Promoting young people’s resilience through enjoyable structured activities.

Introduction

Concerns about child protection and wellbeing have been increasing in the UK (Kids Company 2014) and internationally (WHO 2012), particularly for those experiencing significant adversity. Such adversity has been defined as intense and/or persistent negative life events including: neglect, abuse, poverty, mental health challenges, addictions, disability and discrimination (Hart et al 2007). Lack of appropriate supports to respond to adversity can have a detrimental impact on children’s development and adult life (Masten and Cicchetti 2010). Resilience involves a dynamic process of positive adaptation to adversity and, accordingly, a resilience frame of reference can facilitate the understanding of young peoples’ strengths and challenges (Hart et al 2007, Masten 2011). Assessing resilience requires taking into account assets and resources within an individual and their environment, and longitudinal processes that lead to resilient outcomes (Ungar 2009). Successful recovery from adversities can contribute to future resilience and debate has focused on internal factors and external factors that may promote resilience (Rutter 2012); yet an occupational perspective (Wilcock and Hocking 2014) calls attention to the potential role of human doing which involves an interaction of internal capacity with the external world.

Literature review

Current resilience research employs multidisciplinary approaches to investigate how individual and environmental factors work together to promote resilience among the most disadvantaged youth (Hart et al 2007, Masten 2011). This includes expanding the evidence base for activity-based interventions (Hart and Heaver 2013) and exploring the perspectives of the professionals involved (Teram and Ungar 2009). A resilience research project, Imagine (2015), has proposed investigating past resilience-building strategies to facilitate reflection on current practices and enhance service provision.

Some studies suggest that activity participation can enhance resilience in young people through development of positive self-identity, including improvement in self-esteem, sense of control, self-awareness, coping, taking care of themselves, confidence, belonging, satisfaction, goal-orientated behaviour and optimism (DeLuca et al 2010, Hart and Heaver 2013, Scholl et al 2004, Woodier 2011). Accordingly, Jessup et al (2010) and Grunstein and Nutbeam’s (2007) found leisure activities promoted all of the above.

Participation in leisure activities and apprenticeships has been linked to the resilience indicators of improved learning outcomes, and development of new roles and responsibilities (Hart et al 2007, Ungar 2009). A robust study (Scholl et al 2004) found that graduates with and without disabilities from a youth apprenticeship programme reported advancement in their technical, communication, problem-solving and time-management skills, and made meaningful work transitions with appropriate support. Other studies identified a positive impact of leisure or vocational activities on school performance and further education (DeLuca et al 2010, Hart and Heaver 2013, Jessup et al 2010, Woodier 2011).

Developing friendships, interpersonal skills and belonging to supportive relationships is another resilience domain (Hart et al 2007, Masten 2011) associated with activity participation (Grunstein and Nutbeam 2007, Hart and Heaver 2013, Scholl et al 2004, Woodier 2011). DeLuca et al (2010) illustrates the important role of support and guidance in facilitating these positive outcomes. Two case studies were compared and demonstrated that appropriately graded adult assistance during an apprenticeship promoted positive personal, inter-personal and work outcomes. Conversely, lack of support was found to result in gradual disengagement until help was provided.

These findings are consistent with Wilcock and Hocking’s (2014) theory that through doing people shape who they are – they become – particularly as they move into adulthood. Thus receiving professional support and belonging to a social group appears to be important in promoting occupational wellbeing and resilience. Participation in appropriately structured play/leisure, exercise and employment related activities may address occupational injustice and the resilience indicator of meeting basic needs (Hart et al 2007, Masten 2011, Ungar 2009).

Evidence suggests that activity participation can promote resilience, however, the studies reviewed have a number of methodological limitations, including the lack of detailed description of settings, participants and interventions. Only Jessup et al’s (2010) research focused on leisure activities and only one study (Woodier 2011) was UK-based. Of the studies which included practitioners’ perspectives (DeLuca et al 2010, Woodier 2011) – just DeLuca et al (2010) provided in depth description of specific practitioner support strategies used to promote resilience.

Some longitudinal studies ranging up to three years were identified, but no papers presented accounts of past practices. Historical research may help to capture the complex processes of adversity and the use of occupational strategies in adapting to life transitions, including the change in availability of adequate supports (Kirk and Wall 2010, Wiseman and Whiteford 2007). Research into past practices may illuminate changes in both individual and organisational resilience over time. The research reported below explored the role activities have played in service provision over recent decades and its impact on youth resilience.

