The Management of Young People’s Goals in Alternative UK Mental Health Services

Nested Ethics

— Rosie Jones McVey

Published: 26 April 2023

Mental health Ethics Youth Goals Agency UK

https://doi.org/10.17157/mat.10.1.6764

Abstract

Youth mental health interventions in the UK increasingly use goal-setting procedures to shape services and measure outcomes in ways that are intended to be meaningful to service users. This research article questions this premise, departing with the ethnographic observation that many young people do not seem to welcome the invitation or requirement to direct their therapeutic aims and set the terms for service evaluation in the form of goals. I will show that goal-setting procedures are examples of a broader field of complex ethico-political dilemmas navigated by mental health service staff. While wanting to enable young people to be healthy agents, staff are simultaneously critically aware of the risk of imposing normative, unrealistic and unfair expectations onto young people. I propose that these staff are engaged in a specific form of ethico-political practice, which I call ‘nested ethics’. I use this term to describe instances where staff ethically evaluate their own conduct in line with the capacity to enable the ethical life of another person (youth, in this case). Viewing goal-setting processes as an example of an uneasy politics of nested ethics enables a new perspective from which to advance debates about the enablement of service user choice within care provisions.

The trouble with goals

In 2015, a UK government task force published a report on children and young people’s mental health called Future in Mind . Its vision statement on children and young people’s health begins as follows: ‘You have goals and ambitions you want to achieve. We want you to grow up to be confident and resilient so you can develop and fulfil these goals and make a contribution to society.’ Further down in the text, a phrase is highlighted in bold: ‘You are experts in your care and want to be involved in how mental health services are delivered and developed…’ (UK Department of Health 2015, 11).

These sentiments could be read as empowering, respectful, and engaging. They appear to allow young people to be recognised as goal-setters, achievers, and experts, and to put young people—rather than the therapists or other adults around them—in the driving seat.

Yet, while undertaking ethnographic fieldwork and volunteering at an equine-assisted therapy centre in 2020–2021, I observed that when young people (a phrase denoting roughly ages 10–20) were invited to participate in a formal goal-setting exercise as an early part of their therapeutic intervention, these sentiments were not always welcomed. Young people were usually asked to devise goals at the beginning of their second or third session. Shortly after arriving by minibus, they would be gathered by staff around picnic benches just outside the stable yard, and supported in setting their goals. But supporting them, as I observed during one of the sessions, was not easy. For example, 15-year-old Bella began to pace angrily, clenching her jaw, when she was asked what goals she might like to work towards. Sixteen-year-old Geoffrey slumped into his chair, held the goals form on the clipboard at arms’ length and offered only a minimal response to the questions asked, thanks only to the rapport already built by a tactful staff member.

In contrast to Geoffrey’s reaction, some young people seemed almost too compliant, ready to write down whatever they thought staff wanted to hear. Nineteen-year-old Sam stared at the goal form with apparent willingness, the pen resting to his mouth as though in deep thought. He seemed faded, defeated even. He looked tentative and fragile as though a breeze might knock him over. He nodded absently in response to my efforts to engage him with questions intended to draw out his perspective, handed me the pen, and told me despondently that I could put whatever I liked down for his goals, he didn’t mind.

The goal-setting forms that Sam and his peers were being asked to complete (known as the goal-based outcome measure, or ‘GBO’) (Law and Jacob 2013) are becoming common features in the landscape of alternative education, youth work, mental health services and health and social care in the UK (CORC 2021). This research article presents ethnographic observations regarding the handling of these forms at an alternative mental health and education provision (i.e., not a state-run service such as the UK National Health Service ). Fieldwork for this research was carried out at an equine assisted therapy and learning centre, though this article will only briefly touch on the subject of horses. I will use the management of goals as an exemplar of the ethico-political complexities that face those working in a broad range of mental health services as they attempt to recognise and manage young people’s agency. By ‘agency’ I am referring to the capacity for young people to make a change in their own lives (though later I will supplement this with the important category of ‘healthy agency’— the capacity for people to make beneficial changes in their lives). By ‘ethico-political’ I refer to the intersection between the ethical (how people—in this case mental health workers—feel they ought to act) and the political (how people experience power in their life). Service providers’ ethico-political challenges revolve around figuring out how they ought to manage the power discrepancy between staff and young people, or, to put it another way, what sort of agency young people ought to have in relation to their care.

Two questions arise: firstly, why is it that some young people are unable or unwilling to engage sincerely in goal-setting processes? And secondly, given that staff recognise the unpalatability of goal setting for some of these young people, why is it that they persist in achieving it? After all, such persistence seems to go against the remit of the exercise—to let young people take the helm.

Existing approaches within medical anthropology have provided the theoretical resources required to answer the first question rather than the second. Young people’s resistance to goal setting (including over-compliance) can be seen as demonstrative of the obstacles facing care provision once it becomes too eagerly wedded to the ‘logic of choice’ (Mol 2008). That logic presumes that patients will benefit from being treated as individual decision-makers in relation to their own care, as though this will buy them independence and control over their conditions. Yet, as Annemarie Mol shows, care is always rooted in relationships of interdependence, and health is always somewhat unpredictable. Other ethnographers have shown that good care does not always equate with chosen care (Harden et al 2011), and that the ideal of enabling autonomous agency in care provision does not hold universal value across cultures (Borovy and Hine 2008) and classes (Lazarus 1994).

In line with this scholarship, providing good mental healthcare for young people will always necessitate providing more (and probably less) than young people could possibly choose or define as pre-determined ‘goals’. In fact, the whole concept of ‘goals’ might appear ironic if not paradoxical in this particular case, since young people’s lives are in many ways controlled by adults, and since some of those adults have already identified in the youth an apparent lack of capacity for healthy agency, legitimising treatment in the first place. While the intent behind goal setting may be to alleviate the way young people are routinely undermined, it can inadvertently emphasise or exacerbate the problem (as has been found for other forms of service user involvement, e.g., Pilgrim 2005; Lewis 2014).

