key: cord-0950378-54i29nid authors: Mindel, Charlotte; Salhi, Louisa; Oppong, Crystal; Lockwood, Joanna title: Alienated and unsafe: Experiences of the first national UK COVID‐19 lockdown for vulnerable young people (aged 11–24 years) as revealed in Web‐based therapeutic sessions with mental health professionals date: 2022-04-09 journal: Couns Psychother Res DOI: 10.1002/capr.12533 sha: 367cc75cf02c0f3b1cca3bc74eef5886d355aab9 doc_id: 950378 cord_uid: 54i29nid BACKGROUND: The COVID‐19 pandemic and subsequent lockdowns have disproportionately affected young people, and those who are vulnerable are disadvantaged further. Here, we seek to understand the experiences of vulnerable young people accessing Web‐based therapeutic support during the pandemic and early lockdown, as revealed through the observations of mental health professionals. METHODS: Four focus groups with 12 professionals from a digital mental health service were conducted to understand the experiences of vulnerable young people during the pandemic lockdown. Workshops with young people with diverse experiences resulted in the co‐design of the focus group topic guide and the interpretation and validation of analysis. The experiential inductive–deductive framework of thematic analysis was used to analyse the workshop transcripts. RESULTS: Four main themes and subsequent subthemes were identified: escalation of risk; the experience and consequence of loss; feeling supported and empowered; and feeling separate and isolated. CONCLUSIONS: Findings reflect early data that suggest that those with existing vulnerability face an increased risk of poor outcomes through the pandemic and the restrictions of lockdown, but evidence is also provided of positive outcomes from lockdown and its function as a catalyst for change. Results reinforce the need for focused support for vulnerable young people as we emerge from lockdown, and point to supportive and protective factors of relevance to online and offline support provision. Increasing evidence is revealing the economic, social and psychological ways in which the COVID-19 pandemic and subsequent national lockdowns have detrimentally and disproportionately impacted the lives of children and young people (Leavey et al., 2020; Major et al., 2020; Young Minds, 2020a) . The UK national lockdown saw a rapid closure of all education settings, hospitality, leisure and many non-essential public services. Social distancing rules were brought into force, non-essential travel was prohibited, and rules around mixing between households were enforced. The first UK national lockdown began on 23 March 2020 and was removed in a phased manner depending on the number of regional COVID-19 cases. Since the first lockdown, there have been numerous regional lockdowns (based on a tiered system) and a further two national lockdowns, which included school closures (Institute for Government, n.d.) . The closure of schools, removal of some public services and the lockdown rules on household mixing and social distancing are likely to contribute to the growing mental health crisis among young people (Leavey et al., 2020) . Strikingly, poor mental health was predicted even prior to the pandemic to be a leading issue facing children and young people by 2040 (RCPCH, n.d.) . Economically, those younger than 25 years have faced poorer labour market outcomes and greater loss of earnings and working restrictions than older employed adults during the pandemic (Brewer et al., 2020; Major et al., 2020) . Financial hardship and employment instability have particularly affected those from lower socioeconomic circumstances and minority ethnic backgrounds (Leavey et al., 2020; Wright et al., 2020) . The closure of education settings and the wider loss of extra-curricular provision and play spaces in the community have negatively impacted educational, physical and social opportunities, and support networks for young people (Ford et al., 2021; Guessoum et al., 2020; Romanou & Belton, 2020) , which is likely to have an immediate and long-term impact. Pooled estimates from a systematic review of global evidence indicate that 79.4% of children revealed a worsening of their behaviour or psychological state as a result of the pandemic, including increased levels of anxiety, depression and irritability (Panda et al., 2021) . In the UK, young people have reported increased boredom and frustration over the pandemic, with more than half of young people surveyed reporting feeling lonely during the first lockdown (Brooks et al., 2020; Kooth plc, 2020; Place2Be, 2020) . Taken together, the potential costs to young people of the pandemic and lockdown are stark. Those with heightened vulnerability prior to the pandemic, due to their experiences, life circumstances or existing mental health difficulties, are likely to share an unequal burden (Jaspal & Breakwell, 2022; Romanou & Belton, 2020) . Young people with heightened vulnerability, such as those at elevated risk for adverse childhood experiences (ACEs), may experience increased risk during times of unprecedented change, such as during the COVID-19 pandemic (Bryant et al., 2020) . ACEs are defined by 10 experiences including physical, emotional and psychological abuse, as well as having family members with mental health problems (Asmussen et al., 2020) . These experiences put children and young people at risk of physical, emotional or psychological harm, as well as increasing their susceptibility to poorer outcomes in life (DoH, 2009; HM Government, 2018; NSPCC, 2020) . In comparison with young people with no ACEs, young people who have faced four or more ACEs are four times more likely to have low levels of well-being and life satisfaction, seven times more likely to have been involved in violence, and are more likely to binge drink or have poor diets (Young Minds, 2020c) . Adverse experiences such as domestic violence increased with the introduction of lockdown restrictions in the UK (Stripe, 2020) , and increased time in lockdown has exacerbated risks for vulnerable young people in unsafe and insecure home environments (NYA, 2020; Wright et al., 2020) . For children who are already experiencing abuse or neglect by household members, confinement at home has meant prolonged exposure to potential harm (NSPCC, 2020) alongside reduced opportunities to escape or disclose, for example at school (Donagh, 2020) . When faced with adversity, individuals may adopt both adaptive and maladaptive coping mechanisms in order to deal with their situation (Amnie, 2018) , with the latter increasing the risk of self-harm or other harmful behaviours (Aldao et al., 2010; Compas et al., 2017) . Of note, not only experiencing adversity (such as physical or psychological abuse), but also worrying about adversity over the first 45 weeks of the COVID-19 pandemic has been associated with an increased risk of self-harm thoughts and behaviours in those aged over 18 (Paul & Fancourt, 