Reviewing the current literature led to the formulation of the following research question: how did retired professionals use activities to promote the resilience of young people they previously supported?

Methods

Study design

Ethical approval for this study was granted by the relevant University Research Ethics Panel. A qualitative approach was chosen for this exploratory study (Silverman 2010) underpinned by a critical realist ontological and epistemological position (Danermark et al 2002). This methodology holds that while every vulnerable youth experiences their situation of adversity subjectively, the reality of the adverse circumstances exists independently of that experience. Therefore it is valid for critical realist research to try and identify explanations for phenomena which may be relevant to different individuals in related contexts. The impact of the researcher’s experiences and views was acknowledged in line with a critical realist perspective that interpretations of reality will vary according to the perceptions and attributes of different people (Archer 1995). In-depth interviews were conducted with retired professionals to gain accounts on how they had previously used activities to promote young people’s resilience.

Participants

Purposive (snowball and criterion) sampling was used to recruit five participants allowing gathering of rich information within limited time constrains (Silverman 2010). The participants were retired people aged over 60 who had worked in health, social care and education and who used activity-based strategies to promote resilience in young people (aged 12-18) experiencing adversity in the UK. Participants were able to give their consent, had fluent English and confirmed that the young people they discussed were over 18 at the time of the research interview. The first five respondents were interviewed.

Procedure

After consent was gained, approximately 80 minutes long interviews were carried out on university premises using semi-structured open questions, examples of which participants were given in advance. The questions included ‘Could you describe how you used an activity with a young person you worked with?’, ‘Could you describe the types of adverse situations the young person was going through?’ and ‘How did the activity engagement make a difference in the life of…?’ These questions were informed by resilience literature (Masten 2011, Ungar 2009) and discussions with boingboing resilience forum members (boingboing 2013), and their utility was confirmed by a pilot interview. During the interviews further prompts were given to encourage participants to expand or clarify particular points. These interviews were audio-taped and transcribed using pseudonyms to ensure confidentiality.

Data analysis

Data were analysed using a two stage narrative analysis methodology as rich narrative accounts can help to understand the meaning and social significance of the activities in a particular context (Polkinghorne 2010). The first stage was the creation of a chronologically organised core story with a beginning, a middle, an end and contextual factors (Clandinin and Connelly 2000). This chronological picture of the events afforded the potential to suggest the difference the activity participation made (Polkinghorne 2010). The second stage was interpretative and involved looking for regularly reoccurring themes within individual narratives and across them (Clandinin and Connelly 2000). Some themes emerged from the data and some were informed by the authors’ existing understanding of wider literature thus a combination of inductive and deductive approaches were used consistent with the critical realist methodology (Danermark et al 2002).

Credibility was enhanced through member checking in which participants were invited to comment on the key themes (Silverman 2010). The researcher also used a reflective journal throughout the duration of the research to ensure the confirmability.

Results

The five participants came from social work, family therapy and teaching professions. Their detailed narratives covered periods of up to thirty years from the present. 12-18 years old youths’ experiences of adversity were found to be related to bereavement, trauma, anger management, anxiety, poverty, social deprivation, domestic violence and disabilities. The background characteristics of participants are described in table 1 below and a summary of their reported activity-based interventions for young people are shown in table 2. (Names of all individuals and organisations have been changed to protect anonymity).

Table 1. Participant practice information

Participants reflected on the most recent 10 years before they retired.

• Matt – began career as youth worker in 1970s subsequently qualified as a social worker and then as a family therapist. Retired in 2012.
• Jude worked as Special Educational Needs Co-ordinator in schools and nurseries since 1980s. Alongside that she volunteered at the Sparkle – a charitable organisation that provided weekly activities and occasional trips. Retired in 2013.
• Sam – social worker at the Rainbow – a country-side based residential place offering ‘youth in trouble’ support to engage in constructive activities over the weekends. Retired 30 years ago.
• Pat – qualified as social worker in 1980s. Discussed experiences at The Sunshine – a centre supporting children with learning and physical disabilities. Retired in 2012.
• Ruth qualified as a primary school teacher in 1970s. Also volunteered with various youth organisations. Retired in 1990s.

Table 2. Summary of young people’s background, interventions and outcomes.