Several factors should be considered here. First, goal setting presumes young people want support with their personal development and does not leave much space for acknowledging that such interventions are assigned by adults and sometimes resisted by youth. Second, the notion of setting and accomplishing goals can place the onus for rehabilitation on service users, despite the complex and challenging world these often vulnerable young people may exist within (Pols 2016; Brodwin 2013). Thirdly, the trust, articulacy, openness, sincerity, psychological dialect, and so on required to engage wholeheartedly in therapeutic goal setting depend on an idealistic, exclusionary notion of agency that does not apply straightforwardly to young people like Bella or Sam. Finally, it is important to acknowledge that the GBO process is a measurement tool— hence standardised and formalised—which may override its capacity to cultivate authentic engagement in dynamic and sensitive therapeutic relationships (Nazanderani, Noorani, and Dudwhala 2020; Klaus and Bødker 2020). The fact that young people display an aversion to goal setting supports the argument that ‘accountability’ and ‘empowerment’ are contradictory processes, and that only a ‘thin’ form of empowerment can ever be accommodated within accountability measures (Armstrong 2016).

Although these lines of analysis are valuable, they fail to provide the tools to address the second question. If the goal-setting process is taken as evidence of misguided faith in the power of patient autonomy, this can limit how staff who implement such procedures are perceived. They can be seen as naïve—unaware that goals are often produced with only the superficial and coerced engagement of young people, or, on a more serious note, unaware that goal-setting logics may play into a broader pattern of the responsibilisation of disadvantaged young people. Alternatively, it might be concluded that staff are subsumed within a system, and unable, either through dogmatic obedience or infrastructural rigidity, to rid themselves of the requirement to formalise the active engagement of users by recording goals. Another explanation could be that staff are tactical or even cynical in their understanding that goal setting is part of playing the game that produces referrals and funding, engaging in the ‘data hustle’ (Carruth 2018) of service work, regardless of whether or not it genuinely engages young people in their treatment. My observations during research at The Meadows, however, did not substantiate the above suppositions. Staff were deeply, critically and ambiguously invested in the concept of young people guiding their own journey (through goal setting and other means) and committed to the idea that services should be held to account for their capacity to provide the sort of care that young people need, not just the care that those in power deem appropriate.

In order to delve further into the question of why staff persist in actively persuading young people to have goals, this article will follow the example of Tom Matza’s ethnographic work with youth (2012). Studying psycho-education programmes for Russian elite youth, Matza draws attention to the ethical engagement of staff as a means of complexifying the possible story in which staff feature as mere mechanisms for the projection of neoliberal logics (such as entrepreneurship, measurement and choice) into youth mental healthcare. That being said, Matza’s approach does not fully suffice in addressing my question. In his research, he focusses on the hopes that staff hold for the meaningful impact of their work, above and beyond the official marketable aim to improve youth ‘potential’ in a socio-economic sense. Matza is interested in showing us what staff value in their work with youth. I will focus instead on something subtly, but crucially, different: what sort of ethical project is required of staff such that they can create the ‘space’ in which young people can complete their own ethical reflections. This line of questioning is interested in the ways in which staff value young people’s own schemes of value.

This approach will develop existing research on the forms of personhood afforded to service users and service providers within mental healthcare. In this body of literature, authors have emphasised the impoverishment of care when it offers its recipients no agency over their treatment, or within their lives (Goffman 1961; Biehl 2013). In contrast, and as a complement to these cautionary cases, other scholars have painted optimistic (yet not overly simplistic) pictures about what mental healthcare can look like when it enables service user agency (Nakamura 2013). For example, Neely Myers describes how living well in recovery involves ‘moral agency,’ a central aspect of which is the opportunity to build meaningful relationships, including the ability to fail along the way. A third strand of work investigates what it is like for staff and service providers to operate as ethical, self-evaluative beings while attempting to provide mental healthcare (e.g., Bodwin 2013). A conceptual apparatus is yet to be forged for considering what is specific to the ethical demands placed on staff (or family, or friends) as and when they attempt to enable service users to exercise their ethical agency. By ethical agency I mean the capacity for service users to evaluate themselves and act in accordance to their own sense of what they ought to do.

In this article, I will suggest that there are important distinctive features about the ethical lives of those who conscientiously orientate themselves towards the support and enablement of the ethical lives of dependent others (be it those in mental health recovery, education programmes, parenthood, or other positions of intimate ethical dependency). I call this dynamic of interrelation and dependence ‘nested ethics’, which consists of those who are ‘nesting’ others, and those who are being ‘nested’ by others (notwithstanding the fact that the same person can hold both positions). This approach invites future comparative investigations into the variety of ethico-political dynamics inherent when one person is ethically orientated towards enabling the ethical life of another.

The Meadows

My research involved 15 months of ethnographic fieldwork volunteering as an equine assistant in three equine assisted therapy and education centres, while visiting and conducting interviews at other centres (with 25 providers in total). Participant observation was supported by unstructured, audio-recorded focus group discussions with staff and volunteers on the theme of ‘goal setting’ and several informal in-depth discussions with key informants on this topic. In this article, I focus on one provision, pseudoanonymised as The Meadows. All individuals are anonymised, with some details changed or omitted to protect their identity. While all the young people (and their carers) gave consent to take part in this research, I have provided only those ethnographic details required to support the argument, and restrained from excessively detailed descriptions of these young people’s stories and struggles. The Safeguarding Lead at The Meadows has approved this publication.

The Meadows is a charity that provides therapy and learning programmes for young people using horses. Equine Assisted Therapies are becoming more of an important feature on the national landscape of youth services. The Meadows should also be seen as an example of two other, broader categories of care—‘third sector’ or charitable provisions for mental health and wellbeing, and ‘alternative’ approaches to talking therapy (such as those that involve music, art, sport, novel experiences, green spaces and so on). As in many other examples in those categories, The Meadows operates across a very sensitive and somewhat permeable boundary between ‘proper therapy’ work (i.e., that which occurs with an accredited mental health practitioner such as a clinical psychologist and usually in response to a diagnoses), and other forms of intervention, such as alternative education, community support, or efforts to improve personal skills. The Meadows caters for individuals or groups, with young people referred through social services, schools, pupil referral units, parents, foster carers, or other charities or youth services. The funding arrangements are complex—largely involving grants from other charities and private trusts, with payment also coming from councils, schools, or through individual ‘education and health care plans’ (EHCPs). The sessions consist of varied activities: mucking out stables, brushing horses, or learning to train them with a series of ‘ground’ (as in, not ridden) exercises, such as taking the horses out for walks. The question as to why or how horses might be helpful is a live one that practitioners are working hard to ascertain in a variety of ways (e.g., Bivens et al 2007). For the purpose of this article, it is enough to suggest that the outdoor setting, the practicality of the tasks, and the highly sensitive nature of horses are all thought to help young people try out new ways of relating to themselves and to others.

