All YOT workers described how YP needed to become ready for a referral to CAMHS and that the development of their relationship with YP allowed them to successfully support this process. However, for many of the participants, CAMHS was experienced as imposing barriers to this process which reinforced negative beliefs about them. Closer working relationships between YOT workers, YP, CAMHS and mental health workers appeared to overcome these types of barriers and were associated with more positive beliefs about CAMHS. 
\section[{b) Links to previous theory and research}]{b) Links to previous theory and research}\par
The findings indicate that YOT workers play a key role in the process of help seeking for mental health problems experienced by YP within their services, providing empirical support to social theoretical models of young person's help seeking more generally (e.g. \hyperref[b8]{Costello et al., 1998;}\hyperref[b32]{Rickwood et al., 2005)} and offering "CAMHS sits on its own and so do social services sits on its own, YOT sits on its own. Alright I link in with CAMHS, but it is just me" (MHW) an insight into the particular factors which may influence YP within the YOT services specifically.\par
Becoming "ready": It was interesting to note how the strategies YOT workers used to support YP to become ready for a referral to CAMHS ranged along a spectrum from implicit to more explicit mental health assessment and interventions. These findings appear to demonstrate ways in which YOT workers were responding and attempting to overcome the hypothesised "cycle of avoidance" that YP experience \hyperref[b3]{(Biddle et al., 2007)}; whereby they are reluctant to assess their experiences as "real" or "normal" and need support to move towards "realisation". Some of the strategies used were similar to those described within other help seeking models such as "problem recognition" \hyperref[b8]{(Costello et al., 1998)} and "problem legitimisation" \hyperref[b27]{(Murray, 2005)}. This process was experienced as challenging for both YP and YOT workers. Many of the workers described a lack of acknowledgement, training or support in this role and there were mixed views as to whether it was their role at all. Influence of beliefs: Many YOT workers described using empathy to inform them when to conduct certain interventions which were based upon how they believed they would feel in a similar situation. Generally, this was perceived as a positive and sensitive way to support YP. However, if the YOT worker held fears or stigmatised views of mental health or CAMHS, then mental health interventions or a referral to CAMHS were vulnerable to delay or avoidance through referrals to other services. These findings support research and theory which highlight how the beliefs, preferences and fears of adults around YP can influence YP's process of help seeking \hyperref[b8]{(Costello et al., 1998;}\hyperref[b12]{Flink et al., 2013)}. Importantly, research has also demonstrated that adults around YP often make inaccurate assumptions about YP's barriers to help seeking \hyperref[b13]{(Gilchrist \& Sullivan, 2006)}, which indicates that a reliance on the use of empathy could be ineffective.\par
However, the findings also indicate that for some YOT workers, their preference for referring to informal services was actually a strategy for preparing YP for a referral to CAMHS rather than a way to avoid it. These differences highlight the importance of using qualitative methods to explore the beliefs behind particular actions, as the same action may influence a different help seeking outcome.\par
Building relationships: Research has shown that young people within the YJS are often untrusting and wary of adults around them due to negative experiences of relationships in their past leading to the development of insecure attachment styles \hyperref[b40]{(Walsh et al., 2010;} {\ref Paton et al., 2008)}. YOT workers appeared to use a number of techniques to gradually build trusting and collaborative relationships with YP within their services. Harder, Knorth, and Kalverboer (2013) found that the use of similar techniques by care workers with young offenders in a secure facility allowed them to become a secure attachment base which promoted the YP's healthy development. In the presence of a secure base, an individual feels safe enough to express distress and explore the world, including building relationships with others \hyperref[b20]{(Holmes, 2014)}. It is likely that insecure attachment styles and consequent difficulties with trust, as well as on-going difficult life experiences of YP within YOTs, could go some way to explain why engaging with CAMHS is difficult, and also why the recruitment to the study was so challenging. 
\section[{c) Clinical implications}]{c) Clinical implications}\par
The key findings from this study suggest implications for improving the working relationships between YOT teams and CAMHS, taking into consideration the specific needs of YP within YOTs. Mental health workers were highly valued as members of YOT teams. Building upon this role may be a useful way forward. In addition, it may be helpful for CAMHS to provide more training, support and advice to YOT workers about mental health and mental health services. Formal training would be one way to provide this. Improved collaboration between YOT and CAMHS may be another useful way. On the basis of the current findings, joint care planning/working whilst YOT workers are preparing a young person for CAMHS, may; provide YOT workers more reassurance in their role; allow for more reflection on the strategies used; improve clarity and accuracy of information provided to YP, and provide more streamlined and timely access to mental health services which may improve engagement. Joint working during this process may also improve YOT workers' sense that their efforts are being acknowledged, improving working relationships between them and CAMHS. 
\section[{d) Research limitations}]{d) Research limitations}\par
Although Grounded Theory does not aim to generalise to wider populations or contexts, it is worth noting that the sample of YOT workers were selfselected which may represent an interest in improving practices. It would have been informative to include YOT workers who may hold different views about how the current systems are working and of the mental health needs of YP in their care.\par
In addition, whilst recruiting YP into the project, it appeared that researcher experienced the very same barriers that YOT workers experience when engaging YP into mental health services. As a consequence, after much effort, only two YP were recruited and both had already accepted referrals to CAMHS. Recruitment of more YP into the study who had and had not engaged with CAMHS, may have provided a useful insight and comparison of experiences and beliefs about their help seeking processes and YOT workers' role within this. Given the time pressures within the project, it was not possible for participants to feedback on the results of the project which would have increased the validity of the findings. 
