Balancing autonomy and safety in care for youth with severe and enduring mental health problems

Balancing autonomy and safety for youth with severe and enduring mental health problems (SEMHP) is a major challenge in (residential) child and adolescent psychiatry (CAP). While autonomy supports engagement and recovery, high-risk behaviors such as suicidality often necessitate safety measures that restrict autonomy. These conflicting priorities lead to clinical dilemmas and inconsistencies in care. To provide a nuanced understanding and enhance clinical support for youth with SEMHP, this study explores how autonomy and safety are understood and negotiated in residential CAP from the perspectives of youth, caregivers, and practitioners. In this qualitative study, we conducted two focus groups and eleven semi-structured interviews, involving youth with SEMHP (n = 7), practitioners (n = 8), and caregivers (n = 6). A reflexive thematic analysis was applied, and perspectives were compared. Autonomy and safety emerged as deeply interrelated concepts. Three main categories were deducted: (1) Foundation for safety and autonomy, (2) Regulation of safety and autonomy, and (3) Tensions and risks. Youth highlighted the need for relational proximity, trust, and shared decision-making, while practitioners emphasized boundaries and procedures. Caregivers expressed varied views, often evolving over time. These differences can lead to tensions, particularly in high-risk situations, where autonomy and safety are difficult to uphold simultaneously. Balancing autonomy and safety requires staying connected to support gradual growth within a predictable and supportive care environment. Particularly in high-risk situations, maintaining a relationship-centered approach, involving youth and caregivers in decisions, and creating space to slow down are key to fostering safety and autonomy in residential CAP.