Community Ment Health J DOI 10.1007/s10597-014-9778-8
BRIEF COMMUNICATION
Youth with Mental Illness: Attitudes Towards and Therapeutic Benefits of Residential Stepped Care Lynne E. Magor-Blatch • Laura Ingham
Received: 28 January 2013 / Accepted: 7 October 2014 Springer Science+Business Media New York 2014
Abstract There is little research reporting the ‘‘lived experience’’ of young people undertaking treatment for mental health conditions. This pilot study explores the phenomenological experiences of a small group of six young people aged 14–18 years who were resident of a youth stepped-care mental health program in the Australian Capital Territory. Using semi-structured interviews, data were collected and two main themes emerged: (a) ‘‘Life engagement’’ and (b) ‘‘Relationships.’’ Participants also provided responses on self-report measures at baseline and follow-up and feedback on aspects of the program. Further research is suggested to build on this study to increase research outcomes. Keywords Youth Mental health Engagement Relationships Stepped-care
Introduction The 2007 Australian National Survey of Mental Health and Wellbeing (NSMHW) estimated 45.5 % of Australians
L. E. Magor-Blatch (&) L. Ingham Faculty of Health, Centre for Applied Psychology, University of Canberra, Canberra, ACT 2601, Australia e-mail: [email protected] L. E. Magor-Blatch School of Psychology, University of Wollongong, Wollongong, NSW, Australia L. E. Magor-Blatch Australasian Therapeutic Communities Association, Yass, NSW, Australia L. Ingham ACT Health, Canberra, ACT, Australia
aged 16–85 years (7.3 million people) had experienced a mental disorder over their lifetime, while 20 % (3.2 million people) experienced symptoms of mental illness over the 12 months prior to survey (ABS 2008). In that period, anxiety, affective and substance use disorders were experienced by 14.4, 6.2 and 5.1 % of the population respectively (DoHA 2009). Research indicates that the onset of various types of mental illness often begins in the adolescent years (Frojd et al. 2007; Hickie et al. 2005). For example, the onset of psychotic disorders is most typical in young people under 25 years of age (Hickie et al. 2005). The psychological wellbeing of youth, aged 12–25 years (Patel et al. 2007) has emerged as a major social issue in Australia. Prevalence rates of mental illness amongst young Australians are reported as being as high as 19 % (McGorry et al. 2007). Similar findings have been reported internationally. Research conducted in 2007 in Europe suggested that approximately 25 % of youth had experienced an episode of depression (Frojd et al. 2007). In the US, prevalence estimates of any DSM-IV disorder amongst young people are 40.3 % at 12 months (79.5 % of lifetime cases) and 23.4 % at 30 days (57.9 % of 12-month cases) (Kessler et al. 2012). Contributing Factors to Poor Mental Health in Youth Many factors contribute to the mental health of adolescents. Research suggests that children who are raised in families with a history of conflict and aggression become more sensitive to stress, anger, anxiety and fear (Repetti et al. 2002). Lack of participation in community activities may also contribute to poor mental health, with decreased engagement in sporting events and religious activities coinciding with increased exposure to illicit substances (Hickie et al. 2005; McGorry 2007). Additionally, many
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young people experiencing mental health issues have been victims of physical, sexual and emotional abuse. A study of youth in residential treatment for mental illness found 22–38 % had experienced physical, sexual or emotional abuse (O’Herlihy et al. 2004). Impact of Poor Mental Health in Youth The onset of mental illness during adolescent years is of significant concern as it coincides with several important developmental milestones, including development of social supports and networks, completion and/or commencement of further study and entrance to the workforce (Patel et al. 2007). Additionally, individuals experiencing mental illness have been shown to be less likely to participate in paid work when compared to those who are physically disabled. Research undertaken in 2005 indicates that 60 % of disability support costs were related to a mental illness for individuals aged 15–34 years (Hickie et al. 2005). Youth Help-Seeking for Mental Illness Although a moderate proportion of youth experience mental illness, research indicates that youth are the population least likely to seek assistance. Rates of help-seeking amongst young people with mental illness have been reported to be as low as 17–39 % (Frojd et al. 2007; Sawyer et al. 2000 in Ciarrochi et al. 2003). Several factors have been identified as contributing to these low rates of help-seeking. Type of mental illness symptoms, low emotional competence and the type and perceived quality of the relationship to the help-giver, are factors affecting youth help-seeking (Ciarrochi et al. 2003). Additionally, the focus of mental health services on illness and recovery also presents as a barrier. Traditionally the focus has been on treatment once a crisis has occurred, often resulting in presentation to hospital emergency or to mental health service (McGorry 2007). In this context, the STEPS program seeks to change that process by intervening through earlier identification and detection of mental health problems and opening up referral pathways through primary care. A shift to a more proactive approach is required for intervention in the earlier stages of mental illness. As a result, stepped-care models that emphasize early intervention, mental health promotion and prevention have been supported in Australia (ACT Health 2009; McGorry 2007). The stepped-care approach is best described by Davison (2000, p. 580) as: ‘‘the practice of beginning one’s therapeutic efforts with the least expensive and least intrusive intervention possible, moving on to more expensive and/or more intrusive interventions only if deemed necessary in order to achieve a desired therapeutic goal.’’
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The stepped-care approach allows for increased integration of services when a client needs to step down from services (such as leaving hospital to go back into the community) or step up to services (transition from home to short term residential or institutional stay) (ACT Health 2009). Consequently, the stepped-care model provides an alternative to hospitalisation for youth with mental illness, which includes access to primary prevention residential stepped-care programs. Residential Stepped-Care Model Residential stepped-care facilities offer a plausible alternative to hospitalisation for youth with complex mental health needs (Duppong Hurley et al. 2009) and are characterised as accommodation in the form of a residential facility that has limited beds and paid, rostered staff members to provide support in daily living skills (Ainsworth and Hansen 2005; Duppong Hurley et al. 2009). Stepped-care provides treatment within both residential and aftercare settings, which may include a halfway house and/or community-based support once the person has returned home. The current model under review provides residential treatment within a short-term (up to 3 months) facility and supports both the young person and their family through individual and group processes. Residential care is able to relieve the pressure for beds in smaller, acute hospital wards, provides continuity of care in the community and a short term service for youth to facilitate a step up to other mental health services, treatments or environments; or step down into the community and home (Drell 2006; Duppong Hurley et al. 2009). According to Hickie et al. (2005) residential stepped-care models have great potential, as they offer a cost effective alternative to intervene earlier with youth experiencing mood disorders and first onset of psychosis. Residential Stepped-Care in Australia: STEPS Program Residential stepped-care programs are emerging in the area of youth mental health care in Australia. One example for youth is the STEPS program in the Australian Capital Territory (ACT), which aims to improve the integration of care and support for youth experiencing mental illness. STEPS provides a sub-acute residential facility for young people (aged 14–18 years) who are experiencing moderate to severe mental illness without requiring admission to an inpatient hospital unit and provides accommodation for up to 12 weeks for a maximum of seven residents, to ensure a smooth transition from hospital inpatient units (step down), or from home to mental health services (step up) (Department of Human Services 2008).