The adversities faced by young people:

• Antisocial behaviours: stealing, lying, aggression, violence, property damage, youth offending.
• Poor school performance/attendance/suspended.
• Childhood trauma, including parent’s death, divorce, illness, single parenting, drinking, unemployment, chaotic routines, abuse, domestic violence, ‘bad parenting’.
• Physical, mental health and learning difficulties/disabilities, substance misuse.
• Poverty and financial struggles.

Activities used:

Mindfulness, family therapy, liaising with school and parents, (international) camping trips, running hip-hop groups, cooking, making beds, looking after chickens, Qi Gong, games, roller-skating, football, ice-skating, canoeing, walking in the woods, gardening, painting, knitting, visiting theatre, volunteering, psycho-education.

Themes

– representing mechanisms and contextual factors associated with participation in structured activities which influenced young people’s resilience – were identified from the data. These were: promoting positive emotional experience and expression; developing routines, responsibility and roles; constructive relationships; and, social policy and service-level change. These themes are presented in further detail below.

Promoting positive emotional experience and expression

Most participants stated that activity engagement promoted positive emotions in youth. Special Educational Needs Co-ordinator (SENCO) Jude explained that the games they play should always be fun. “That’s the whole essence of it in my mind. If they’re fun, then the children enjoy playing them.” While most enjoyed exploring a variety of activities, gardening was the only occupation that Eva took pleasure in and benefited from. “Everybody else was at the same stage as she was. She felt more at ease, […] less tense, more amenable and interested in what would happen – to see the flowers come out, the tomatoes forming”, reflected primary school teacher Ruth.

Activity enjoyment was also linked to increased confidence and self-esteem. For example, Bob was bullied at school and was never picked to play football, one of his favourite sports, as “macho boys would pick big guys” to join their team. The staff arranged for him to beselected, and “he was good at it – very quick and agile. […] The next time the other team wanted him as well”, remembered social worker Sam. This helped to build his self-respect, confidence and maturity – “he would not accept being bullied anymore”. This shows that increased resilience can enhance youth’s ability to both cope with and challenge adversity.

Family therapist Matt considered that embodied meditative activities transformed negative energy into positive and aided emotional and physical healing. “Sara could write a book on anxiety management. But in her body she was still experiencing huge anxiety’, recalled Matt. She stopped going to school and spent her days in bed. Qi Gong helped her to use negative anxious energy in her body, gather warm calm positive energy, placing and storing it in her lower belly. A few months later Sara returned to school and was relatively free from Irritable Bowell Syndrome.

Similarly, mindfulness-based approaches helped Paul to develop awareness and management of his anger enabling him to be happier and work towards his aspirations. Mindfulness helped Paul to notice the physical sensations in his hands, and how this related to his thoughts and feelings. “If you notice your hands clenching, is that happening when you are relaxed, tense, feeling angry? If the hands are relaxed, then you are relaxed”, explained Matt. Paul had to physically release his hands when they were tensing up. “With kids, if you get them to work with their bodies, it’s much easier than getting them to work with their emotions.” Paul did not get involved in any further violence. He returned to college and did well, aspiring to enter the same skilled trade as his father. Such enjoyable and meditative activities helped promote healing, active engagement, positive self-image and confidence.

Developing routines, responsibility and roles.

Improvement in structured routines, learning, sense of responsibility and future transitions was another category of reported resilience outcomes. Some young people had difficulties with following structured routines due to “chaotic” home environments, explained social worker Sam. A countryside-based residential home ‘Rainbow’ provided them with such opportunities for up to three days a week. They had to get up at certain time in the morning, help to make beds and prepare meals (some discovered they liked vegetables).

On occasions occupational participation involved disappointments and subsequent feelings of guilt, which, when reflected upon, could foster a better understanding of the consequences of their actions and a stronger sense of responsibility. Sam explained, “The big boys would go out and make sure the fox does not get any chickens. One day the fox got some of the chickens and they were very sad about that. Next time they would make sure the fox would never get any chickens.”

Improvement in anti-social behaviours could arise from being encouraged to take responsibility. Jude described how one boy “was at his best [and enjoyed himself] when I said ‘Will you push the wheelchair?’ […] Other times, I remember at one camp where he was on the top of that dung heap swearing loudly as people were passing. Give him a bit of responsibility, and […] he could rise to the occasion and do well and be successful.”