2021) . Typically, young people who are in situations where they could be exposed to multiple ACEs are known to services; however, findings • There needs to be acknowledgement that, as life returns to 'normal', vulnerable young people are not being met with the support they need at the time they need it, particularly for those who feel alienated. • The findings highlight the importance of the consistency and availability of care during periods of uncertainty and restricted face-to-face care access, with digital provision being well suited to provide consistent support. • We recognise the critical role that schools play, not only in the early identification of risk and provision of mental health support but also in providing access to a safe and predictable space and respite away from an abusive or precarious environment, or where young people may experience alienation within the family home. • Our findings directly indicate that mental health professionals and anyone working on the 'front line' with young people now, and in the aftermath of the pandemic, would benefit from additional trauma-informed training to provide trauma-informed care, which is found to support prevention and early intervention due to the earlier disclosure and trust developed through embedding trauma-informed practices. from preliminary research show that with services becoming overstretched because of the unprecedented pandemic restrictions on service provision and increased demand (BMA, 2020; Romanou & Belton, 2020) , individuals previously accessing support experienced delays in both physical and mental health care (Young Minds, 2020b) . Due to lockdown restrictions, some young people faced the removal of support, such as those being visited by welfare services due to risk (Chanchlani et al., 2020; Young Minds, 2020c) . A report from Young Minds (Young Minds, 2020d) found that 26% of young people who received support leading up to the pandemic are no longer able to access the same level of support due to uncertainty of availability or lack of privacy for remote interaction, leading to increased levels of anxiety. In response, many services worldwide have rapidly adapted to deliver non-face-to-face support, such as telephone counselling Herrington et al., 2021) . Such models are not new and can offer privacy and control to the young person (Boydell et al., 2014) ; these offer a great alternative when physical interactions are not allowed (due to lockdowns) or not preferable (due to travel or time required), but it is important to note that this method of support may not be a viable alternative arrangement for all young people. Established Web-based therapeutic services, such as online counselling, have been in a privileged position since the pandemic started, as they can continue to provide their existing model of direct counselling and well-being support without the need for adaptation. Digital counselling services for youth have reported an increase in usage by service users since the start of the pandemic. For example, one online mental health service for children and young people has reported a 42% increase in usage for those aged between 11 and 25 years (Kooth plc, 2021) and this reflects a wider pattern of increased demand for community-based mental health services. In addition, a higher proportion of those accessing the service presented with 'severe' distress on a standardised mental health assessment (YP-CORE) between April and December 2020, in concordance with the national lockdown periods in the UK (Kooth plc, 2021). While existing studies have provided rapid insight into the impact of COVID-19 and lockdowns, there remains a lack of qualitative insight into the experiences and understanding of lockdown for the most vulnerable children and young people. Practitioners within mental health services may be well placed to understand the impact of COVID-19 on the experiences of these young people, especially where a continuous provision of mental health support has been provided throughout lockdown. We aim to understand how lockdown in the UK has been experienced by young people with heightened vulnerability (due to prior adverse childhood experiences and various life circumstances) who have sought mental health support via a digital mental health service. Specifically, the study aims to assess the experiences of young service users meeting a predetermined definition of vulnerability (see procedures) who have been engaging with the service via structured counselling or ongoing support sessions with a specific practitioner both prior to the pandemic and during lockdown. Access to young people's experiences is sought indirectly through text-based dialogue with practitioners who are well placed to reflect broadly on the experiences of the individuals they work with. This mediated approach has pragmatic and ethical merit and does not add research burden to a vulnerable group at a time of significant disruption. In addition, practitioners are positioned to share insight into patterns of experiences revealed across a consistent model of therapeutic engagement from before and during lockdown. Nonetheless, given that vulnerable groups, including mental health service users, are often excluded from meaningful engagement with research (Daley, 2015; Mawn et al., 2015) we drew on a robust multiphase Patient and Public Involvement (PPI) approach, working with a diverse group of young people to guide the research approach, design and analysis. The study employed a qualitative design, which used online focus groups with practitioners to capture a professional and mediated interpretation of service user experiences during lockdown. Focus groups provided a platform for facilitated discussion and rich insight. Thematic analysis within an experiential inductive-deductive framework was an appropriate method for identifying and analysing patterns in the data (Braun & Clarke, 2006 . Qualitative findings are reported in line with good practice guidelines set by the Consolidated Criteria for Reporting Qualitative Research (Booth et al., 2014) . The study was reviewed and approved by the University of Exeter Ethics Committee (October 2020 [ethics approval reference: eCLESPsy001970]). All practitioners provided informed consent ahead of their involvement in the focus groups. On signing up to the Web-based service, service users are informed their data can be used for research and improvements to the service, and by agreeing to the terms and conditions, consent to their data was being used for these purposes. No service user data were directly accessed by the researchers in this study. Kooth plc (which will hereafter be referred to as 'the service') is a Web-based therapy service that provides mental health support to young people aged 11-25 years. The service has a text-based approach to synchronous counselling and allows the user to access support on any Internet-connected device, providing an anonymous means