\section[{e) Future research}]{e) Future research}\par
More research is needed to fully investigate which factors influence young people within YOTs, and the youth justice system more generally, seeking help for mental health problems. Creative ways to engage this population are needed; perhaps through the building of relationships with them. Methods such as focus groups may be a useful way to capture a wider range of professional views and experiences. Incorporating CAMHS professionals into future research would allow for a broader conceptualisation of YP's help seeking process from their initial contact with YOTs, to their engagement with CAMHS.\par
It may also be useful to utilise quantitative designs in future, to identify the strength and direction of the influence of particular factors. Results from such investigations may inform the focus of any specific interventions aiming to improve the engagement of YP from YOTs accessing appropriate mental health support. Future qualitative research should also endeavour to approach participants for their feedback on findings to improve the validity of developing theories and the acceptability and appropriateness of any suggested clinical implications. 
\section[{VI.}]{VI.} 
\section[{Conclusion}]{Conclusion}\par
The help seeking process for mental health difficulties of YP who attend YOT's appears to be greatly influenced by YOT workers who take on the role of preparing a young person to become ready for a referral to mental health services. YOT workers would value closer working relationships with mental health services to support them during this process which may increase the likelihood of the young person's engagement. Considering the high level of unmet needs within this population, there is a need to continue to develop a better understanding of what and who influence their process of help seeking. Future research should attempt to include more YP and incorporate the views and experiences of CAMHS professionals.    \begin{figure}[htbp]
\noindent\textbf{} \par 
\begin{longtable}{P{0.03141801075268817\textwidth}P{0.4918346774193548\textwidth}P{0.2159274193548387\textwidth}P{0.06112231182795699\textwidth}P{0.049697580645161284\textwidth}}
\tabcellsep Assessed the young person to\tabcellsep \tabcellsep \\
\tabcellsep have MH difficulties\tabcellsep \tabcellsep \\
\tabcellsep Relationship between YOT worker and\tabcellsep \multicolumn{2}{l}{YOT worker role and responsibility}\\
\tabcellsep young person\tabcellsep \multicolumn{2}{l}{1. Managing self-expectations}\\
Year 2018\tabcellsep 1.It's all about the relationship 2.HowYOT develop relationships with young people 3.Partnership is key 4.Using the relationship to build rapport with\tabcellsep \multicolumn{2}{l}{2. YOT worker distress 3. YOT worker confidence in mental health expertise 4. Using the self to inform interventions}\tabcellsep Year 2018\\
\tabcellsep other professionals\tabcellsep \tabcellsep \\
6\tabcellsep \tabcellsep \tabcellsep \tabcellsep 5\\
( H )\tabcellsep \multicolumn{2}{l}{Beliefs about CAMHS 1. Beliefs about consequences of a referral to CAMHs 2. Relevance of MH services to young person's needs 3. Influence of family and cultural beliefs 4. Knowledge and experience of CAMHS Becoming ready to talk explicitly about mental health}\tabcellsep -Referral to other services (e.g. parenting, informal CAMHS, drug and alcohol services) -Do work themselves\tabcellsep Volume XVIII Issue II Version I ( H )\\
Global Journal of Human Social Science -\tabcellsep 1. A tentative process over time 2. A door in without realising 3. Raising awareness of problems 4. Reducing discrepancy 5. Overcoming assumptions 2. CAMHS not effectively engaging YOT young CAMHS barriers 1. CAMHS not being child centred people\tabcellsep \multicolumn{2}{l}{CAMHS facilitators 1. Positive experiences of collaboration between YOT and CAMHS 2.The key role of the MHW}\tabcellsep Global Journal of Human Social Science -\\
\tabcellsep 3. A lack of collaboration between YOT and\tabcellsep \multicolumn{2}{l}{3.Organisational priority for YOT young people}\\
\tabcellsep CAMHS\tabcellsep \tabcellsep \\
\tabcellsep Less Likely to facilitate a successful\tabcellsep \multicolumn{2}{l}{More Likely to facilitate a successful}\\
\tabcellsep referral\tabcellsep referral\tabcellsep \end{longtable} \par
  {\small\itshape [Note: Figure 1: Theoretical model of the influence of YOT workers on young people's help seeking]} 
\caption{\label{tab_1}}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{} \par 
\begin{longtable}{P{0.7888814913448735\textwidth}P{0.0611185086551265\textwidth}}
\tabcellsep Year 2018\\
\tabcellsep ( H )\\
So you can kind of see things, from your perspective but you are helping them to begin to see it" (YW5) "And its them recognising their behaviours before you can even kind of say well what is it, is it mental health, is it emotional, is it, what can be done to help". (YW6). Reducing discrepancy: If a YOT worker held beliefs that\tabcellsep Global Journal of Human Social Science -\\
CAMHS could effectively support a YP with their\tabcellsep \\
particular needs, then they spent time supporting the\tabcellsep \\
young person to see how CAMHS could be relevant and\tabcellsep \\
beneficial to them. YOT worker's described this as a key\tabcellsep \\
facilitative strategy which enabled YP to accept a referral\tabcellsep \\
to CAMHS;\tabcellsep \\
"It depends what they want...being able to see his\tabcellsep \\
problems and how CAMHS can help him" (YW5)\tabcellsep \end{longtable} \par
 
\caption{\label{tab_4}}\end{figure}
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\end{bibitemlist}
 			 		 	 
\end{document}