All the professionals wondered if the resilience that the activity promoted at the time had supported future transitions. There was evidence of improved school attendance and performance as Sara’s and Paul’s stories demonstrated, and they subsequently expressed clear aspirations for the future. Primary school teacher Ruth reflected that development of interests and skills could influence career choices. “It was amazing how some children would learn to cook, get a badge and eventually become a chef.” . Sometimes small improvements were observed while other times professionals were uncertain as to whether resilience was carried into home and school environments.

For some resilience only really manifested itself in adulthood. For example, Nora presented with difficult behaviours at the youth organisation. “But her lowest time was when she wasn’t [there]. She was virtually living on the streets for a while. […] She turned up to help years later. Her mother […] was incredibly impressed with her. […] Maybe all those experiences have given her real empathy. She really has turned a corner and is a very pleasant young woman […] training to be a social worker”, stated Jude.

Constructive relationships

According to the participants, structured activities could promote collaboration, constructive role-modelling, strong friendships, autonomy and reduction in antisocial behaviours. Teamwork was considered important by Jude because, “we all do our best if we cooperate rather than be in competition.” Cooperation was promoted by encouraging youth to play without winners and losers, learning to negotiate and compromise. “If you have never had socialisation and responsibility to a group you won’t [compromise] because the child is so strong in you”, explained social worker Sam.

Many professionals reported young people learned to consider and help others through engagement in structured activities. 14 year old Ann spent “so much time thinking about her own problems, things that she didn’t like […]”, remembered Jude. When they went on a camping trip overseas “everybody was ill [and] I expected her to be one of the worst, but […] she actually rose to the occasion.” She helped the children “who were really rough. […] Seeing somebody in a worse situation helped her to see that she had to think about them. […] I saw a side to her that I hadn’t seen anywhere else.”

Sometimes helping others involved becoming a role model of how to behave, being caring and helpful. “The younger ones knew they could rely on this older girl who was there to help to look after them’, recalled school teacher Ruth. Social worker Sam reflected that supporting others allowed children to learn that everybody has different strengths. She recounted how a 12 year old boy was teaching her roller-skating. “I was petrified – ‘I’m going to fall, break my neck!’ And he would say, ‘you won’t fall’. There was roundness in the relationship – it was not just about us teaching them.”

A few participants emphasised that activities helped to establish strong friendships that continued years after they left the youth organisations. Jude remembered Simon had “a massive head injury” as a result of a serious car accident. When his friends from the Sparkle went to see him, “he realised who they were and went to speak to them. His father was almost in tears because it was the first indication that his mind was working properly.” Simon made “a remarkable recovery” and his friends from the Sparkle “have been supporting him during all this time.”

Therapeutic support

Most professionals acknowledged that they played a central role in ensuring the activities were enjoyable and successful. SENCO Jude’s experience suggests that the role of the facilitator is to ensure that activities are fun. “It’s got to remain fun. If it doesn’t, then you quickly adapt the rules or move on to a different game. You don’t want to knock their confidence. You need to be vigilant.”

Professionals reported they nurtured youth’s resilience through role-modelling, encouragement, feedback and guidance within a safe space. Jude knew Peter was able to dance hip-hop, and so consistently encouraged and supported him to run a session for the younger ones. “I think he felt very pleased with himself afterwards.” With Jude’s guidance Peter was able to encourage a boy with learning difficulties who already knew some hip-hop. “It’s the sort of double-edged success. It’s a lot to do with giving opportunities, but then support to make sure that it does work.” By contrast, according to family therapist Matt and social worker Sam, some unstructured activities with peers could promote antisocial behaviours and maladaptive coping strategies.

Helping young people to reflect on their experience was an important part of the process. Family therapist Matt enabled Paul and his family to share their experience of bereavement exploring helpful strategies in supporting each other. While Eva was supported to explore “the other person’s point of view”, according to primary school teacher Ruth.

Social Policy and Service-level change

Some participants reflected that the integration of services, including working with families as a whole can help to sustain resilience outcomes, and considered they had witnessed improvements in this over time. According to social worker Sam who retired 30 years ago “there weren’t enough communication and togetherness [between the organisation and the parents]. It was quite isolated – we took them out of that sphere and put them in another. Our job was limited to 48 hours”. However, in more recent social worker Pat’s experience, “you are supporting the family so the family can keep the child at the centre. […] Now family social workers, might suggest working with brother and sister together […]. In those days there was nothing like that.”