of communication and agency (Dhesi et al., 2022) . Anonymity provides a viable option for those who face cultural or societal stigma related to mental health help-seeking or who are not comfortable disclosing their difficulties in a face-to-face setting. The service is commissioned in over 85% of NHS clinical commissioning group areas in England and, therefore, is free at the point of access to users, dependent on geographical location. The study design and analysis were guided by online involvement workshops with young people, facilitated by Leaders Unlocked, who were commissioned by the service and paid a fee for recruitment and resource purposes. Leaders Unlocked is an organisation that enables under-represented groups and young people to have an equal voice, partnering with organisations to enable participatory work. Three co-design workshops were held with 11 members of Leaders Unlocked to inform the conceptualisation, design, focus group topic guide (workshop 1), analysis/interpretation of results (workshop 2) and dissemination plans (workshop 3). Workshops took place between October 2020 and January 2021 via Zoom and consisted of five female adolescents and six men, aged 16 to 25 years, from a range of ethnic backgrounds (White 55%, Asian 18%, Black 9%, and Mixed ethnicity 18%). The young people taking part in the workshops did so on a voluntary basis and provided informed consent. Workshop 1 explored notions of vulnerability, priorities for understanding lockdown from the perspective of vulnerable young people, and the scope and acceptability of the topic guide. Important outcomes included the necessity to clearly understand and define 'vulnerability' and identify additional and potentially under-represented groups, which meet these criteria and the importance of reflecting youth behaviour during lockdown in relation to coping mechanisms. Workshop 2 was conducted with the same group of young people halfway through the focus group stage and served to review initial findings, support the ongoing analysis of data, and inform the approach to data collection and analysis in the remaining focus groups (see Appendix A for the workshop material agenda). Workshop 3 saw the group bring their examples of accessible research to a discussion about how research can be translated into accessible media for consumption and use by young people and adults. Figure 1 describes the PPI and research process. Three of the four researchers were based at the service during their involvement in the study, including the two researchers who conducted the focus groups. The researchers recognised their status as 'insiders' within the same organisation as study participants, and the potential bias this introduced through having a shared investment in the service. The PPI sought to provide an additional mitigating perspective to shape the study process. In addition, it was important for researchers to acknowledge the practitioners as the experts in the room and that no prior assumptions were made about the experiences of vulnerable young people, both during data collection and analysis. Researchers three and four were newly appointed by the service and an outsider of the organisation, respectively, and therefore were also able to offer a critical and distinct perspective. The study ran between November 2020 and January 2021. Twelve practitioners (age range 26-66 years; 11 women and 1 man; 83% White British and 17% White Other) took part. All were employed at the service as qualified counsellors or emotional well-being practitioners. All the counsellors have a minimum of two to three years' prior experience working with young people in face-to-face or online settings. Years of experience working at the service ranged from 1 to 5 years. Despite the service being an early intervention service, service users often present with high 'risk'. These young people often have high levels of psychological distress (measured on the YP-CORE and observed by practitioners in their chat assessments); they could be a danger to themselves or others or be in an unsafe situation. Therefore, these young people also meet the criteria of our vulnerable population. Service users tend to sit within different theoretical service use pathways related to how they choose to engage with the service. These consist of brief intermittent interventions, which are drop-in sessions with any practitioner who is available at the time, structured interventions in which the user engages with a series of scheduled sessions with a consistent practitioner, and ongoing support for those who have more complex situations and require support either to engage on the service platform or with other services available to them. The service users whose experiences were being discussed in this study were engaged in either structured or ongoing support (Hanley et al., 2021) . Opportunity and purposive sampling methods were used to recruit participants. To draw on experiences specific to the COVID-19 pandemic, the inclusion criteria stipulated that practitioners needed to (a) have been employed with the service prior to February 2020, that is, before the first UK COVID-19 lockdown; and (b) have worked with a minimum of one service user between March and October 2020 who they identified as meeting the agreed vulnerability criteria prior to the start of the first lockdown. Study advertisements were distributed through internal communication channels in the service (e.g. email/Slack) to all practitioners who were eligible based on their start date at the service. In addition, senior practitioners who manage teams of practitioners were provided with study information to share with members of their team who they identified as meeting the criteria as a secondary means of recruitment. Practitioners were invited to read the study information sheet and provided informed consent before being invited to take part in one of four online focus groups. Sessions lasted 90 min and were facilitated by two researchers (CM and CO) via Zoom videoconferencing software. Each group comprised three practitioners, and allocation was determined based on availability and their range of experience. Given the specific experience of participants as practitioners, and the breadth of experience in their profession, a total of 12 participants were deemed to provide sufficient information power for the analysis (Malterud et al., 2015) . Focus groups with practitioners were audio-recorded and transcribed verbatim, with additional notes recorded in the session to demarcate key points of agreement or contention. Practitioners were offered an overtime contribution for their participation as reimbursement for their time and were encouraged to speak to peers and engage with support if they found participation in the study and the issues raised to be distressing. This was particularly important to reinforce given the unsettling and emotionally demanding nature of an ongoing