CAMHS into the wild
Â鶹ԭ´´ Children, Young People and Families, March 2025

What is it about a campfire in the woods that enables attendance to a Children and Adolescent Mental Health Service (CAMHS) by young people who would ordinarily avoid therapy? Or about ponies that support a young person with autism, previously not attending school, or even leaving the house for months, to come out and join a CAMHS intervention? And what enables a young person with attention deficit hyperactivity disorder (ADHD) to sit quietly and patiently by the lake waiting for their first ever catch? Social and green prescribing tell us that offering opportunities for self-chosen social and physical activities supported by health professionals, has a role to play in improving mental and physical health.¹

We take the title for this article from our work in a small woodland area in ‘Alder Hey in the Park’, based in the large, urban city of Liverpool. Here at Liverpool CAMHS (Alder Hey Children’s NHS Foundation Trust), we are developing social and green prescribing to give young people access to novel and personally chosen interventions, either alongside clinical, therapeutic treatments-as-usual from the multidisciplinary team, or as a treatment in and of itself. We have listened to young people, and with a generous donation from a famous artist, we are delivering new, creative, arts and nature-based interventions. Young people with neurodevelopmental conditions make up the majority of referrals into the service, although we acknowledge that autism and ADHD affect everyone differently, and our services are available to all young people.

The unbearable pain of disconnection 

The world is waking up to the increase in young people with neurodevelopmental conditions, diagnosed or not. It has been highlighted by Sir Professor Simon Baron-Cohen, director of Cambridge University’s Autism Research Centre, that one in 36 children are diagnosed as autistic, which represents a 700% increase in prevalence since the year 2000.² Services need to keep up with the massive increase in demand to ensure that the mental health needs of autistic children are supported. Currently, there are unacceptably high rates of poor mental health in autistic people – a sign that society is failing them.² At the same time, data reveal that the number of open referrals to CAMHS is the highest on record.^3Ìý

A common feature of autism is debilitating, chronic social anxiety, frequently resulting in avoidance of education or any social connection at all, which can persist into adulthood. This may be due to overwhelming sensory sensitivity, but also bullying of children who desperately want, but often fail, to fit in. It has been identified that autistic adults are among the most isolated and lonely in the UK,⁴ being four times more likely to be lonely than the rest of the population. As loneliness is a recognised risk factor for poor mental health,⁵ recognising the impact early is important. For example, research has shown that autistic children who are lonely are 28 times more likely to think about or attempt suicide than other young people.⁶ Given this backdrop, increasing capacity and providing the right therapeutic reach is key to our work. 

Other influences impacting young people’s sense of disconnection are the longer-term consequences of the pandemic lockdowns, and the potentially harmful effects of social media on self-esteem. Posts viewed online can lead young people to compare themselves unfavourably to images and lifestyles that bear no resemblance to reality, and they can be vulnerable to cruel comments online which they would never hear in person. Identity-based harassment, known as trolling, and cyberbullying are on the increase and can have serious psychological effects, including disrupted sleep, self-esteem problems and suicide.⁷ Our ‘Lads group’ and the ‘Absolutely fabulous’ programme are designed to support young people’s mental health and self-esteem, offering spaces to explore how social media and face-to-face conflict can be addressed by supportive group interaction with skilled practitioners.

Social prescribing 

Social prescribing is embedded in NHS strategy for adults, and is largely a supportive signposting activity, accessing community assets, such as choirs, art classes and walking groups to support physical and mental health wellbeing needs.⁸ However, its value for children and young people has not yet been expanded, nor evaluated in the same way. As a CAMHS team, we have developed social prescribing within our service. Many of our young people are not yet ready to step out into the community in the same way that would be expected in mainstream social prescribing, so our work is largely delivered by CAMHS practitioners, giving the interventions further therapeutic impact. While being in nature can be therapeutic in and of itself, what we offer has a more active and structured therapeutic intention. 

In developing this work, in addition to offering something that young people are drawn to, we need credible theoretical foundations and a proven evidence base. To this end, we are integrative in our approach, drawing specifically on a pluralistic model with an underpinning philosophy that, ‘Different clients are likely to benefit from different therapeutic methods at different points in time.’⁹ This enables a fluid and responsive approach to the needs of young people, which is, ‘…rooted in ethical and pragmatic commitment to valuing diversity… [and] links into a much wider set of values and practices, linked to democracy, social justice and progressive change.’¹⁰ We draw on a range of psychological theories and therapeutic practices, including cognitive behavioural therapy (CBT), psychodrama, art therapy, graded exposure and behavioural activation, nature-based theory (e.g., biophilia and stress reduction theory) and theories of social prescribing (e.g., social cure theory, self-determination theory and normalisation process theory). This has enabled us to translate clinical theories and practices into a social prescribing framework, supported by staff who have undertaken additional training. Safeguarding and risk assessment are fundamental to delivering this work, and we have excellent collaboration with the leadership and health and safety teams within the Trust, as well as standard operational procedures for risk management. For young people accessing community activities, we have a 24/7 crisis team, which can also be accessed by carers and professionals. 

Our main offer is Base Camp, both a building and a concept, which is a bespoke 15ft Perspex dome, providing a focal point in the grounds of Alder Hey NHS Foundation Trust. Base Camp activities include, for example, a forest school intervention and ‘NatureWell’ – a mindfulness-based programme developed in conjunction with the Natural Academy organisation. Our approaches are, in part, based on five ways to achieve nature-connectedness: explore, beauty, meaning, emotion and compassion,¹¹ which help facilitate therapeutic engagement. Many young people we work with struggle with the direct question, ‘How are you feeling?’, but exploring, discovering and connecting with nature can open an emotional connection that was previously inaccessible. Young people can take time out in hammocks and have space to reflect and manage emotions. These are popular and offer a feeling of physical containment while looking up into the tree canopy. Young people comment on how relaxed they feel with the hammock gently rocking, watching and listening to nature. So, when we speak of connection we are referring to self-connection, self-other connection and also self-nature connection. As summarised by forest medicine specialist Dr Qing Li, ‘We are hard wired to affiliate with the natural world, and just as our health improves when we are in it, so our health suffers when we are disconnected.’¹²

One of the exciting things about our work is collaborating with community colleagues, such as a nearby fishery for our fishing project, ‘Calmer waters’, local potters and artists for our ‘Dreamers’ programme, and a stables for our ‘Connecting with ponies’ offer. All our partnerships are with DBS-checked professionals and providers. Future goals include developing art-based projects in nature for families, a bespoke Duke of Edinburgh Awards initiative, and a cinema intervention in the Trust’s new ‘Medi-cinema’. The fictionalised vignettes on p08 and p09 offer insight into how we integrate community assets successfully in the true spirit of social prescribing. 

An important part of our ongoing work includes researching the impact of our social prescribing initiatives as part of an integrated CAMHS offer, and we will be reporting more on these findings in the months ahead. Stepping outside of our comfortable rooms and traditional boundaries can challenge us as therapists, but meeting children and young people outside of familiar clinical settings offers wider possibilities for sustainable therapeutic impact and benefit. 

Â鶹ԭ´´ Children, Young People and Families, March 2025