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Young people are assisted in their mental health recovery by focusing on their strengths, resilience and skills whilst in the residential facility and then supported through transitional outreach support over a further 12 weeks to ensure stability is sustained. STEPS is situated in a semi-rural setting and co-located with a youth substance abuse program. This offers an opportunity for an interdisciplinary team approach to address both mental health and substance use issues. The program includes accommodation to stabilise mental health issues; case management, information, referral, advocacy and information; clinical support; assistance with accessing accommodation options; help to improve and develop life skills; access to education, work and community resources; with an overall aim to increase understanding, knowledge, skills and confidence to manage future crises. Parents and/or carers are also encouraged to participate in the young person’s recovery plan and are able to access support through STEPS or be linked to appropriate services. Staff are recruited from mental health, psychology, welfare and education and are rostered 24 h a day, 7 days a week to provide early intervention and support by assisting young people to increase their functioning and living skills, and facilitating referrals to mental health and other support services as required (Department of Human Services 2008). Residents within STEPS are supported to maintain involvement in school and/or employment, and continue to attend their own school or workplace whilst undertaking treatment. This may mean leaving the facility during the day to undertake studies or employment, and returning in the afternoon to take part in counselling, groupwork and other therapeutic activities. This includes counselling for associated comorbidities, such as substance use, and residents have the opportunity to undertake a range of creative and recreational activities to support recovery. Referrals come from General Practitioners, psychologists and psychiatrists working with the mental health system and through self-referral (most often with the support of a family member). This process presents fewer barriers to treatment as it opens the doorway to primary care, family and self-referral pathways and negates the need for referral through psychiatric assessment or crisis service, although this may still occur. Furthermore, as a Government-funded service, there is no cost to the individual, other than for medication, whilst the young person is residing in STEPS. This removes a significant barrier to treatment. Length of residence for participants varies, particularly as treatment plans are constructed according to individual need. Recent review of STEPS program data shows that residents on average remain in the program for 55 days.
Outcomes from Residential Stepped-Care Programs Initial research conducted into residential stepped-care program for adults experiencing mental illness [e.g., Prevention and Recovery Care Program (PARC) Australia], reveals potentially positive findings. Residents report improved functional capacity and mental health, confidence in coping (self-efficacy) and enhanced connections to community programs (Department of Human Services 2008). However, a review of the residential stepped-care literature reveals little is known about their therapeutic value for youth (Ainsworth and Hansen 2005). The concept of self-efficacy has been shown to be a factor that influences general mental health, as high levels of self-efficacy have been shown to be associated with identifying and pursuing goals, resulting in a belief that actions will lead to positive outcomes in the future (Luszczynska et al. 2005). This construct could be very important for youth in residential stepped-care programs experiencing mental illness, particularly as research has demonstrated that general selfefficacy is related to other psychological constructs such as optimism, self-regulation and self-esteem (Luszczynska et al. 2005, p. 80). Factors believed to be therapeutic in the stepped-care model include the resemblance of facilities to a family home, where workers act as parental role models by ensuring the safety and needs of residents are met on a daily basis (McNeal et al. 2006) and the group environment, which is conducive to the development of interpersonal skills. As such, stepped-care models provide a focus on daily living skills and independence, resulting in a change in attitudes and behaviours (such as managing emotions and conflict) (Bratter et al. 1993; Leichtman 2006). Research has also shown that residential steppedcare may increase residents’ hope and that the values and behaviours learned in care will continue after the resident has left treatment (McNeal et al. 2006).
Aims of Current Study This pilot study aimed to identify the concerns facing young people accessing acute mental health services, their attitudes towards a stepped-care program (STEPS), and the factors which were found to be therapeutic and helpful. Qualitative research provides the opportunity for a greater understanding of the unique experience of participants and what it means for them in living in a particular experience or situation. These perspectives are important as a way of identifying the factors that engage participants in treatment and provide understanding of the issues which are faced in navigating this journey. Self-report measures were also introduced at baseline and 3-months’ follow-up to provide
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objective measure of change in terms of mental health symptoms, hope and self-efficacy.
Design Adopting a phenomenological approach (Smith et al. 2003), which centres on the person’s own understanding of their lived experience, this study focused on gaining an understanding of young peoples’ experiences in coming into the mental health system, and their treatment experiences of the STEPS program. A semi-structured individual interview was conducted at follow-up and the data analysed according to Braun and Clarke (2006). Participants also completed a self-report questionnaire at baseline and follow-up comprising the Children’s Hope Scale (CHS; Snyder et al. 1997); the General Self-efficacy Scale (GSS; Schwarzer and Jerusalem 1995); and the Kessler Psychological Distress Scale (K-10; Kessler et al. 2002).
Methods Participants Participants were six young people ranging in ages from 13 to 18 years (M = 15 years), including one male and five females. All six of the STEPS program residents resided in the ACT. During the period of survey, only these six young people were admitted to the program. All consented to take part in the study. Procedure Participants were recruited to the study upon entry to the STEPS program, when the resident and their parent or legal guardian were provided with a participant information and informed consent form by program staff. Consent to participate in the study was provided by signing informed consent forms and placing them in a sealed envelope, which was then provided unopened to the researcher by STEPS staff. The researcher then met with the young person in their first week of residence and provided the self-report questionnaire for completion. Three months post-admission, the researcher again met with the young person to conduct a follow-up semi-structured interview comprising six questions. These asked how the young person had been referred to STEPS; what they had learned while resident which had helped them to deal with their mental illness; whether participation in school, training, work or hobbies had changed since being at STEPS (i.e., post-discharge); whether they had noticed changes in their relationships; and what they liked most/least about STEPS.
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There was also the opportunity to provide any further comment. Participants once again completed the self-report questionnaire in order to provide objective report of change over the 3 month period. Notes of the resident’s responses to interview were recorded in writing and read back to the young person to ensure accurate reference of themes and attitudes. During the transcription process, all participants were given a code to maintain anonymity and all personal identifiers removed. The study was undertaken over a 6 month period. At the time of follow-up, four participants remained in the program, and two had left. Analysis A thematic analysis of the initial data set was undertaken to identify, analyse and report patterns or themes using Braun and Clarke (2006) analysis. This comprised a six-phase process and provided the opportunity for a greater understanding of the unique experience of participants and the meaning they were able to make from these experiences. The first phase involved becoming familiar with the data, repeatedly reading through the responses and beginning to identify codes through key words and patterns. Following this familiarisation phase, initial codes were generated in a systematic fashion across the data set and entered into a Microsoft Excel Spreadsheet. In the third phase, codes were collated into potential themes. In phase four, the themes were checked in relation to the coded extracts (Level 1) and the entire data set (Level 2) in order to generate a thematic ‘map’ analysis. In phase five, ongoing analyses were conducted to refine the specifics of the themes and the overall story from the analyses, generating clear definitions and names for each theme. The final phase comprised the development of thematic maps to illustrate the main themes and connected sub-themes. To enhance reliability, emerging themes from the transcripts were independently reviewed in the early stages of analyses by the researcher’s supervisor and one other independent reviewer who was expert in qualitative research. Checking confirmed that all themes identified were deeply embedded in the transcripts and consensus was gained on consistency through discussion.