pandemic. Children and young people were classified as vulnerable if they met any of these criteria: experience of physical, sexual or psychological abuse, experience of physical or psychological neglect, witness of domestic abuse, experience of parental separation or divorce on account of relationship breakdown, having a close family member F I G U R E 1 Schematic of study design process with mental health problems, having a close family member who served time in prison and having a chronic physical comorbidity. Additionally, if a young person had experience of familial economic disadvantage, discrimination based on religion, ethnicity or gender, identifies as a refugee or asylum seeker or was a sufferer of peer victimisation, they were also classified as vulnerable. Focus groups followed a semi-structured topic guide, which broadly explored five areas: (a) the physical elements of lockdown, such as the impact of closure or change of interaction with physical institutions such as schools; (b) the emotional experience of lockdown, exploring presenting issues that were considered unique to the circumstances of the pandemic by the practitioner; (c) coping mechanisms adopted by young people due to their pandemic experiences; (d) general experiences or tropes unique to the pandemic circumstances; (e) long-term changes, referring to any shift in experiences for young people as restrictions eased and tightened throughout the pandemic. Topics were informed by anecdotal insights from practitioners and service delivery staff at the service, research and media reporting, and participatory discussions with Leaders Unlocked. Practitioners were asked to share general insights or discuss cases in a general way and not provide details of individual cases that might identify individuals, and to adhere to the ethical frameworks of counselling and protect the confidentiality of the clients. As the service is anonymous, with personal identifiable information only shared at the discretion of the user during a safeguarding interaction, the risk of practitioners sharing personally identifiable user information with the researchers was also reduced. Any case details that could be identifiable were redacted prior to the analysis of the transcripts. Data were analysed following the principles of thematic analysis (Braun & Clarke, 2006 . Initially, two researchers (CM and CO) were immersed in the workshop transcript and familiarised themselves with the data by reading and re-reading the transcripts, before coding. The codes were transferred into an online whiteboard tool, Miro, which facilitated the visual organisation and moving of data and supported the clustering of codes, generation of initial themes and creation of thematic maps. Themes were developed and reviewed according to deductive (based on prior research) and inductive processes. Midway through the analysis, identified patterns and relationships in the data were presented for discussion with young people within the second participatory workshop. The discursive process involving multiple researchers and our PPI group brought rigour and cohesion to the analysis and ensured that interpretations could be challenged and validated by young people. A final step involved refining, defining and naming the major themes and subthemes, involving all four researchers (CM, CO, LS and JL) in a process of iterative, critical and reflexive discussion. As shown in Table 1 This theme refers to both environmental factors that increase the risk of harm to an individual, such as abusive or harmful behaviour, or a lack of oversight and care, as well as the risk of harm that is brought about through increased use of maladaptive coping mechanisms. Increased abuse in the home was relayed by practitioners and associated directly with the impact of lockdown. For example, it was recognised that changed behavioural patterns of parents and adults, such as increased substance abuse, resulted in increased adversity for young people. Practitioners described feelings of confusion and distress. ID:1 (F2) described the experience of one young person TA B L E 1 Major themes and subthemes identified through analysis Escalation of risk Risk is intensified through changing external factors and maladaptive coping This major theme had no subthemes who understood the relationship between alcohol and her father's abuse, but nonetheless struggled to make sense of how lockdown contributed to an escalation of these behaviours: 'The sexual abuse increased over lockdown, and she wasn't really able to account for why that was. She was aware of the relationship between the abuse and her father's alcohol use. His alcohol use increased over lockdown' (F2, ID:1). ID:2 described the escalation of abuse for one young person, which resulted from spending more time than usual living with an abusive parent, and was made more intense by that parent now working from home: 'that was dreadful for them as they had quite an abusive dad, and they were unsure how to cope and relying on friends a lot, and dad was putting them down. He was working from home so they couldn't get away from him' (F2, ID:2). Hence, being homebound escalated the risk by reducing means of escape. In addition to describing external and interpersonal factors that contributed to increased risk and adversity, several practitioners highlighted that young people were increasingly talking about maladaptive coping mechanisms such as self-harm or overexercising, alongside increased suicidal thinking. Practitioners recognised that this pattern of thoughts and behaviour had intensified during lockdown, either through increased numbers of young people talking about self-harm or progressing from thinking about selfharm to acting on those thoughts, or through a change in selfharm presentation to more frequent behaviours and changes in method. The effects of isolation and closures of wider services contributed to an increase in self-harm for a young parent who had previously struggled with substance misuse, as described by ID:3: 'He doesn't know anybody, everything is closed, everything has been shut down for him, so he is self-harming now, that has escalated, when it had previously reduced, it's escalated right up again' (F4, ID:3). Practical uncertainties around childcare provision and the inability to rely on pre-lockdown support structures amplified distress. The knock-on effect was increased reliance on self-harm as a coping mechanism. Similarly, ID:4 (F3) referred to another young person who described a changing pattern of self-harm behaviour in response to feelings of isolation: 'When she first started accessing [the service] and getting support, she didn't really talk about suicidal thoughts or self-harm,… definitely in recent months, I suppose since things have progressed, being in and out of different lockdowns, I definitely noticed an increase in not only suicidal thoughts but now there has been