The Meadows tends to work with young people who have been hard to engage in other settings. Many do not attend school regularly, 15% were permanently excluded from mainstream school ¹ . Some refused to see more traditional office-based therapists. Many had fallen through the net of the overstretched CAMHS ² — they may have spent months or years on waiting lists, failed to meet the criteria for treatment, or felt unsupported by the services on offer. There was a high proportion of socio-economic disadvantage among these young people (46% pupil premium ³ , 20% looked after children, 21% current and 38% previous safeguarding involvement). They showed a range of ethnic diversity (48% identified as White British with 19 other categories of ethnicity represented ⁴ ) and a roughly even representation of gender (54% male). The problems presented at The Meadows included (a non-exhaustive selection) difficulty with concentrating in the classroom, not following adult instructions, disruptive and dangerous behaviours, anxiety of many different forms, problems with anger, self-harm, suicidal ideation or attempts at suicide, trauma recovery, breakdown in family relationships, difficulties in maintaining social relationships (for example bullying, being bullied), criminal activity, unsafe sexual activity, selective mutism, anorexia, and low self-esteem.

Holding space

It is significant that the list above is not limited to diagnostic mental health terms, as could be derived from the Diagnostic and Statistical Manual of Mental Disorders (DSM) handbook used by psychiatrists. A key ethos of The Meadows holds that young people should not be so readily identified by such labels. When I began fieldwork I was struck by the restraint that was exercised by staff when describing young people. At first, I often felt alarmingly underinformed in my role as volunteer. Pre-session planning meetings would leave me hungry for more detailed descriptions about the young people I was going to work with. Senior team members would have enough information to manage the risks, but the general ethos was that staff and volunteers would have to meet the young people and learn who they were, or could be, on this day and in this place—which might be very different from the person described in diagnostic terms or service referral stories. As one of the session leaders explained, negative stories (and sometimes diagnostic labels) could be a weight around the neck of young people, pulling them down, and polluting all of their relationships. Our job was to provide a space where young people’s capacities would not be predetermined by external judgements or standardised criteria, they explained to me, a space where these young people had the opportunity to make new stories or retell their past experiences in a new way.

Such an approach involved an active withholding of our (the staff’s, the volunteers’ and the ethnographer’s) own judgements and opinions. During a staff training event, it was emphasised that equine staff (whose role was to be responsible for safety and equine welfare) needed to be extra cautious about their own presumptions, since they had not had the training in countertransference and critical approaches to psychiatry that mental health staff had undergone. Equine staff might inadvertently undermine the therapeutic environment by doing something apparently benign, like showing a young person how to catch an unwilling pony. This was for two, linked, reasons, the training facilitator emphasised. Firstly, because whichever explanation the staff member gave about the pony, (e.g., ‘he’s being lazy/scared/disrespectful, therefore you need to be encouraging/calming/authoritative), it could eclipse and obscure the meaning that the young person may have ascribed to their encounter. This pony’s evasive behaviour may have worked as a metaphor for the young person’s school refusal, or an unwanted relationship, or their mother’s disinterest. Each young person’s interpretation was paramount. Where young people’s interpretations were not yet forthcoming, it was important that volunteers and staff did not ‘fill the space’ with too many of our own narratives and meanings.

Secondly, it was considered important that young people were trusted to come to a solution in their encounter with horses by themselves. Often this was a solution that the equine staff member would not have thought of, like singing to the horse, or walking backwards. It did not matter if young people did not do things in the way that the British horse world would necessarily approve of. As a horseperson in this setting, I learned to catch words in my mouth before they escaped. I learned to literally stand back, further away from the horse and young person, to curtail my desire to demonstrate a more effective way of handling the horses. In other words, I learned to cultivate something that equine assisted therapists call ‘holding space’. ⁵ ‘Holding space’ can be seen as a virtue. In the anthropology of ethics, virtues can be understood as deliberately cultivated, habitual ways of engaging with the world (Laidlaw 2013; Faubion 2001; Mattingly 2012), though I will revisit ‘holding space’ as a very particular form of ethical practice later in the article.

When I asked about the importance of ‘holding space,’ one equine assisted educator introduced me to the concept of ‘unconditional positive regard’ by telling me to read Carl Rogers— a founding father of the ‘humanist’ tradition in American psychology ([1961] 1995). His approach worked to flatten the hierarchy between therapist and client, with the assertion that the client is the only one who can see the world from her own perspective, and therefore phrase the questions needed, let alone find the answers. From this perspective, the therapist’s job is not to determine the problem and its treatment, and certainly not to advise, but to offer the sort of supportive, empathic, curious dialogical partner with whom the client can begin to articulate their challenges on their own terms. Rogers explains, ‘In my early professional years I was asking the question: How can I treat, or cure, or change this person? Now I would phrase the question in this way: How can I provide a relationship which this person may use for his own personal growth?’ (idem, 32).

The Meadows staff each had a different training background (clinical psychologists, counsellors, psychotherapists). Collectively, they were influenced by a comprehensive mixture of therapeutic models including but not exclusive to Rogerian approaches. Nevertheless, Rogers’ ‘person-centred therapy’ (i.e., the predecessor of the now prevalent ‘person-centred care’ approach across health services) exemplifies an ethos of determined, disciplined egalitarianism that accompanies the withholding of judgements and the mitigating of staff ‘expertise’. The Meadows demonstrated a ‘Rogerian’ style of listening, not only during actual conversations with young people, but in the way they managed spaces, timeframes, and session plans. They aimed to construct supportive, responsive, engaging environments in which young people could be trusted and enabled to reconfigure their own ways of relating to themselves, one another, and the wider world.

At the Meadows, this was not just about therapeutic efficacy but also ethical and political justness—a way of handling hierarchical relationships that had become ethically problematised. The Meadows operated within a world of ethically sensitive political hierarchies: between adults and youth; white (98% of staff) and ethnically diverse (young people); middle class (most staff, certainly senior staff) and working class (most service users); employed or vocationally engaged (staff, volunteers, trainees) and economically precarious (young people). These hierarchical contrasts all intersected with the intensely problematised therapist/client hierarchy, giving mental health staff an acute sense of the ethical risks inherent in the power they held.