Results Systematic coding resulted in the emergence of two global themes: (a) ‘‘Life engagement’’ (engagement with the mental health system, the development of lifeskills and the STEPS environment as facilitating change); and (b) ‘‘Relationships’’ (concerns about family stability, the development of peer relationships and shared experiences).
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These themes emerged from the semi-structured interview, which sought information on referral, engagement and relationships. Additionally, participants provided responses in their evaluation of the STEPS program as an environment as which facilitated change. As numbers in the study did not allow analyses of quantitative data other than as individual measures, line graphs were generated to illustrate individual trends on each measure. In each case, the upward trend for CHS and GSS and the downward trend for K-10 showed participants reported increased hope and self-efficacy, and a reduction in mental health symptoms as a result of their treatment within the STEPS program.
P1.
Global Theme One
P1.
Life engagement incorporated participants’ views around their prior engagement in the mental health system, the development of lifeskills and increased engagement in the wider social system, including school, work and hobbies. It reflected attitudes and engagement both prior to and following involvement in STEPS.
P4.
Prior Mental Health System Interaction Some participants described coming to the STEPS program after their first interaction with the mental health system whilst others described a history of interaction with mental health through the Child and Adolescent Mental Health Service (CAMHS) and previous admissions to STEPS. P1. P2.
P4. P5.
I came from hospital, then went home for two nights, then to STEPS. I never had a CAMHS worker. In a mental health ward for 6 weeks before that. CAMHS were working in the hospital with me. CAMHS thought it would be a good program for me Been in the STEPS program before and CAMHS referred me. I was living with my Dad. I was having problems in my relationship with my Dad and I was couch surfing for two or 3 weeks before I got myself into STEPS.
P5.
Time management techniques. I learned it [sic] to help me at STEPS and that decreases my anxiety levels. Communication skills and suggestions about how to communicate with my parents, which makes it easier to manage those relationships now. A lot of the suggestions they made to help me in my relationships with my parents and mental illness helped me.
Increased Social Involvement It was reported by some of the participants that as a result of their time at the STEPS program, they experienced an increase in their participation in school and life generally. Going more to school. Getting more involved and trying harder. Doing more generally. I still attend school regularly. I was able to still attend while at STEPS and I still do now.
Global Theme Two Relationships refers to personal and interpersonal relationships with family, peers and mental health workers, including staff of the STEPS program. Participants also noted the positive value of the STEPS environment in assisting them to develop positive relationships and the opportunity for self-reflection. Improved Relationships Reductions in conflict and increased stability and consistency were highlighted by some of the participants as a factor that they found beneficial about their time in the STEPS program. P1. P5.
Less fighting, less up and down, more consistency. My relationship with my Dad has improved dramatically just because we can communicate more and are more open with each other.
Relationships at STEPS Development of Life Skills Some participants reported that they were taught communication, conflict and time management skills that they were able to utilise in their continuing relationships with family and friends, and which assisted in reducing anxiety after leaving the program. P1.
Being effective in how to get out of the argument, not just what I want. Effective conflict skills.
A theme that featured during the interviews was how the positive relationships between the STEPS residents and staff helped residents to feel respected, with the shared experience seen as beneficial to mental health wellbeing. P1. P2.
The staff [names highlighted]. Support was really good. Being around people my own age who understood what you were going through. Being able to interact properly with other people.
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P5.
The workers were always very fair and respectful and they would talk to me about things, which I didn’t get a lot of at home. Not so much treated as an equal but treated fairly. In that environment the workers have to be neutral and this allows for a lot of selfreflection and healing.
outside school or work studies, the structure provided may have been seen as supportive, while for those less engaged, a perceived lack of structure may have been problematic. Nevertheless, for those coming from unstructured home environments, providing structure into the young person’s life is seen as beneficial for long-term recovery. P1.
Environment Facilitates Making Changes Several participants discussed how being in the STEPS environment alleviated their stress and allowed them to reflect on and make changes in their lives in order to improve their mental health and wellbeing. At the same time, this was very difficult for some, who came to understand that family relationships were impeding, rather than encouraging, mental health recovery. P4.
P5. P5.
I severed my relationship with my Mum because at the moment, she is not helping my relationship and she is not helpful to me at this point in time. I didn’t have to interact with this really negative presence in my life [my Mum] and that really helped me. I liked the closed environment and that allowed me to think about a lot and mull things over. I’d been distracting myself before, so I didn’t realize what was wrong and I couldn’t verbalize what was wrong. It [STEPS] gave me space to mull over my thoughts, feelings and make sense of it all.
Personal Evaluations of STEPS A final question in the semi-structured interview asked participants to provide feedback on the STEPS program, including those aspects which they least liked and believed did not facilitate positive change. There were two main themes which emerged in this discussion. The first related to the structure of the program itself, and the second to the acquisition of skills which participants believed would help them to cope once leaving the program. Structure of STEPS Program Some participants described the structure of the STEPS program as detracting from their ability to benefit from the program. In particular, these participants described lack of structured activities, strict program rules, lack of rapport with staff and limited personal attention as the aspects they least liked about STEPS. As STEPS was in the early stages of development, the program content and structure were still developing. It should also be noted that these personal responses of participants reflected their own participation rates. For those engaged in
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P2. P2.
P4. P5.
[I didn’t like] how unstructured it was. Need to have more structured activities. A bit annoying being in bed at a certain time. I didn’t like my worker I got. Other people’s workers helped them on short term goals, but my worker didn’t… [The workers] should have paid more attention to us. I did not like some of the workers. I did not like the fact I did not get to socialize [with friends] but it was one of the biggest things that helped me to deal with my issues.
There was also some acknowledgement of the role personal difficulties played in preventing residents from fully engaging with the program, although it was suggested that because of their experience of mental illness, staff needed to persevere more with residents who were finding it difficult. This would assist residents to engage, and to identify and achieve goals. P2.
I was too depressed to take initiative. So would be helpful for worker [sic] to take initiative with me.