self-harm' (F3, ID:4). Practitioners spoke of the devastating implications of removal of sources of potential protection or safeguarding, which led to an increase in risk. Some described how it appeared that risk and abuse for young people were given greater reign in the absence of monitoring from a responsible adult or outside agent. For one practitoner, for example, the decision to remove a child from care to live with family members who were judged as having no boundaries, permitted an increase in sexual exploitation, and this situation was exacerbated by a lack of available oversight from school. Practitioners described a sense that the increased demand on support services, and lack of service capacity, had inevitably led to vulnerable young people being unsupported and let down. They described young people being placed with unsuitable family members, or a feeling that young people were being discharged from a caseload prematurely. Added to this, the removal of informal opportunities for someone to step in and monitor or offer support, for example at school or within peer groups, or the reduced capacity of family members who may be dealing with their own mental health difficulties, left individuals in a precarious situation with opportunities for protective oversight reduced, and less access to informal, as well as formal, sources of support. This major theme describes the pervasive notion of loss and its consequences, which was notably common to most young people's experiences of lockdown, according to practitioners. Feeling disconnected from friends unsurprisingly affected lots of young people, with those with both large and small peer groups similarly describing finding it harder to reach out for help and more challenging to cope with difficulties without their friends. Practitioners described the belief of young people that they would be a burden if they were to reach out to their peers or a trusted adult for support, and that sense of burdensomeness appeared to be exacerbated by the physical removal from friends, an additional physical and mental barrier to reaching out: 'she's got a couple of friends she might reach out to but then feels that she might be a burden if she does reach out to them, so yeah definitely since spending more time at home it has been harder to reach out' (F3, ID:4); 'she doesn't want to be a burden on them and because obviously she's not actually seeing people as much, I think it's having a real impact on her' (F3, ID:5). Practitioners reflected on how the young people they worked with were not aware of how important teachers and school had been in their life until they no longer had them. This void was felt keenly-some practitioners felt-for those with few resources at home to fuel hobbies and interests: 'they don't cope well without their teachers. School is actually a safe place, especially for the young people who have the more difficult home lives… you know there isn't money to buy the resources to bake cakes every day' (F4, ID:6). ID:4 (F3) echoed this notion of coming to realise how important physical connectedness had been for young people, though it had not seemed that way previously: 'even though they struggle with friendships, just being around other people has been helpful compared to the situation now'. Practitioners alluded to a sense of 'stasis', whereby an individual's ability to progress with their therapeutic process felt like it was on hold. Young people described feeling physically and emotionally trapped by their circumstances, which practitioners suggested limited the ability to make therapeutic gains. ID:7 described one young person who lived with a violent partner, with no outlet for relief: 'so they were stuck in that place together all the time and there was no outlet for either of them' (F2, ID:7). Stasis was compounded by the loss of options that professionals could suggest for seeking help while restrictions were in place. A dominant experience of loss consistent throughout the focus groups related to the notion of a perceived loss of agency and autonomy that young people found frustrating. They described to practitioners a sense of losing choice, losing options, losing places to escape to, and losing the ability to express themselves or make themselves heard. ID:9 described a young person living away from home, finding themselves in an abusive relationship and feeling unable to remove themselves from the situation, despite wanting to. ID:9 explained: 'She's just got that sense of having to stay because the government says I'm not allowed to go back or not allowed to go stay with a friend…you know she often will say, "I don't want to be here but even if I want to leave I can't leave, or even if I get to a point where I choose to leave, where am I allowed to go to?"' (F4, ID:9). Similarly, ID:6 described another young person wanting, but feeling unable, to leave a domestic abuse situation at home. She described the layers of fear, guilt, inner conflict and subsequent resignation that emerged for someone who had identified an escape option (an older relative) but could not act upon it. She explained, 'they actually needed to get out but they were afraid, they were frightened that if they did…, they couldn't go to their gran's, that would be the place that they would go…, and of course we had this bombardment of "older people are more susceptible" so they had that guilt, and they couldn't go there' (F4, ID:6). Other instances were described where a change in the family dynamic during lockdown had led to suppression of expression and self-exploration. ID:2 described how an overbearing parent repeatedly checking in on their son had left him with a sense of powerlessness and entrapment. She explained how the balance of control had shifted: 'he is now being treated on the laptop as a 7-year-old; she checks every message; it's almost like she is trying to stop him ever going forward with his sexuality; again, that was because of COVID and the intenseness. "What's he doing online with his friends? What's going on?" And so every day, that's sort of the problem (be)'cause mum is over-checking' (F1, ID:2). This main theme connects an important pattern of findings, which described beneficial and adaptive outcomes that were associated with lockdown, including experiences that demonstrated that individuals benefited from the restrictions. In contrast to accounts of inadequate support and poor outcomes due to overstretched services, for several young people, there was consistency in support or even an increase in professional provision. Online provision was able to provide a consistent place for support that young people could return to weekly and connect with even when other options were no longer available or other structures, such as school, had been disrupted. ID:1 suggested: 'you know she felt that this one hour in the week was such a big part of her routine, just because there is so many gaps in the structure at the