The Meadows staff held the concept of ‘therapist’—and especially—‘typical therapist’ in critical regard. The most senior, educated staff members could articulate this unease with reference to decades of internal clinical debate and external criticism about biomedical models of madness (see Skull 2019). They were familiar with Foucault, Tsasz, Liang and Goffman, and followed the developments of the new UK based anti-diagnostic ‘Power Threat Meaning Framework’ with interest (Johnstone and Boyle 2018). The equine staff and those newer to the sector had less developed critical positions but harboured a strong sense that ‘typical therapy’, like ‘mainstream education’, was too stuck in its ways, too narrow in its expectations, and not responsive enough to the real needs of young people. From staff member’s perspective, what might be going wrong for these young people was not the makeup of their brains, but the world that they lived in ⁶ . When discussing youth mental health in general or in relation to individual cases, staff drew on a wide array of problems that they saw as likely causes. These included global issues: social media, racial politics, environmental degradation; national issues: class politics, educational pressures, poor funding of public services, deficiencies in health and social care; and personal challenges: experiences of trauma, poverty, family dysfunction, racial stigmatisation, violence, abuse, neglect.

With these predicaments in mind, it was not only that staff and volunteers should not exert our judgement as an authority over young people by dint of a contemporary moral principle that all individuals should each be entitled to their own unique perspective (a feature that Deborah Cameron (2000) calls ‘righteous tolerance’). There was something more specifically restorative, cautious, and fragile than that: it was that with a historical sense of their position vis a vis these young people’s (who were marginalised as pathological for one reason or another, subject to traumas that others may never fully understand, and often, clearly suffering), external judgements and narrow expectations would be particularly unfair. Staff were motivated by a democratic rationale (Beresford 2002) to acknowledge and enable what political theorist Tehseen Noorani calls the ‘experiential authority’ of those who have lived through mental health struggles and treatment journeys (2013). Yet, as I will show next, it is very difficult to curate a space for young people’s agency to emerge that is not also an imposition upon that emergence.

Goal based outcomes

The Meadows were introduced to the Global-based outcomes (GBO) measure form when a local council asked them to use it to report on the progress of the young people it was referring for their programmes. The GBO form asks for three goals to be set by young people in dialogue with their therapist or support workers. Young people rate their current progress towards each goal on a numerical scale of 0–10 at the start of treatment, and again at the end. From the perspective of the service provider, service evaluation involves an aspect of pragmatism—competing for funding by proving one’s worth. The Meadows proudly reported that 90% of young people had reported improvements to all three goals on its website. But measuring outcomes was also a matter of integrity. The staff showed a genuine interest in learning the extent to which the needs of young people had been met through goal-setting, and therefore in what way their programme was successful and how it could be improved for the service users. They knew from their own experience working with the young people that something seemed to be working well, but the evaluation helped confirm why.

As part of their portfolio of evaluation procedures, The Meadows maintained their use of the GBO form with all clients, above and beyond that initial council requirement. It was a particularly useful tool because of its dual function—it helped staff to shape the provision around the things that young people themselves wanted to work on, and enabled service evaluation on terms that young people had set. Like other idiographic (individually varied, as opposed to standardised) measures (Wolpert et al 2012), the GBO plays an important ethico-political role in the history of treatment measurement. It responds to the critique that any apparent ‘evidence’ about treatment efficacy inevitably advances certain schemes of value that determine what counts as ‘being well’ (Tannenbaum 2005).

The Meadows had struggled to find applicable psychometric measurement tools that did not make inappropriate presumptions about their service users. For example, some tools measured aspects of social and emotional functioning by asking young people to rate how often they lied. The presumption in the test design is that frequent lying reveals poor social and emotional health. But for young people who may have reasonable, astute and even compassionate reasons for lying (such as protecting those who may be engaged in criminal activity), lying is a much more complex and ambiguous measure of social and emotional health. With the GBO, staff asserted, young people could determine what they felt were appropriate or healthy patterns of behaviour, thought, or feeling, and they could set the specific goals that they felt ready and able to work towards. This measurement tool would seem to fit within the broader ethos of ‘holding space’; the idea of extending curiosity and openness towards others. It would also seem to safeguard against the possibility of inadvertently saddling vulnerable young people with unfair expectations and norms in the name of ‘better’ (i.e., more measurable and accountable) treatment.

This is not to suggest that staff had bought into an emancipatory ideal about goals hook, line, and sinker. During focus group discussions about goal-setting procedures, staff’s observations resonated with my own—that goal setting could feel awkward, and needed tactful handling. Staff had a good sense of why that might be. Young people did not arrive at The Meadows as though they were preparing to embark on a teleological journey of personal growth. These were not middle class, private clients who had deliberately chosen to engage in therapy with a sense of ‘work to be done on self’ in mind. They had arrived by dint of a series of adult decisions and were often unclear about why they were there and what it might do for them. They walked into the stables already reeling with emotional responses to complex contexts. The following three brief vignettes illustrate the point:

Fourteen-year-old Geoffrey’s goal-setting session happened to fall on the day when classmates had been laughing about their parents’ outdated first names during the minibus ride to the stables. His own mother had passed away two years prior and his behaviour had deteriorated ever since. Geoffrey had broken a lot of things—windows, an oven, cars, doors. He had not damaged anything at The Meadows, but he did sometimes seem cross, he would set his jaw and kick stones, blinking back tears. Staff only found out about the discussion that had taken place on the minibus after he had already completed his goals form, on which he had first written ‘fuck off’ and then crossed it out and written ‘run with Lacey’ (one of the horses). Sensing he had already ‘given enough’, staff had not required him to improve upon that entry that day.

Fifteen-year-old Daisy’s goal-setting session was delayed until week five, since she arrived very late every week, clearly in distress, often weeping, and hugging her arms around her torso as though to protect or cradle it. Her condition seemed aggravated by efforts by staff to comfort her or find out what was wrong. Attempts to meet Daisy’s eyes, let alone begin a conversation, felt like intrusions. Her new grey-haired foster carer seemed at a loss, too, shrugging his shoulders when anybody caught his eye, like a well-meaning stranger. Quietly brushing horses with very little verbal or formal human-human interaction was the only thing that seemed to sooth Daisy. Slowly, week by week, Daisy was drawn to engage in horse care activities, which led to the beginnings of rapport with staff. By the time Daisy could articulate a goal, the most profound shifts had already taken place.