Continuity of funding of youth organisations was reported to be a significant challenge in both the recent and more distant past. It led to the closure of the Rainbow thirty years ago and elsewhere it was implied that limiting therapy input might have contributed to Sara’s and Luke’s relapses. Matt and Jude reflected that getting government grants, is much more difficult now, and that time-limited interventions, targets and long waiting lists have become more predominant. Matt stated that in mental health services more funding is being directed towards talking therapies, while forty-fifty years ago “activities were all we ever did”. By contrast, social worker Sam believed activity participation has become more valued in school settings.

Some participants considered the sort of resilience-building work they used to do is being challenged by increasing recording on complex computerised systems as part of a drive to evidence accountability. Pat was concerned this can reduce the direct contact of working with children and their families. Sam was apprehensive about the lack of flexibility, increased focus on materialism and negative perceptions regarding being tactile with children. She was among those who expressed a relief they are not part of the current system.

Discussion

A range of different activity types were reported, often closely aligning meditative or cognitive approaches, and those based more on activity itself. Retired professionals’ descriptions of the impact activity participation had on young people facing a range of adversities revealed commonalities. Structured activities promoted competence, confidence, self-esteem, self-awareness, roles, routines, responsibility and constructive relationships as was also found by Hart et al (2007), Jessup et al (2010) and Scholl et al (2004). Sometimes this translated into long-lasting friendships, better learning outcomes and future achievements supporting the findings of DeLuca et al (2010) and Woodier (2011).

The extent to which resilience was achieved varied and appears to have depended on a number of factors. Successful outcomes were linked to positive emotional experience. This elaborates upon some findings in previous studies that have made more limited reference to role of positive emotions in building resilience through activity participation (DeLuca et al 2010, Jessup et al 2010, and Woodier 2011). More broadly, positive emotions have been proposed to be an underlying mechanism for resilient adaptation, associated with resistance to and recovery from stressful life events (Ong et al 2010). Thus some of the successful transitions undertaken by young people may have been aided by positive emotions experienced during the activities which participants described.

When enjoyment is the main reason for pursuing an activity and the level of challenge matches the existing skills, flow or optimal positive experience can occur (Csikszentmihalyi 2002). Such deep and sustained immersion in the activity can contribute to opening up to new opportunities emphasised also in resilience research (Ungar et al 2005), potentially leading to a turning point in a young person’s life. Positive emotions are also related to feeling calm, safe, connected and trust in others (Csikszentmihalyi 2002), which may have further contributed to successful resilience outcomes of the kind reported by our participants.

Because children and youth naturally enjoy play (S Bazyk and J Bazyk 2009), experience of flow may be a significant mechanism in their engagement and resilience. According to flow theory, pursuing the optimal experience is the main motivation, while skills naturally develop as the level of challenge required to enter flow gradually increases (Csikszentmihalyi 2002). Yet, rather than reflecting on the direct impact of the experience of doing, many of the participating professionals emphasised the way in which activities helped people develop transferable social, educational and life skills as was also the case with studies discussed in the literature review (DeLuca et al 2010, Grunstein and Nutbeam 2007, Hart et al 2007, Jessup et al 2010, Peck et al 2008, Scholl et al 2004, Woodier 2011).

Given that enjoyment may be central in promoting positive experience and success, a good knowledge of how to nourish such experience would seem to be important for those using activities to support young people. There was some suggestion this was more challenging when young people presented with disabilities that professionals were less familiar with. Despite Csikszentmihalyi’s (2002) indication that matching challenges and skills is a vital component of achieving flow (2002), and suggestions that it may also promote resilience (Scholl et al 2004, Ungar et al 2005, DeLuca et al 2010), there was limited discussion by the professionals interviewed in this study of the importance of adapting activities, and increasing the level of challenge. That is not to say that participants did not use strategies of adaptation and grading that are familiar to occupational therapists (Creek 2010) – rather, it may be that the participants’ professional backgrounds provided them with lenses which drew attention to other areas and a language which is better able to express them rather than occupational factors. Similarly, whilst there was little evidence of using goal setting strategies (Dawes and Larson 2010), professionals showed their expertise in rule-setting, fostering collaboration and debriefing – helping youth to consider more constructive stories about themselves and others around them. This was also recognised to be important by DeLuca et al (2010), Jessup et al (2010) and Woodier (2011).