Failure to Acquire Skills Difficulty engaging in the program because of impairment due to mental illness was identified as a barrier that prevented some participants from benefitting from the STEPS program. Additionally, there were some participants who reported that they did not learn any skills whilst at STEPS and their engagement in life and relationships after STEPS remained the same as before they entered. One participant noted this as: P2.
Didn’t really learn any skills. They said I wasn’t engaging but I was too depressed to engage with them and then they didn’t make an effort either. I was not at school before [STEPS]. Still not at school. Haven’t noticed any changes in relationships. I live with my parents and my relationships with my parents are OK.
Discussion Overall Findings This pilot study explored the phenomenological experiences of a small group of young people aged 14–18 years
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who were resident of STEPS, a youth stepped-care mental health program in Australia. Through this process, participants in the study, who had undertaken the STEPS program, were able to describe the variation in their prior exposure to the mental health system and the impact the STEPS program had on their engagement in aspects of their life, such as in family, education and more generally. Two main themes emerged: (a) ‘‘Life engagement’’ and (b) ‘‘Relationships.’’ The first theme described engagement with the mental health system and the development of lifeskills. Participants described how the STEPS environment facilitated making life changes and the life skills they acquired to cope with mental illness. This included improved communication, conflict and time management skills. The second theme highlighted concerns about family stability, the development of peer relationships and shared experiences. In particular, participants described how they benefitted from relationships with staff and others who were resident in the program, which in some cases resulted in positive and improved family relationships. Participants also provided responses in their personal evaluation of the STEPS program, offering a description of the STEPS environment as one which facilitated change. Also discussed, were those aspects of the STEPS program which were found to be supportive, and those which did not facilitate positive change. This also included some understanding of personal failure to gain from the STEPS experience, often as a result of impairment due to mental illness. The completion of self-report questionnaires at baseline and follow-up also provided objective report of changes on measures of mental health symptoms, hope and general self-efficacy. Implications for Further Research This pilot study was narrow in focus, in that its prime purpose was to provide residents of a sub-acute mental health treatment facility with the opportunity to record information on their personal experiences of coming into treatment, and those aspects which they had found most or least helpful in the treatment experience. While the stepped-care approach is likely to be beneficial for some young people, more research is needed. The study suffered from a low sample size. It is acknowledged that the STEPS program was only able to accommodate small numbers (up to seven residents) and during the 6 months of the study period, only six young people were admitted. All consented to participation in the study. Therefore, in order to gain more participants, any further studies need to be undertaken over a longer period (of approximately 12 months duration). This would allow adequate time for follow-up to determine if the gains from treatment were sustainable over time.
A larger sample size would also provide the opportunity to further expand on a mixed methods approach, which would strengthen results by providing an objective measure of change. While results from the self-report questionnaire administered at baseline and follow-up were analysed for each individual, a larger sample size would allow greater opportunity for analysis. Nevertheless, in this study the upward trend for the CHS and GSS and downward trend for K-10 for each participant, showed increased hope and self-efficacy and reductions in mental health symptoms from admission to 3 months’ follow-up, and supported results of other studies (Department of Human Services 2008). An expanded study could also include a comparison group, such as those receiving mental health care in the community or within another residential setting, and would contribute greatly to the literature. Nevertheless, results of both qualitative and quantitative analyses provide evidence of both clinical and research value. This is a relatively new model of treatment which holds promise as a youth mental health intervention in Australia and elsewhere. This study did not include information on reason for referral or diagnosis. Residents accepted into STEPS are those who are deemed in need of a sub-acute residential setting in order to gain more targeted support and are experiencing moderate to severe mental illness. However, for some participants in this study, the reason for referral included factors other than mental health concerns alone. In interview some talked about problems which they were experiencing at home and in their relationships with family. Some acknowledged depression and self-harming behaviour, while for others, more pervasive mental health concerns were evident. Therefore, any further study should collect relevant demographic and diagnostic information, as the latter, in particular, informs the development of individual treatment planning. Limitations of the Current Study As highlighted, the prime limitation of the current study was the small sample size. Future research would benefit from an extended data collection timeframe to maximise the sample size in order to gain further perspectives from residents about their experience of the STEPS program. Secondly, the STEPS program did not offer a standardised intervention for all residents, and consequently staff members work with residents to develop individual treatment plans. Length of residence therefore varies and is dependent on each resident’s plan. Consequently, residents may reside at the program for varying periods from 1 week to 3 months, providing each participant with a different experience at STEPS. While important as a way of tailoring intervention and care to the needs of the individual,
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these factors may also contribute to each person’s perspectives on the STEPS program. Strengths of Current Study This study provided the opportunity to pilot a process which included gathering information on the lived experiences of a small group of young people undertaking a treatment program within a subacute mental health facility. As there is little literature evaluating stepped-care programs amongst a youth population, this study provides the opportunity for further research development and most importantly, provides a report of the phenomenological experience of young people experiencing mental health concerns. Results indicated there were some residents who benefited from their time at the STEPS program. Aspects of the program that were endorsed by the residents as beneficial included relationships with staff and fellow residents, being taught life skills to cope with mental illness and interpersonal relationships, and being in an environment that facilitated change.
Conclusion Research indicates that the onset of many psychological disorders from depression to psychosis, begin in youth (Frojd et al. 2007; Hickie et al. 2005). However, research also shows that youth are a population that are the least likely to seek help when they experience mental illness symptoms (Ciarrocchi et al. 2002). Consequently, new models of care focussed on early intervention with youth with mental illness are now being developed, with the STEPS Program in the ACT pioneering a residential stepped-care model in Australia. Results of this pilot study indicate some support for the stepped-care model and provide some direction for further research studies. Acknowledgments The authors acknowledge the support of CatholicCare Canberra and Goulburn (Australia), and ACT Health in the development of this study.