Fourteen-year-old David rested his head on the table during his goal-setting session. I sat with him, feeling that he was benefiting from my company, but not sure what to say. David was usually friendly enough with staff, he would smile and say please and thank you. He had been referred into The Meadows since his school could not get him to do anything much except for being polite. He had not written or read a single word for over a year. He often looked weighed down, as though gravity pulled more strongly on him than most. After a minute or two, he spoke up unprompted, ‘Do you ever just lie in bed thinking and thinking and thinking, when you should be sleeping?’ he asked, half smiling as though reflecting on a curious human trait. ‘What do you think about?’ I asked. ‘I think, where will I live? What house will I be in? What bed will I have next year? That’s what I think,’ he said, as though he was being daft.

Engaging with young people like Geoffrey, Daisy and David, The Meadows team were well aware that collecting goals was not the same thing as attending to needs. They knew that having a goal was not synonymous with expressing a perspective, or making a choice, or wielding agency in the therapeutic environment. The latter could be done by refusing to get off the minibus. Young people seem to have both less autonomy (sometimes unable to set goals), and more autonomy (very able to resist goal setting) in relation to their treatment than the designers of the GBO seem to anticipate (for a similar dynamic in a very different context, see McKearney 2021).

For Geoffrey, Daisy and David, The Meadows was helpful in ways that out-scoped anything that might be articulated as meeting a personal goal. For one thing, it provided refuge and respite from unhelpful or even unbearable aspects of everyday life. Refuge is not the sort of thing called to mind when one is asked to list goals. Seeking refuge almost seems like the opposite of an aspiration for personal growth. Though, with refuge in mind, it makes sense to take seriously the young people who answer ‘a day away from school’ when asked for a goal.

Getting goals done

Helping young people in their goal setting was not always so challenging for staff. Yet even when it was a smooth procedure, I noted the tact and care that staff employed to curate the time and space in which goals could be formed and articulated. Some decided to set and review goals while young people were brushing horses, or clearing the paddocks of horse manure, noticing that these seemed to be inherently calming activities that gave young people time to think without feeling scrutinised. Sometimes it was important that staff removed the pressure of completing a goals form in writing, in which case they discussed goals verbally and wrote it up on young people’s behalf. But in other cases, young people might appreciate a hands-off approach, in which they were given the form and very little verbal interaction. This could be better for those who struggled with hierarchical relationships with adults, had challenges with using their voice (e.g., selective mute) or found verbal dialogue difficult.

Several staff told me about their careful use of body language, eye contact, and tone of voice. They conscientiously tried to present the goals task in a way that would not seem too invasive, too ‘heavy’, or patronising. Sometimes, staff explicitly asserted to young people that it was their sense of need and achievement that was important. But interestingly, this did not always lead to young people opening up. Framing goals as ‘something for the funders’ could make it an easier task to complete, lighter somehow, and easier to swallow—as other methods could come across as too close an inquiry into young people’s real desires and intentions.

Staff intervention was required not just to complete the goals task, but to complete it correctly. Young people often articulated the wrong sorts of goals, to ‘ride a horse’ or ‘brush the horses,’ for example. Staff knew that these were not really the sort of goals that young people were supposed to be producing. The aim was to find an authentic goal, one that enabled more personal reflection and growth. In a blog advising service providers in how to use GBOs, the tool designer Duncan Law (n.d.) described the importance of shifting a ‘vehicle’ into a ‘destination’ (which is a proper goal). Utilising his language here, ‘brushing a horse’ can be seen as a vehicle but not a relevant destination in itself. Staff could try asking why the young person might want to brush a horse, and what they might get out of that in terms of their own personal learning. ‘To learn what calms me down,’ or ‘to learn how to build trusting relationships’ would be more appropriate entries.

While Law recognises and warns against the possibility of too much clinician input during the formulation of goals, his main concern is that clinicians could set goals that are easier to achieve in order to boost their own outcome ratings (Law and Jacob 2013). During my time at The Meadows, I did not see anything like that occurring. But in the designation of what counts as a good goal, or indeed, what counts as a goal at all, I noticed that young people’s utterable motives were redefined in line with the values already established within funding cycles and therapeutic logics. The question was not ‘what do you want or need?’ but ‘what sort of self-development do you want?’ or ‘what therapeutic outcome do you want?’. Which is effectively, ‘what do you want (of what I am selling?)’.

Ethical pedagogy: Between enablement and intervention

The care taken to allow young people agency over language during sessions (through holding space) seemed to contradict the deliberate adjustments staff made to the way young people chose to articulate their motivations (or not to articulate their motivations) when setting goals. As others have found in a variety of ethnographic contexts, an invitation for youth agency turned out to have rather specific requirements and demands (on ‘creativity’ in Viet Nam, see Bayly 2014; on ‘political agency’ in Botswana, Durham 2008). It would seem as if young people were merely obliging (to more or less of a willing degree) when they conceded to produce their experiences and desires in the language of goals and through the medium of a form (see Mazanderani, Noorani, and Dudwhala 2020). Goal setting could be seen as yet another imposition placed upon the young, marginalised, and dependent, by the powerful parties who set the terms for legitimisation, a sort of ‘routinised intimacy’ (Armstrong 2016), rather than an act of real, engaged autonomy. These points notwithstanding, I would like to emphasise a slightly different point. For staff, the same ethos of ‘holding space’ for young people to grow could both legitimise goal setting and substantiate its critique. Staff were not unaware of the imposition of goals; hence the extreme care, and sometimes critical ambiguity, over how and when goals should be completed. Staff tried to hold back such impositions and mediate their negative impact, giving young people space from goals, as well as agency though goals. As session leader Jenny expressed in a post-session debrief to describe why she had not completed a young person’s goals form that day: ‘it wasn’t right for him today … Those are our needs, not his.’

If staff are to be understood as invested in the concept of youth autonomy—if their telos (end goal) is to provide these young people with the broadest scope of opportunities for self-determination, then their use of goal setting seems paradoxical or misguided. Can staff not see that young people often do not want to be asked what they wish to develop about themselves? But I have already shown that staff can see that—hence their careful and critical consideration of when, and how, goal setting is most appropriate. Why then, do they persist? Is their interest in youth autonomy only lip service? I have already shown that it is not, that it pervades their constant reassessment of their capacity to do good by their wards.