While flow involves a deep level of enjoyment with the awareness of time and space drifting into the background, mindfulness-based activities, also highlighted in the findings, entail conscious awareness of whatever arises in one’s physical, emotional and social being, including unpleasant experience (Reid 2011). In some cases the state of mindfulness and flow may merge and more research is required to examine this. Nevertheless, the findings support Rempel’s (2012) literature review which identified an association between mindfulness and pursing positive experience, reducing problem behaviours and promoting desired outcomes. Similarly, Schonert-Reichl and Lawlor’s (2010) high quality quasi-experimental study found mindfulness can significantly increase positive emotions, social and emotional competence, particularly optimism, self-awareness, attention and concentration, in turn improving classroom learning and resilience. While their finding is consistent with the current study, Sara’s relapse suggests that following up mindfulness interventions is important.

Retired practitioners in the current study suggested that addressing a young person’s capacity to cope with adversity on an individual basis alone may not be sufficient to sustain resilience – a point advanced by resilience researchers such as (Hart et al 2007) and Ungar (2009). Many young people had a history consistent with Wilcock and Hocking’s (2014) definition of occupational deprivation involving limited opportunities to engage in meaningful occupations due to the lack of resources, poverty and fragmented families. In this context maladaptive coping strategies became attractive alternatives to meet their physical and psycho-social needs (Caldwell and Smith 2013, S Bazyk and J Bazyk 2009). The UK government is targeting child poverty (HM Government 2014), however, the proposed strategy has been critiqued as insufficient in the context of widening inequalities and more comprehensive resources, child protection and wellbeing approaches are required (Kids Company 2014).

Limitations

The interpretation of data was influenced by the researcher’s unique life experience and could be interpreted differently by other researchers. Multiple factors contribute to resilience, and this study highlighted the contribution of activity participation and only from the professionals’ perspectives. Young people’s experiences might have been different and future studies could gather data from both parties. Memory bias is also possible and further research could include interviewing current professionals. Recruiting occupational therapists could provide a comparative analysis of how that profession’s use of activities across services has changed over time. Definite conclusions are difficult to draw from the study due to the heterogeneity of the professionals’ and youth backgrounds, activities, services and points in history.

Implications for practice

Structured enjoyable activities can be significant in promoting resilience. The practitioners in the current study made valuable contributions that have clear relevance to occupational therapists and other people working with children and young people in adverse circumstances. This includes nurturing the experience of fun, mindfulness applications, family-centred practice, debriefing strategies, promoting collaboration, creative interventions, and considering longer-term impact of participation in activities on young people’s resilience. Analysis also suggest there are opportunities in this area of practice for occupational therapists to offer their knowledge of a broad range of disabilities and associated functional impact, and their expertise in individualised goal setting and activity grading.

Conclusion

Analysis suggests that key mechanisms through which participation in structured activities promoted resilience for the young people were: promoting positive emotional experiences and expression; developing routines, responsibility and roles; alongside this, the presence of opportunities for constructive relationships and therapeutic support were important contextual factors. Participants noticed a number of changes over time to policy and service provision. Increased integration of services were judged to have improved efforts at resilience building, whilst concerns were expressed with regard to funding constraints and that administrative monitoring of professionals’ work provided less time for active engagement with youth. Analysis also identified opportunities for occupational therapists and occupational perspectives to make a greater contribution to supporting young people in adversity.

Key findings:

• Enjoyable structured activities can promote youths’ resilience
• Key mechanisms were: promoting positive emotional experiences and expression; developing routines, responsibility and roles; enabling constructive relationships and providing therapeutic support

What the study has added:

Increased understanding of how participation in structured activities can build young people’s resilience. More broadly the study has helped establish the relevance of occupational perspectives to resilience research and practice.

Acknowledgements

The authors thank: firstly, the participants for sharing their rich experiences; and secondly, Professor Angie Hart and other members of the Boing-Boing Resilience Research and Practice network and collaborators in the Connected Communities Imagine project for advice and inspiration.

Kristina Usaite, Occupational Therapist, Sussex Partnership NHS Foundation Trust; University of Brighton and Dr Josh Cameron, Principal Lecturer, School of Health Sciences, University of Brighton.

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