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Bratter, B. L., Bratter, T. E., Radda, H. T., & Steiner, K. M. (1993). The residential therapeutic caring community. Psychotherapy, 30(2), 299–304. Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3(2), 77–101. ISSN 1478-0887. Ciarrochi, J., Deane, F. P., Wilson, C. J., & Rickwood, D. (2002). Adolescents who need help the most are the least likely to seek it: The relationship between low emotional competence and low intention to seek help. British Journal of Guidance and Counselling, 30(2), 173–186. Ciarrochi, J., Wilson, C. J., Deane, F. P., & Rickwood, D. (2003). Do difficulties with emotions inhibit help-seeking in adolescence? The role of age and emotional competence in predicting helpseeking intentions. Counselling Psychology Quarterly, 16(2), 103–120. Davison, G. C. (2000). Stepped-care: Doing more with less? Journal of Consulting and Clinical Psychology, 68(4), 580–585. Department of Health and Ageing (DoHA). (2009). The mental health of Australians 2: Report on the 2007 national survey of mental health and wellbeing. Canberra: DoHA. Department of Human Services, Mental Health and Drugs Division. (2008). Final report for evaluation of the prevention and recovery care (PARC) services project. Retrieved from http:// www.health.vic.gov.au/mentalhealth/publications/parc-evaluation. pdf Drell, M. (2006). ‘‘Sweet are the uses of adversity’’: A transition program for children discharged from an inpatient unit. Psychiatric Services, 57(1), 31–33. Duppong Hurley, K., Trout, A., Chmelka, M. B., Burns, B. J., Epstein, M. H., Thompson, R. W., et al. (2009). The changing mental health needs of youth admitted to residential group care. Journal of Emotional and Behavioural Disorders, 17(3), 164–176. Frojd, S., Marttunen, M., Pelkonen, M., Von der Pahlen, B., & Kaltiala-Heino, R. (2007). Adult and peer involvement in helpseeking for depression in adolescent population. Social Psychiatry Psychiatric Epidemiology, 42, 945–952. Hickie, I. B., Groom, G. L., McGorry, P. D., Davenport, T. A., & Luscombe, G. M. (2005). Australian mental health reform: Time for real outcomes. MJA, 182(8), 401–406. Kessler, R. C., Andrews, G., & Colpe, L. J. (2002). Short screening scales to monitor population prevalence and trends in nonspecific psychological distress. Psychological Medicine, 32, 959–976. Kessler, R., Avenevoli, S., Costello, J., Georgiades, K., Green, J. G., Gruber, M., et al. (2012). Prevalence, persistence and sociodemographic correlates of DSM-IV disorders in the National Comorbidity Survey Replication Adolescent Supplement. Archives of General Psychiatry, 69(4), 372–380. Leichtman, M. (2006). Residential treatment of children and adolescents: Past, present and future. American Journal of Orthopsychiatry, 76(3), 285–294. Luszczynska, A., Scholz, U., & Schwarzer, R. (2005). The General Self-Efficacy Scale: Multicultural validation studies. The Journal of Psychology: Interdisciplinary and Applied, 139(5), 439–457. doi:10.3200/JRLP.139.5.439-457. McGorry, P. D. (2007). The specialist youth mental health model: Strengthening the weakest link in the public mental health system. MJA, 187(7), S53–S56. McGorry, P. D., Purcell, R., Hickie, I. B., & Jorm, A. F. (2007). Investing in youth mental health is a best buy. MJA, 187(7), S5–S7. McNeal, R., Handwerk, M. L., Field, C. E., Roberts, M. C., Soper, S., Huefner, J. C., et al. (2006). Hope as an outcome variable among youths in a residential care setting. American Journal of Orthopsychiatry, 76(3), 304–311.
Community Ment Health J O’Herlihy, A., Worrall, A., Lelliott, P., Jaffa, T., Mears, A., Banerjee, S., et al. (2004). Characteristics of the residents of in-patient child and adolescent mental health services in England and Wales. Clinical Child Psychology and Psychiatry, 9(4), 579–588. Patel, V., Flisher, A. J., Hetrick, S., & McGorry, P. (2007). Mental health of young people: A global public-health challenge. Adolescent Health, 3(369), 1302–1313. Repetti, R. L., Taylor, S. E., & Seeman, T. E. (2002). Risky families: Family social environments and the mental and physical health of offspring. Psychological Bulletin, 128(2), 330–366.
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BRIEF COMMUNICATION
Youth with Mental Illness: Attitudes Towards and Therapeutic Benefits of Residential Stepped Care Lynne E. Magor-Blatch • Laura Ingham
Received: 28 January 2013 / Accepted: 7 October 2014 Springer Science+Business Media New York 2014
Abstract There is little research reporting the ‘‘lived experience’’ of young people undertaking treatment for mental health conditions. This pilot study explores the phenomenological experiences of a small group of six young people aged 14–18 years who were resident of a youth stepped-care mental health program in the Australian Capital Territory. Using semi-structured interviews, data were collected and two main themes emerged: (a) ‘‘Life engagement’’ and (b) ‘‘Relationships.’’ Participants also provided responses on self-report measures at baseline and follow-up and feedback on aspects of the program. Further research is suggested to build on this study to increase research outcomes. Keywords Youth Mental health Engagement Relationships Stepped-care
Introduction The 2007 Australian National Survey of Mental Health and Wellbeing (NSMHW) estimated 45.5 % of Australians
L. E. Magor-Blatch (&) L. Ingham Faculty of Health, Centre for Applied Psychology, University of Canberra, Canberra, ACT 2601, Australia e-mail: [email protected] L. E. Magor-Blatch School of Psychology, University of Wollongong, Wollongong, NSW, Australia L. E. Magor-Blatch Australasian Therapeutic Communities Association, Yass, NSW, Australia L. Ingham ACT Health, Canberra, ACT, Australia
aged 16–85 years (7.3 million people) had experienced a mental disorder over their lifetime, while 20 % (3.2 million people) experienced symptoms of mental illness over the 12 months prior to survey (ABS 2008). In that period, anxiety, affective and substance use disorders were experienced by 14.4, 6.2 and 5.1 % of the population respectively (DoHA 2009). Research indicates that the onset of various types of mental illness often begins in the adolescent years (Frojd et al. 2007; Hickie et al. 2005). For example, the onset of psychotic disorders is most typical in young people under 25 years of age (Hickie et al. 2005). The psychological wellbeing of youth, aged 12–25 years (Patel et al. 2007) has emerged as a major social issue in Australia. Prevalence rates of mental illness amongst young Australians are reported as being as high as 19 % (McGorry et al. 2007). Similar findings have been reported internationally. Research conducted in 2007 in Europe suggested that approximately 25 % of youth had experienced an episode of depression (Frojd et al. 2007). In the US, prevalence estimates of any DSM-IV disorder amongst young people are 40.3 % at 12 months (79.5 % of lifetime cases) and 23.4 % at 30 days (57.9 % of 12-month cases) (Kessler et al. 2012). Contributing Factors to Poor Mental Health in Youth Many factors contribute to the mental health of adolescents. Research suggests that children who are raised in families with a history of conflict and aggression become more sensitive to stress, anger, anxiety and fear (Repetti et al. 2002). Lack of participation in community activities may also contribute to poor mental health, with decreased engagement in sporting events and religious activities coinciding with increased exposure to illicit substances (Hickie et al. 2005; McGorry 2007). Additionally, many
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young people experiencing mental health issues have been victims of physical, sexual and emotional abuse. A study of youth in residential treatment for mental illness found 22–38 % had experienced physical, sexual or emotional abuse (O’Herlihy et al. 2004). Impact of Poor Mental Health in Youth The onset of mental illness during adolescent years is of significant concern as it coincides with several important developmental milestones, including development of social supports and networks, completion and/or commencement of further study and entrance to the workforce (Patel et al. 2007). Additionally, individuals experiencing mental illness have been shown to be less likely to participate in paid work when compared to those who are physically disabled. Research undertaken in 2005 indicates that 60 % of disability support costs were related to a mental illness for individuals aged 15–34 years (Hickie et al. 2005). Youth Help-Seeking for Mental Illness Although a moderate proportion of youth experience mental illness, research indicates that youth are the population least likely to seek assistance. Rates of help-seeking amongst young people with mental illness have been reported to be as low as 17–39 % (Frojd et al. 2007; Sawyer et al. 2000 in Ciarrochi et al. 2003). Several factors have been identified as contributing to these low rates of help-seeking. Type of mental illness symptoms, low emotional competence and the type and perceived quality of the relationship to the help-giver, are factors affecting youth help-seeking (Ciarrochi et al. 2003). Additionally, the focus of mental health services on illness and recovery also presents as a barrier. Traditionally the focus has been on treatment once a crisis has occurred, often resulting in presentation to hospital emergency or to mental health service (McGorry 2007). In this context, the STEPS program seeks to change that process by intervening through earlier identification and detection of mental health problems and opening up referral pathways through primary care. A shift to a more proactive approach is required for intervention in the earlier stages of mental illness. As a result, stepped-care models that emphasize early intervention, mental health promotion and prevention have been supported in Australia (ACT Health 2009; McGorry 2007). The stepped-care approach is best described by Davison (2000, p. 580) as: ‘‘the practice of beginning one’s therapeutic efforts with the least expensive and least intrusive intervention possible, moving on to more expensive and/or more intrusive interventions only if deemed necessary in order to achieve a desired therapeutic goal.’’