I would suggest that staff are invested, not in providing a radical or complete form of youth autonomy, but in supporting opportunities for young people to develop their capacity for ethical self-reflection. From this perspective, it is possible to acknowledge that the ethico-political tension in goal-setting processes (and other processes of deliberate enablement of healthy agency, as I will discuss in the last section) is inherent to the politics of ethical pedagogy, though exasperated in this setting. This tension does not need to be framed as a delusion or oversight on the part of staff; rather, we will see that such tension is actively maintained as a critical, reflective, ethical engagement with the political dynamics at play.

Further explanation is needed to justify this shift, since staff do not use the term ‘ethical reflection’ to describe their hopes for their impact on young people. They may balk at the term ‘ethical’ if it were taken to suggest that they were in the business of correcting moral character—as though the young people they work with are morally failing. They would also question the way that ‘ethical’ might draw attention away from wellbeing, and towards proper conduct. Their desire is to alleviate suffering, and enable flourishing, not to promote socially normative codes or manners. But in fact, those aspects are perfectly well accommodated within contemporary anthropological approaches to virtue ethics.

In these approaches, heavily informed by Foucault’s use of Aristotle, ethics is understood as that aspect of life in which the self is constructed through self-reflection, such that a person is behaving ethically when they think about what they ought to do, or who they should become, and when they apply themselves towards betterment in line with those evaluative criteria (Laidlaw 2013; Mattingly 2012). For Aristotle, those who were able to cultivate virtues were not merely pursuing societal approval or performing norms. They were enacting the capacity for eudaimonia—happiness, or flourishing—which is a holistic rather than a narrow concept not far from a contemporary sense of ‘well-being’ (Deci and Ryan 2018). This means that when young people were put in a situation where they had to consider what they felt was an appropriate way of responding, and when the overall aim was to improve their capacity for flourishing, the work of staff can be analysed as prompting ethical reflection.

To return to Carl Rogers, he makes the link between person-centred therapeutic relationships and ethical reflection particularly clear; ‘the more I can keep a relationship free of judgment and evaluation, the more this will permit the other person to reach the point where he recognizes that the locus of evaluation, the center of responsibility, lies within himself’ (1958, 14). For Foucault (1997, cited in Laidlaw 2013), on the other hand, the capacity for ethical self-reflection is a very particular sort of freedom. James Laidlaw further clarifies that this is not freedom from the workings of power in one’s life (2013, 101–102). Rather, one is instigated to reflect on oneself through one’s immersion in relationships with others, and via historically variable, normative possibilities.

As session leader Carrie explained: ‘goals may not be easy for them, but it is such a powerful thing to practice’. The GBO tool can then be viewed as a pedagogical device for teaching young people how to engage in forms of reflective agency that they would otherwise not usually adopt. This pedagogical use of the GBO has the potential to logically undermine its utility as a tool for user-led treatment and/or user-reported measurement. A pedagogical tool will not make a successful user-led treatment tool if its aim is to shape young people towards particular ends. After all, few young people in this situation would prioritise being better at setting and meeting goals. A pedagogical tool will likely not make an effective user-reported service evaluation tool, since the latter relies on young people’s capacity to know what they need and to evaluate their attainment towards those ends, whereas the former exists through recognition of the current limitations to that skillset.

Recognising the pedagogical, ethical work of goal setting supports a critique of GBOs in as much as the latter should not be mistaken as a broad and inclusive way of enabling or acknowledging young people’s agency. But it can also be acknowledged that staff are not only ‘listening’ to young people’s goals (or ideas, or other expressions of agency), they are also tending to young people’s capacity for self-reflective agency; looking for it, provoking it, stretching it through specific application. Being prompted into new forms, or enhanced moments of self-evaluation may well be uncomfortable, confronting, or disquieting. This much has been well-established across varied approaches towards the anthropological study of ethics (Das 2010; Mattingly 1998; Zigon 2007).

In provoking self-reflection, staff differ from the policy recommendations I referenced at the start of this article. The latter seem to presume young people have goals in relation to their care. The correct moral response to such pre-existing goals is straightforward—support and enablement. But staff are working to coax, encourage, develop, and rehabilitate a goal setting capacity—this involves a much more fragile ethical position in relation to power. For Foucault (1997; cf. Laidlaw 2013), power in social relationships is always power over ethics. The ability to ‘structure the possible field of action of others, to “orchestrate” their conduct. [power] is action carried out not directly on an object or a person-as-object but on the action – that is, the irreducibly reflective, conscious, and to some extent free conduct – of other subjects’ (Laidlaw 2013, 97). When The Meadows staff withheld their guidance in the stable, or provoked the production of goals, they wielded power in order to ‘hold space’ for ethical self-reflection to emerge in certain forms.

Nested ethics

It becomes clear that ‘holding space’ is not the same as giving space, which might be seen as a complete withdrawal or neutral allowance. In contrast, holding space is an active management of the sort of space available, it is a self-conscious curation of the challenges presented, or, as I prefer to define it, a form of nesting. ‘Nesting’ captures a geometric aspect—that a concept of young people’s ethical conduct sits within the staff’s own ethical reflections—as well as an active aspect, a form of incubation or mediation from the world.

There are always likely to be ethical risks associated with such nesting. James Faubion (2001) emphasises that ethical pedagogy invariably involves the relationship between (at least) two ethical subjects, and the potential for conflict between their disparate schemes of evaluation. This has to be the case, since were ethics to be taught by rote, such that the student became a repetition of the master, it would not be ethical (i.e., self-evaluative) at all. But cases such as The Meadows impel us to go further than Faubion in demonstrating that the ethical work of those doing the ‘nesting’ is quite distinctive from the ethical work encouraged in those being ‘nested’.

While young people were supposed to want to develop on their own terms, and for the sake of their own flourishing; staff’s ethical orientation was the opposite—they wanted to help another person (in this case, a young person) develop in terms inherently somewhat external and alien to them. Staff at The Meadows had a very fragile sense of ultimate telos in their work, since it was not only other-dependent, but ideally, other-defined. The real point of the work was specifically not subsumable within available metrics, policy discourses, or staff’s desires. This means that for staff, the deontology (the means of relating to the goals) remained under scrutiny, itself a form of ontology (the substance to be worked on). The scales themselves were often weighed.