time' (F1, ID:1). With the service digitally supporting several vulnerable young people to prepare to engage with faceto-face services (e.g. CAMHS), there were those for whom the continuation of access to those services was essential for the trust they had spent time developing. Inevitably, however, new or additional support models, while providing much needed provision, could elicit fears and anxieties for the individuals as a result of change: 'he did have more input as well, he got put in touch with a psychologist and they did it online with him and everything so he still had a lot of input going in for him which was great, but it was very different so he obviously had to deal with his anxieties with doing it through Zoom' (F2, ID:1). In addition to formal sources of support, some individuals felt empowered during lockdown to seek support closer to home in a way that they had not before. ID:4 described an individual who had previously struggled to reach out to their foster parents but, with limited other options, found this to be a useful tool for support and distraction from thoughts of self-harm: 'their foster parents are really supportive… if they were having thoughts of harm, that was a distraction for them and they were able to share a bit about what was going on for them…they did start to reach out more, and I think the foster parents were really helpful' (F3, ID:4). The circumstances of lockdown helped this individual become aware of the support that existed for them in their home environment; for others, this presented as finding innovative ways of coping at home such as organising things in their bedrooms or making comfortable dens to hide out in when they needed space and time alone. Practitioners suggested that many young people welcomed the break from the school environment, especially those who faced peer victimisation: 'There were some that loved it [lockdown] (be)'cause they were no longer being bullied at school and it suited them to be at home, they didn't have to endure pain every day' (F1, ID:2). The relief of not needing to attend school was linked to decreases in selfharm and suicidal ideation for some. However, the temporary nature of school closures meant the transition back to school was a cause for anxiety for these individuals: 'they then started to get anxiety about going back' (F1, ID:2). The transition between lockdown and the easing of restrictions served as a catalyst for change for some young people who had used the time to reflect on and engage with their situation, becoming empowered to make decisions that had felt too challenging previously: 'However hard it was at the very beginning, [it] almost gave them strength to change their situation and then when lockdown ended, they went out and did something about it' (F2, ID:7). Strength and resilience were the words ID:7 used to describe the change that she saw in a couple of the young people she worked with. She suggested that the intensity and challenge of their situations during the first UK lockdown acted as a catalyst, prompting the realisation that change was necessary. This theme pulls together the alienation and isolation of those individuals who felt alone in their experiences, unable to relate to their peers or seek help from their families due to parental difficulties such as financial concern or mental health. This unrelatability extends to feeling as though their experiences of lockdown did not necessarily match those of others. Young people from disadvantaged backgrounds and within families experiencing financial hardship often did not feel able to ask for support from their families due to fear of being a burden or creating additional problems, and therefore carried a sense of shouldering their worries and concerns on their own. Parents may have been physically or emotionally unavailable, perhaps due to a lack of understanding of their child's concerns, or their own mental health difficulties, which left young people feeling isolated within their home environment, as ID:4 described: 'So she won't tell her "oh I Really wanting to be believed, and I thought it was important to be able to be there and tell them that it was not a question of belief,… but yeah the sense of being alone in this very unsafe world' (F2, ID:10). We explored the experiences of young people with heightened vulnerability (due to prior experiences, life circumstances and existing mental health difficulties) during the COVID-19 pandemic and national lockdown as understood by mental health professionals working with these groups in a structured or ongoing capacity via a Web-based platform. Overall, our findings broadly reflect early indications of a significant impact on the mental health and well-being of children and young people during the pandemic and lockdown (Brewer et al., 2020; Major et al., 2020; Romanou & Belton, 2020) . Findings point specifically to the contributions of separation and isolation, loss, feeling trapped and feeling hopeless, which have exacerbated and escalated the risk of mental health difficulties and outcomes such as self-harm, which were already on the rise in young people pre-COVID. Importantly, our findings also illustrate resilience and the function of lockdown as a catalyst for change. We offer reflection on the implications of this research for Web-based therapy and the wider provision of therapeutic support. A striking but predictable pattern across our data of the experiences of young people during the pandemic and associated lockdowns was the recognition among practitioners that young people who were already vulnerable and at risk of harm were experiencing increased risk both inside and out of the home. This is consistent with data collected early on in the pandemic, which described increased risk in relation, for example, to escalated domestic violence, precarious home environments and other prior experiences of ACEs (Bryant et al., 2020; NSPCC, 2020; Stripe, 2020) . A contributing factor in the accounts of our practitioners was reduced access to support through the loss of contact with responsible adults and subsequent missed opportunities for care. This resulted in less risk monitoring and detection, and young people feeling unsupported, unnoticed and unsafe. These findings resonate with existing studies (Donagh, 2020) , which have called out the invisibility of young people at risk of domestic abuse during the pandemic. Our findings point to the critical role that schools play, not only in the early identification of risk and provision of mental health support, but also in providing access to a safe and predictable space and respite away from an abusive or precarious environment, or where young people may experience alienation within the family home. The disruptive impact of school closures on disadvantaged young people for whom consistent attendance at school may have been already challenging is likely to have significant repercussions beyond the short