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The stepped-care approach allows for increased integration of services when a client needs to step down from services (such as leaving hospital to go back into the community) or step up to services (transition from home to short term residential or institutional stay) (ACT Health 2009). Consequently, the stepped-care model provides an alternative to hospitalisation for youth with mental illness, which includes access to primary prevention residential stepped-care programs. Residential Stepped-Care Model Residential stepped-care facilities offer a plausible alternative to hospitalisation for youth with complex mental health needs (Duppong Hurley et al. 2009) and are characterised as accommodation in the form of a residential facility that has limited beds and paid, rostered staff members to provide support in daily living skills (Ainsworth and Hansen 2005; Duppong Hurley et al. 2009). Stepped-care provides treatment within both residential and aftercare settings, which may include a halfway house and/or community-based support once the person has returned home. The current model under review provides residential treatment within a short-term (up to 3 months) facility and supports both the young person and their family through individual and group processes. Residential care is able to relieve the pressure for beds in smaller, acute hospital wards, provides continuity of care in the community and a short term service for youth to facilitate a step up to other mental health services, treatments or environments; or step down into the community and home (Drell 2006; Duppong Hurley et al. 2009). According to Hickie et al. (2005) residential stepped-care models have great potential, as they offer a cost effective alternative to intervene earlier with youth experiencing mood disorders and first onset of psychosis. Residential Stepped-Care in Australia: STEPS Program Residential stepped-care programs are emerging in the area of youth mental health care in Australia. One example for youth is the STEPS program in the Australian Capital Territory (ACT), which aims to improve the integration of care and support for youth experiencing mental illness. STEPS provides a sub-acute residential facility for young people (aged 14–18 years) who are experiencing moderate to severe mental illness without requiring admission to an inpatient hospital unit and provides accommodation for up to 12 weeks for a maximum of seven residents, to ensure a smooth transition from hospital inpatient units (step down), or from home to mental health services (step up) (Department of Human Services 2008).
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Young people are assisted in their mental health recovery by focusing on their strengths, resilience and skills whilst in the residential facility and then supported through transitional outreach support over a further 12 weeks to ensure stability is sustained. STEPS is situated in a semi-rural setting and co-located with a youth substance abuse program. This offers an opportunity for an interdisciplinary team approach to address both mental health and substance use issues. The program includes accommodation to stabilise mental health issues; case management, information, referral, advocacy and information; clinical support; assistance with accessing accommodation options; help to improve and develop life skills; access to education, work and community resources; with an overall aim to increase understanding, knowledge, skills and confidence to manage future crises. Parents and/or carers are also encouraged to participate in the young person’s recovery plan and are able to access support through STEPS or be linked to appropriate services. Staff are recruited from mental health, psychology, welfare and education and are rostered 24 h a day, 7 days a week to provide early intervention and support by assisting young people to increase their functioning and living skills, and facilitating referrals to mental health and other support services as required (Department of Human Services 2008). Residents within STEPS are supported to maintain involvement in school and/or employment, and continue to attend their own school or workplace whilst undertaking treatment. This may mean leaving the facility during the day to undertake studies or employment, and returning in the afternoon to take part in counselling, groupwork and other therapeutic activities. This includes counselling for associated comorbidities, such as substance use, and residents have the opportunity to undertake a range of creative and recreational activities to support recovery. Referrals come from General Practitioners, psychologists and psychiatrists working with the mental health system and through self-referral (most often with the support of a family member). This process presents fewer barriers to treatment as it opens the doorway to primary care, family and self-referral pathways and negates the need for referral through psychiatric assessment or crisis service, although this may still occur. Furthermore, as a Government-funded service, there is no cost to the individual, other than for medication, whilst the young person is residing in STEPS. This removes a significant barrier to treatment. Length of residence for participants varies, particularly as treatment plans are constructed according to individual need. Recent review of STEPS program data shows that residents on average remain in the program for 55 days.
Outcomes from Residential Stepped-Care Programs Initial research conducted into residential stepped-care program for adults experiencing mental illness [e.g., Prevention and Recovery Care Program (PARC) Australia], reveals potentially positive findings. Residents report improved functional capacity and mental health, confidence in coping (self-efficacy) and enhanced connections to community programs (Department of Human Services 2008). However, a review of the residential stepped-care literature reveals little is known about their therapeutic value for youth (Ainsworth and Hansen 2005). The concept of self-efficacy has been shown to be a factor that influences general mental health, as high levels of self-efficacy have been shown to be associated with identifying and pursuing goals, resulting in a belief that actions will lead to positive outcomes in the future (Luszczynska et al. 2005). This construct could be very important for youth in residential stepped-care programs experiencing mental illness, particularly as research has demonstrated that general selfefficacy is related to other psychological constructs such as optimism, self-regulation and self-esteem (Luszczynska et al. 2005, p. 80). Factors believed to be therapeutic in the stepped-care model include the resemblance of facilities to a family home, where workers act as parental role models by ensuring the safety and needs of residents are met on a daily basis (McNeal et al. 2006) and the group environment, which is conducive to the development of interpersonal skills. As such, stepped-care models provide a focus on daily living skills and independence, resulting in a change in attitudes and behaviours (such as managing emotions and conflict) (Bratter et al. 1993; Leichtman 2006). Research has also shown that residential steppedcare may increase residents’ hope and that the values and behaviours learned in care will continue after the resident has left treatment (McNeal et al. 2006).