In contrast, the nested ethical reflections encouraged in young people seem somewhat buffered, protected, inward facing, and unworldly when compared to the epistemological fragility and the other-orientation that determines the staff’s means of self-critique. It is worth clarifying here that I do not mean to suggest that all young people’s ethical lives were subsumed within the nesting projects of the mental health service staff. Young people exist as ethical agents in their own right above and beyond this dynamic—including in relationships that staff did not know about or understand. Yet The Meadows could provide a space that protected and buffered young people from some moral pressures (for example, from having to learn about the expectations of British horsemanship, or from having to follow set session plans), but only at the same time as curating certain sorts of ethical demand (having to produce and expose one’s own solutions in the shape of a goal).

This protection and buffering could also be seen as a curtailment of the breadth and complexity of young people’s ethical agency. After all, young people in this context were not supposed to aim to learn how to brush horses for the horse’s sake, or try to be funny just to make their peers laugh, or get better grades to please their teachers or parents. Unlike the staff, young people are denied/relieved from obligation, care or approval as legitimate incentives—those things were not considered real self-orientated ‘goals’. At times, I lamented this curtailment. I felt it would have been easier on young people—perhaps even ‘healthier’—if there had been less of a focus on young people’s self-direction. But alternative possibilities seemed problematic or even harmful. Would it really be better if there were more of a focus on answering to the needs and demands of others (i.e., becoming a good yard worker, student, or peer group member), or following norms, desires and impulses without reflexively considering the ultimate benefits and harms of those within one’s life.

It seemed there was no easy way out of the ethico-political predicaments that staff faced. Programmes like The Meadows exist to make young people’s lives more liveable, but have no capacity to change the broader contexts in which these young people live. The only feasible solution for staff at The Meadows was to ‘develop’ or ‘support’ (or phrased more critically, change) the young people themselves. It seemed as though the least that staff could do was to allow young people to set the terms for their own ‘development’, even when that, in itself, was also an imposition.

Healthy agency

In The Meadows, the exasperated ethical risks of nesting included the risk that from a position of power, one could inadvertently coerce, dominate or blight the ethical development of the other. But also, there was a correlating risk that, if denied proper guidance or support, the other may reflect on themselves in a way that was not healthy or helpful. Staff did not just want young people to steer their own ship in just any direction, they wanted them to reflect on themselves such as to chart a journey away from suffering and towards flourishing.

There was relief, joy, and euphoria when young people acted in a way that seemed authentically self-directed, effective, and healthy. These seemed like moments of genuine flourishing, empowerment, and healing—such as when Sam became animated beyond all expectations whilst trying to inspire a slow horse into trotting over a jump, and sticking at that task with grit, despite failing several times. ‘It is like he was able to feel that he could want something and try for it!’, staff member Trudy commented proudly to the others in the post-session debrief. But even these achievements were fragile, subject to possible re-evaluation. Should he have been subjected to all of those failures and frustrations? Was it right that Trudy stepped in and encouraged the horse into a trot without Sam noticing as a reward for his endeavour? Or was his risk of failure only uncomfortable because of her desire to see him ‘succeed’? For The Meadows staff, a balance could never be finally struck between support on the one hand, and imposition on the other. There was no ‘golden mean’ (in an Aristotelian sense) only a bearable momentary compromise, a pragmatic decision of ‘best good’ (Mattingly 1998), which could provide the fodder for further reflection.

The difficult distinction between healthy agency and normative agency was even more ethically fraught when applied to troubling cases—as when 17-year-old Lisa discussed her plans to leave home so that she could live with a much older lover that her adoptive family had banned her from seeing. Her written goal had been to ‘build self-confidence’ —but she had hoped this would enable her to stand up to her father and ‘make her own life how she wanted it.’ Staff members remained unsure whether to support Lisa in her goals as legitimate aims for her, or trust in their own hopes that increased self-confidence would in fact lead her towards a ‘healthier’ (as in, less sexualised, more independent, more age appropriate) path.

‘Healthy agency’ is a useful term, then, for describing a hopeful aim that is ever-unsettled by the infringements of normativity. It prevents sweeping assertions about the provision of ‘more agency’ by raising (rather than answering) questions about what form of agency comes to count as non-pathological, or as beneficial—either to the individual or society.

Questions remain about the variability of nested ethical projects. If curating healthy agency is the key concern in this setting, what variety of ethico-political tensions exist in other projects of nested ethics? The particular case described here is notable for its context of late modern critique—of mental health treatment, of education, of socio-economic systems, of race relations, and of technological developments. It is distinctive in that the moral response to that environment of critique is an increased emphasis on the importance of the individual—not because individuals are considered responsible for societal problems, but because they are held as the authority of their own struggles, which is seen as a recourse against systems of power. This has a particular impact on the fragility of ethical authority in this therapeutic setting.

It is helpful to maintain breadth and think of nesting ethics as those instances where somebody takes conscientious steps to manage the world such that another can ethically relate to it in a particular way. This might include instances where the nested ethical life—the incubated subject—is in fact considered more mature, complete, pure, wise, important or accomplished than the nesting party. A surgeon’s assistant, a head of state’s spouse, a juror’s confidante, or the lay Jain community who support Jain monks’ ascetic practices (Laidlaw 2013), might all be seen as engaged in nested ethical projects. The nested party may be of profound worldly importance to the nesting party. This much is true of The Meadows too, where much hope is invested in the ethical agency of young people, not as lesser forms of humans, but as the possibility for something new, perhaps more authentic, perhaps less constrained.

Walking through the paddocks one evening, Jenny—who had prescribed my Carl Rogers reading—told me: ‘young people are like flowers, they grow depending on their environment, but each one grows in its own way. Our job is to provide the environment where we can see who each young person can be, if they are just allowed the space to grow.’ This comment demonstrates a certain sort of naturalisation about youth agency as embodied potential. But this was not the form of naturalisation present within the policy-speak, in which all young people are presumed to hold the capacity to articulate ‘goals’ and direct their own growth in a healthy way. For Jenny, it was rather that something had gone wrong in the world (if not biomedically in the brain) when young people were not acting as healthy agents in their own lives. Jenny and her colleagues were keen to put this right, by providing a space, a world, in which young people could grow well, but on their own terms and in their own ways. This translated into a continual reassessment about which intended supports or opportunities for growth were, in fact, unhelpful impositions.