term. Of note, while schools have now reopened, the return to school has remained precarious, and evidence indicates that schools are under-resourced to provide the levels of pastoral care and mental health support that many young people may require as we transition out of lockdown. Young people facing additional adversity and inequality are likely to be particularly at risk (Young Minds, 2020a) . The prevalence of self-harm (with and without suicidal intent) in young people has been rising in the years leading up to the pandemic, most sharply in young women (Geulayov et al., 2016; McManus et al., 2019; Morgan et al., 2017) , and while rates of suicide remain lowest in younger age groups (10-24 years), there has been a pattern of increasing suicide in this age group in recent years (ONS, 2019) . Despite concerns, to date, there is no clear evidence that rates of self-harm and suicide overall have increased during the pandemic and its associated restrictions (John et al., 2020) ; however, data are still emerging, and the longer-term impact of the pandemic is uncertain. Evidence does suggest that those with pre-existing mental health diagnoses or with poorer household incomes have been at greater risk of self-harm and also report higher levels of depression and anxiety (Iob et al., 2020) . Our findings indicate that issues around self-harm and suicide became more common and frequent for young service users following the onset of the pandemic, and while we caution against attributing causality to complex patterns of behaviour, the accounts of practitioners are drawn from relationships established with young people prior to the pandemic and maintained over lockdown; that is, they can comment on perceived change over the period of interest. Findings also support wider service data from 2020, which showed numbers of children and young people presenting with self-harm had increased by 45% in the previous year, and suicidal thoughts had increased by 40%, accounting for 19% of all issues supported by the service (Kooth plc, 2020). These findings support data from other community-based self-harm support organisations, which have reported increased service demand during lockdown (Twist et al., 2020) . Factors identified here by practitioners-such as social isolation, feelings of entrapment and loneliness-are known to contribute significantly to suicide and self-harm risk (O'Connor & Kirtley, 2018) . In addition, practitioners described the sense of young people not wanting to be a burden to others, something exacerbated by the loss of physical closeness. Perceived burdensomeness is a well-documented predictor of suicide (Hill & Pettit, 2014) , emphasised within leading theories of suicide (Van Orden et al., 2010) as a critical factor in suicide prevention. Our findings signal the contribution of enforced physical spacing in contributing to perceived burdensomeness risk, which could arguably relate to the perception of increased 'costs' involved for others in providing support remotely, or reduced opportunities due to enforced distancing for the young person to be reminded that they matter to others. A narrative over the course of the pandemic has been of society as a whole living through an event, which brings individuals together in a collective experience. Such a 'pulling together' effect is referenced in response to other catastrophic global adversities where individuals can feel a sense of togetherness or increased resilience and connection, which may act as protective factors, at least in the short term (Zortea et al., 2020) . Our findings signal that any sense of shared experience was anathema to vulnerable young people, who described feeling more alienated and separate because their experience was so different to the wider societal experience, and finding this to be harmful. These individual insights add to existing data evidencing the inequality of experience during the early weeks of lockdown for those with additional and pre-existing adversity (Nolan, 2020; Wright et al., 2020) and demonstrate the need for research and policy approaches which sufficiently take into account the complexity of risk for groups with heightened vulnerability. However, stories of resilience and the individual-led change that occurred for those feeling empowered and supported suggest that, for some vulnerable young people, the pandemic has been a critical catalyst for change. Counselling and therapeutic support can be a key element to supporting adaptive coping (Amnie, 2018) , and the consistent provision of support from the service may well have contributed to the capacity for resilience demonstrated by some young people referenced within this study. Previous qualitative work has explored recovery and resilience building following adversity in adolescence, highlighting progress through the ability to take agency and shift perspective (Shepherd et al., 2010) . Young people spoke of acknowledging, perhaps for the first time, wider systems of support, such as different family members. Further research is needed to explore the psychological mechanisms and pivotal moments which might underpin these adaptive responses to lockdown for young people. We cannot dismiss the experiences that have previously placed these young people into a vulnerable category, nor the ongoing complexity of individual circumstances. These lived experiences will carry trauma and increase the possibility of maladaptive coping or adverse life outcomes at a later stage in life (Amnie, 2018; Asmussen et al., 2020) . Therefore, longitudinal studies engaging with vulnerable populations following the pandemic are necessary to understand the longer-term impact of lockdown on the relationship between adversity and resilience. Additionally, exploring the contribution of Web-based therapeutic support specifically to the maintenance of factors such as increased resilience will be important to investigate in future research. Digital services undoubtedly have an important role to play in providing a stable source of support for young people where care is otherwise unavailable, or to support existing provision. Crucially, digital or Web-based services that offer anonymity and privacy are seen to provide choice for young people in the support they can seek (Frith, 2017; Hanley et al., 2020 Hanley et al., , 2021 . This is of particular importance for those who do not feel supported or safe within their home and may not be able to engage their parents for support with their mental health or seek face-to-face support independently. Nonetheless, our findings underscore that digital provision is only one aspect of a wider support system for young people and make clear the implications for vulnerable young people where access to safe, accessible, ongoing and consistent mental health support provision is removed. The experiences of young service users of the digital service echoed accounts from early on in the pandemic of overstretched