Aims of Current Study This pilot study aimed to identify the concerns facing young people accessing acute mental health services, their attitudes towards a stepped-care program (STEPS), and the factors which were found to be therapeutic and helpful. Qualitative research provides the opportunity for a greater understanding of the unique experience of participants and what it means for them in living in a particular experience or situation. These perspectives are important as a way of identifying the factors that engage participants in treatment and provide understanding of the issues which are faced in navigating this journey. Self-report measures were also introduced at baseline and 3-months’ follow-up to provide
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objective measure of change in terms of mental health symptoms, hope and self-efficacy.
Design Adopting a phenomenological approach (Smith et al. 2003), which centres on the person’s own understanding of their lived experience, this study focused on gaining an understanding of young peoples’ experiences in coming into the mental health system, and their treatment experiences of the STEPS program. A semi-structured individual interview was conducted at follow-up and the data analysed according to Braun and Clarke (2006). Participants also completed a self-report questionnaire at baseline and follow-up comprising the Children’s Hope Scale (CHS; Snyder et al. 1997); the General Self-efficacy Scale (GSS; Schwarzer and Jerusalem 1995); and the Kessler Psychological Distress Scale (K-10; Kessler et al. 2002).
Methods Participants Participants were six young people ranging in ages from 13 to 18 years (M = 15 years), including one male and five females. All six of the STEPS program residents resided in the ACT. During the period of survey, only these six young people were admitted to the program. All consented to take part in the study. Procedure Participants were recruited to the study upon entry to the STEPS program, when the resident and their parent or legal guardian were provided with a participant information and informed consent form by program staff. Consent to participate in the study was provided by signing informed consent forms and placing them in a sealed envelope, which was then provided unopened to the researcher by STEPS staff. The researcher then met with the young person in their first week of residence and provided the self-report questionnaire for completion. Three months post-admission, the researcher again met with the young person to conduct a follow-up semi-structured interview comprising six questions. These asked how the young person had been referred to STEPS; what they had learned while resident which had helped them to deal with their mental illness; whether participation in school, training, work or hobbies had changed since being at STEPS (i.e., post-discharge); whether they had noticed changes in their relationships; and what they liked most/least about STEPS.
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There was also the opportunity to provide any further comment. Participants once again completed the self-report questionnaire in order to provide objective report of change over the 3 month period. Notes of the resident’s responses to interview were recorded in writing and read back to the young person to ensure accurate reference of themes and attitudes. During the transcription process, all participants were given a code to maintain anonymity and all personal identifiers removed. The study was undertaken over a 6 month period. At the time of follow-up, four participants remained in the program, and two had left. Analysis A thematic analysis of the initial data set was undertaken to identify, analyse and report patterns or themes using Braun and Clarke (2006) analysis. This comprised a six-phase process and provided the opportunity for a greater understanding of the unique experience of participants and the meaning they were able to make from these experiences. The first phase involved becoming familiar with the data, repeatedly reading through the responses and beginning to identify codes through key words and patterns. Following this familiarisation phase, initial codes were generated in a systematic fashion across the data set and entered into a Microsoft Excel Spreadsheet. In the third phase, codes were collated into potential themes. In phase four, the themes were checked in relation to the coded extracts (Level 1) and the entire data set (Level 2) in order to generate a thematic ‘map’ analysis. In phase five, ongoing analyses were conducted to refine the specifics of the themes and the overall story from the analyses, generating clear definitions and names for each theme. The final phase comprised the development of thematic maps to illustrate the main themes and connected sub-themes. To enhance reliability, emerging themes from the transcripts were independently reviewed in the early stages of analyses by the researcher’s supervisor and one other independent reviewer who was expert in qualitative research. Checking confirmed that all themes identified were deeply embedded in the transcripts and consensus was gained on consistency through discussion.
Results Systematic coding resulted in the emergence of two global themes: (a) ‘‘Life engagement’’ (engagement with the mental health system, the development of lifeskills and the STEPS environment as facilitating change); and (b) ‘‘Relationships’’ (concerns about family stability, the development of peer relationships and shared experiences).
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These themes emerged from the semi-structured interview, which sought information on referral, engagement and relationships. Additionally, participants provided responses in their evaluation of the STEPS program as an environment as which facilitated change. As numbers in the study did not allow analyses of quantitative data other than as individual measures, line graphs were generated to illustrate individual trends on each measure. In each case, the upward trend for CHS and GSS and the downward trend for K-10 showed participants reported increased hope and self-efficacy, and a reduction in mental health symptoms as a result of their treatment within the STEPS program.
P1.
Global Theme One
P1.
Life engagement incorporated participants’ views around their prior engagement in the mental health system, the development of lifeskills and increased engagement in the wider social system, including school, work and hobbies. It reflected attitudes and engagement both prior to and following involvement in STEPS.
P4.
Prior Mental Health System Interaction Some participants described coming to the STEPS program after their first interaction with the mental health system whilst others described a history of interaction with mental health through the Child and Adolescent Mental Health Service (CAMHS) and previous admissions to STEPS. P1. P2.
P4. P5.
I came from hospital, then went home for two nights, then to STEPS. I never had a CAMHS worker. In a mental health ward for 6 weeks before that. CAMHS were working in the hospital with me. CAMHS thought it would be a good program for me Been in the STEPS program before and CAMHS referred me. I was living with my Dad. I was having problems in my relationship with my Dad and I was couch surfing for two or 3 weeks before I got myself into STEPS.
P5.
Time management techniques. I learned it [sic] to help me at STEPS and that decreases my anxiety levels. Communication skills and suggestions about how to communicate with my parents, which makes it easier to manage those relationships now. A lot of the suggestions they made to help me in my relationships with my parents and mental illness helped me.
Increased Social Involvement It was reported by some of the participants that as a result of their time at the STEPS program, they experienced an increase in their participation in school and life generally. Going more to school. Getting more involved and trying harder. Doing more generally. I still attend school regularly. I was able to still attend while at STEPS and I still do now.
Global Theme Two Relationships refers to personal and interpersonal relationships with family, peers and mental health workers, including staff of the STEPS program. Participants also noted the positive value of the STEPS environment in assisting them to develop positive relationships and the opportunity for self-reflection. Improved Relationships Reductions in conflict and increased stability and consistency were highlighted by some of the participants as a factor that they found beneficial about their time in the STEPS program. P1. P5.
Less fighting, less up and down, more consistency. My relationship with my Dad has improved dramatically just because we can communicate more and are more open with each other.