Conclusion

Ethical lives always exist in relationships with one another. An understudied aspect of that relationality is the ‘nesting’ of ethical projects—when one person evaluates themselves in line with their capacity to enable another person’s ethical life. Jeannette Pols (2016) convincingly argues that it is insufficient to aim for independence and autonomy in mental health recovery. Instead, societies must support the work that others must do in order to accommodate all of their ‘relational citizens’. This research article addresses one aspect of this relational support, in that it asks what it is like to conscientiously support the ethical life of another. Instances that fall within this category are much broader than the specific case presented here.

In this article, I did not set out to determine whether the GBO procedure in and of itself enables ‘user-led’ care, nor whether being user-led ought to be the parameter for judging good care from bad (others have addressed these issues, e.g., Wallcraft, Read, and Sweeney 2003; Fudge, Woolf and McKevitt 2008). Instead, I have focussed on the way that staff evaluate goal setting. Aside from the tactical role in funding and referral cycles, goal setting is compelling for staff as one part of a broader process of curating moments which imperfectly enable, require, stretch, and apply young people’s own reflections. In a sense, it is unsurprising that there is something disruptive, awkward, or challenging about such moments, because they are not just about accommodating or collecting young people’s choices, they are intended as interventions and provocations both for young people and for the services that surround them—moments to redefine, and to act differently. This is not to suggest that such moments live up to that ideal, nor that they are inherently beneficial. It becomes clear that both the use of the GBO, and its most prominent internal critique, follow a similar meta-ethic: to weed out unhelpful expectations and to curate a space in which young people can grow without harmful impositions. This ethos can be its own undoing.

On one occasion, Mia told me that she did not like it when The Meadows staff encouraged her to start thinking about her plans for the future. Her anxieties about her own school performance, her tendency towards perfectionism, and her concerns about environmental fragility had been part and parcel of her own mental health struggles. She exclaimed to me, half joking, and yet, deadly serious: ‘Don’t ask me what am I going to do next, or what do I want to be in the future, or anything like that. Can’t you see that is exactly the problem. Everyone wants to ask kids about the future. I don’t know! I came here to get away from that shit!’

Listening to young people can involve acknowledging why they do not have goals, do not want goals (or want to share their goals), or have things other than goal-procurement going on in their lives. It is important to ensure that the space to recognise that youth mental health needs are not reducible to articulated goals or personal achievements is retained. Yet when mental health care providers use goal-based outcome measures, they are not merely collecting young people’s goals. They are tending to agency, provoking, and protecting it; they are reflectively using power to curate ethics. They are responding to a very complex ethico-political context, in the hopes of holding space for healthy agency to emerge.

Authorship statement

Ethics statement

This research received ethical clearance from the Research Ethics Committee at the Department of Social Anthropology at the University of Cambridge in October 2020. It was also cleared by the safeguarding leads and directors of each Equine Assisted Therapy or Learning Programme that participated in the research.

Acknowledgements

This research is supported by a Junior Research Fellowship at Christ’s College, University of Cambridge, and a British Leverhulme/British Academy Small Research Grant. Sincere thanks to those who participated in the ethnographic research that informs this article, including young people, teachers, volunteers and EAL staff. I am astounded by the bravery, trust and generosity that participants showed in letting me in. Many thanks to those who have given feedback on earlier drafts of this piece, including Susan Bayly, Matei Candea, Kelly Fagan-Robinson, Ori Mautner, the thorough and generous anonymous reviewers, and the members of the Social Anthropology Research Associates seminar at Cambridge. Any remaining errors are entirely my own. Thanks also to the editorial team at MAT for the clear and helpful communications.

About the author

Rosie Jones McVey is a Junior Research Fellow at Christ’s College and an Affiliated Lecturer in the Social Anthropology Department at the University of Cambridge. Her current research investigates the ethical life of equine-assisted therapy programs for youth in the UK. Rosie’s PhD (2019, University of Cambridge) investigated British horse riders’ ethical understandings of ‘partnership’ with their horses and demonstrated the importance of epistemology within late modern ethical life. Her book Human-horse Relations and the Ethics of Knowing was published by Routledge in March 2023. Before entering academia, Rosie worked as a horse trainer for fifteen years. Her current research interests include theory of mind, ethics, mental health, and human-animal relatedness. Her next research project (supported by a Wellcome Trust Early Career Award, based at the University of Exeter) is titled ‘The Moral Terrains of Green Social Prescribing.’

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The Meadows’ statistics in this paragraph are all taken from their own data analysis (and sources kept anonymous). Compare this figure to the 0.05% of young people permanently excluded and 4.25% suspended from attending school in the general population (UK Department of Education 2022). ↩︎
CAMHS stands for ‘Child and Adolescent Mental Health Services’ (CAMHS) and are part of services provided within the NHS services in the UK. ↩︎
Compare to 24.59% in the general population (UK Education and Skills Funding Agency 2021). ↩︎
Ethnic groups that were not White British were disproportionately well represented at The Meadows even when compared to the urban local area, which had a higher level of ethnic diversity than the national average. ↩︎
The term is promoted by the experiential therapy model utilised by the Equine Assisted Growth and Therapy Association, based in the US. ↩︎
Not that these two things are mutually exclusive explanatory mechanisms—research increasingly shows the interrelationship between neurology and environment (e.g., Callaghan and Tottenham 2016). But the heuristic still held—that the madness, or badness, or sadness, was a feature of the world these young people had experienced and not inherent to their nature. ↩︎

The Meadows’ statistics in this paragraph are all taken from their own data analysis (and sources kept anonymous). Compare this figure to the 0.05% of young people permanently excluded and 4.25% suspended from attending school in the general population (UK Department of Education 2022). ↩︎

CAMHS stands for ‘Child and Adolescent Mental Health Services’ (CAMHS) and are part of services provided within the NHS services in the UK. ↩︎

Compare to 24.59% in the general population (UK Education and Skills Funding Agency 2021). ↩︎

Ethnic groups that were not White British were disproportionately well represented at The Meadows even when compared to the urban local area, which had a higher level of ethnic diversity than the national average. ↩︎

The term is promoted by the experiential therapy model utilised by the Equine Assisted Growth and Therapy Association, based in the US. ↩︎

Not that these two things are mutually exclusive explanatory mechanisms—research increasingly shows the interrelationship between neurology and environment (e.g., Callaghan and Tottenham 2016). But the heuristic still held—that the madness, or badness, or sadness, was a feature of the world these young people had experienced and not inherent to their nature. ↩︎