services unable to service the level of need (BMA, 2020; Chanchlani et al., 2020; Romanou & Belton, 2020; Young Minds, 2020c) and highlighted the sequelae for many service users who began lockdown at greatest risk when wider support needs were unmet. The implications of under-resourced mental health provision were also reported in the frustrations of staff. Practitioners described their experiences as being caught in a 'holding place' alongside the escalation of risk, with limited options for signposting or referring young people for additional support. This left practitioners stressed and close to burnout, providing a critical argument for the importance of integrated services that are equipped to support young people when they need it. This builds on the already globally recognised need for increased integrated support across primary care settings, and digital and communityfocused support (Hetrick et al., 2017) . Our findings support the recommendations for a traumainformed approach to ensure the needs of vulnerable young people are safely met (All-Party Group on a Fit & Healthy Childhood, 2021). A trauma-informed approach involves taking a routine or targeted approach to enquiring about ACEs to create a compassionate and trusting space for support. Health practitioners who trained in trauma-informed enquiry reported feeling more empathetic and understanding of the individuals they came into contact with, especially those who may have previously been considered 'troublesome' (Hardcastle & Bellis, 2018) . The result of using this approach is that young people are more likely to feel heard and achieve better life outcomes. Additionally, using this approach within assessment has been found to support prevention and early intervention due to the earlier disclosure and trust developed through embedding trauma-informed practices (Quigg et al., 2020) . In this study, practitioners reported sometimes feeling out of their depth with the level of risk they were dealing with. Our findings directly indicate that Web-based mental health professionals would benefit from additional trauma-informed training, but also signify that anyone working on the 'front line' with young people now and in the aftermath of the pandemic-as well as the wider service context in which they work-is likely to benefit from training and support in providing trauma-informed care. This, in turn, is likely to improve outcomes for young people with ACEs. Our focus specifically on the experiences of young people with heightened vulnerability pre-COVID is an important strength of the study. Children and young people with increased vulnerability were already at a higher risk of physical, emotional or psychological harm, with an increased susceptibility to poorer outcomes in life (DoH, 2009; HM Government, 2018; NSPCC, 2020) , and growing evidence has suggested that those with heightened vulnerability prior to the pandemic have been disproportionately and detrimentally impacted (Iob et al., 2020; Jaspal & Breakwell, 2022; Romanou & Belton, 2020; Stripe, 2020 We would like to acknowledge Leaders Unlocked and all the young people who voluntarily took part via Leaders Unlocked in the workshops that enriched the design and interpretation of the findings from this study. CM contributed to the design, leading the focus groups, supporting the PPI workshops, analysis of the data from the focus groups and writing of the manuscript. LS contributed to the analysis of the data from the focus groups and the manuscript writing and revisions of the manuscript. CO contributed to the recruitment of practitioner participants, supporting the PPI workshops, assisting the focus groups, transcription of the focus group conversations, the analysis of the data, and the writing of the background and methods within the manuscript. JL contributed to the development of the analysis from the focus groups and the writing of the manuscript. All authors have read and approved the final manuscript. The study was reviewed and approved by the University of Exeter Ethics Committee on 15 October 2020 [ethics code: eCLESPsy001970]. Due to the sensitivity of the thematic codes, these are not provided on a repository for these reasons. However, the data sets analysed during the current study are available from the corresponding author on reasonable request. Consent for participation was collected from all practitioners ahead of their involvement in focus groups. All service users from the service provide consent on signing up to the service for their data to be accessed for research as agreed in the terms and conditions. All data from the service are anonymised and, in this project, are shared through practitioners assessing the relevance of the experiences for the research question specifically; this reduces the need to delve into personal experiences that are not relevant to the research questions. Charlotte Mindel focuses her research on children and young people's mental health support, with a focus on understanding and reducing societal barriers to mental health support. Dr Louisa Salhi's research and background is in the field of cognitive neuropsychology, with a focus on memory, reward dysfunction and clinical factors that affect these processes. Louisa has an interest in clinical psychology and digital technologies, specifically improving access to services. List of eligibility criteria to classify a young person as vulnerable. 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Coronavirus: Impact on young people with mental health needs The impact of Young people's priorities • In smaller subgroups, discuss the question 'If you were doing this piece of work, what would you like to find out?' • Share key findings with other groups Leaders unlocked Theme discussion • Researchers to inform young people which priorities have been identified and how these compare • Taking each theme one by one, sharing 1 slide per theme, discuss as a whole group: What are the essential themes that need to be explored? • Is there anything else you think would be important to cover? For each of the themes, are we focussing on the right elements and is there anything missing/needs to be redefined? Current themes: • Vulnerability • Physical elements of lockdown (e.g. school closure, loss of services, more time with family) • Emotional experiences of lockdown (e.g. abuse, child sexual exploitation, parental substance misuse) • Unique experiences (e.g. increased or different anxieties, different interaction with the service) Thank you and next steps • Details of next steps, following workshops and staying in contact Leaders unlocked Pre-task questions• Was there anything that particularly resonated with you?• Was there anything you found surprising?• Is there an experience that hasn't been mentioned that is of importance?• If you were a decision-maker/prime minister for a day, what would you be your top 2/3 priority areas of focus for supporting YP?