Relationships at STEPS Development of Life Skills Some participants reported that they were taught communication, conflict and time management skills that they were able to utilise in their continuing relationships with family and friends, and which assisted in reducing anxiety after leaving the program. P1.
Being effective in how to get out of the argument, not just what I want. Effective conflict skills.
A theme that featured during the interviews was how the positive relationships between the STEPS residents and staff helped residents to feel respected, with the shared experience seen as beneficial to mental health wellbeing. P1. P2.
The staff [names highlighted]. Support was really good. Being around people my own age who understood what you were going through. Being able to interact properly with other people.
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P5.
The workers were always very fair and respectful and they would talk to me about things, which I didn’t get a lot of at home. Not so much treated as an equal but treated fairly. In that environment the workers have to be neutral and this allows for a lot of selfreflection and healing.
outside school or work studies, the structure provided may have been seen as supportive, while for those less engaged, a perceived lack of structure may have been problematic. Nevertheless, for those coming from unstructured home environments, providing structure into the young person’s life is seen as beneficial for long-term recovery. P1.
Environment Facilitates Making Changes Several participants discussed how being in the STEPS environment alleviated their stress and allowed them to reflect on and make changes in their lives in order to improve their mental health and wellbeing. At the same time, this was very difficult for some, who came to understand that family relationships were impeding, rather than encouraging, mental health recovery. P4.
P5. P5.
I severed my relationship with my Mum because at the moment, she is not helping my relationship and she is not helpful to me at this point in time. I didn’t have to interact with this really negative presence in my life [my Mum] and that really helped me. I liked the closed environment and that allowed me to think about a lot and mull things over. I’d been distracting myself before, so I didn’t realize what was wrong and I couldn’t verbalize what was wrong. It [STEPS] gave me space to mull over my thoughts, feelings and make sense of it all.
Personal Evaluations of STEPS A final question in the semi-structured interview asked participants to provide feedback on the STEPS program, including those aspects which they least liked and believed did not facilitate positive change. There were two main themes which emerged in this discussion. The first related to the structure of the program itself, and the second to the acquisition of skills which participants believed would help them to cope once leaving the program. Structure of STEPS Program Some participants described the structure of the STEPS program as detracting from their ability to benefit from the program. In particular, these participants described lack of structured activities, strict program rules, lack of rapport with staff and limited personal attention as the aspects they least liked about STEPS. As STEPS was in the early stages of development, the program content and structure were still developing. It should also be noted that these personal responses of participants reflected their own participation rates. For those engaged in
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P2. P2.
P4. P5.
[I didn’t like] how unstructured it was. Need to have more structured activities. A bit annoying being in bed at a certain time. I didn’t like my worker I got. Other people’s workers helped them on short term goals, but my worker didn’t… [The workers] should have paid more attention to us. I did not like some of the workers. I did not like the fact I did not get to socialize [with friends] but it was one of the biggest things that helped me to deal with my issues.
There was also some acknowledgement of the role personal difficulties played in preventing residents from fully engaging with the program, although it was suggested that because of their experience of mental illness, staff needed to persevere more with residents who were finding it difficult. This would assist residents to engage, and to identify and achieve goals. P2.
I was too depressed to take initiative. So would be helpful for worker [sic] to take initiative with me.
Failure to Acquire Skills Difficulty engaging in the program because of impairment due to mental illness was identified as a barrier that prevented some participants from benefitting from the STEPS program. Additionally, there were some participants who reported that they did not learn any skills whilst at STEPS and their engagement in life and relationships after STEPS remained the same as before they entered. One participant noted this as: P2.
Didn’t really learn any skills. They said I wasn’t engaging but I was too depressed to engage with them and then they didn’t make an effort either. I was not at school before [STEPS]. Still not at school. Haven’t noticed any changes in relationships. I live with my parents and my relationships with my parents are OK.
Discussion Overall Findings This pilot study explored the phenomenological experiences of a small group of young people aged 14–18 years
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who were resident of STEPS, a youth stepped-care mental health program in Australia. Through this process, participants in the study, who had undertaken the STEPS program, were able to describe the variation in their prior exposure to the mental health system and the impact the STEPS program had on their engagement in aspects of their life, such as in family, education and more generally. Two main themes emerged: (a) ‘‘Life engagement’’ and (b) ‘‘Relationships.’’ The first theme described engagement with the mental health system and the development of lifeskills. Participants described how the STEPS environment facilitated making life changes and the life skills they acquired to cope with mental illness. This included improved communication, conflict and time management skills. The second theme highlighted concerns about family stability, the development of peer relationships and shared experiences. In particular, participants described how they benefitted from relationships with staff and others who were resident in the program, which in some cases resulted in positive and improved family relationships. Participants also provided responses in their personal evaluation of the STEPS program, offering a description of the STEPS environment as one which facilitated change. Also discussed, were those aspects of the STEPS program which were found to be supportive, and those which did not facilitate positive change. This also included some understanding of personal failure to gain from the STEPS experience, often as a result of impairment due to mental illness. The completion of self-report questionnaires at baseline and follow-up also provided objective report of changes on measures of mental health symptoms, hope and general self-efficacy. Implications for Further Research This pilot study was narrow in focus, in that its prime purpose was to provide residents of a sub-acute mental health treatment facility with the opportunity to record information on their personal experiences of coming into treatment, and those aspects which they had found most or least helpful in the treatment experience. While the stepped-care approach is likely to be beneficial for some young people, more research is needed. The study suffered from a low sample size. It is acknowledged that the STEPS program was only able to accommodate small numbers (up to seven residents) and during the 6 months of the study period, only six young people were admitted. All consented to participation in the study. Therefore, in order to gain more participants, any further studies need to be undertaken over a longer period (of approximately 12 months duration). This would allow adequate time for follow-up to determine if the gains from treatment were sustainable over time.
A larger sample size would also provide the opportunity to further expand on a mixed methods approach, which would strengthen results by providing an objective measure of change. While results from the self-report questionnaire administered at baseline and follow-up were analysed for each individual, a larger sample size would allow greater opportunity for analysis. Nevertheless, in this study the upward trend for the CHS and GSS and downward trend for K-10 for each participant, showed increased hope and self-efficacy and reductions in mental health symptoms from admission to 3 months’ follow-up, and supported results of other studies (Department of Human Services 2008). An expanded study could also include a comparison group, such as those receiving mental health care in the community or within another residential setting, and would contribute greatly to the literature. Nevertheless, results of both qualitative and quantitative analyses provide evidence of both clinical and research value. This is a relatively new model of treatment which holds promise as a youth mental health intervention in Australia and elsewhere. This study did not include information on reason for referral or diagnosis. Residents accepted into STEPS are those who are deemed in need of a sub-acute residential setting in order to gain more targeted support and are experiencing moderate to severe mental illness. However, for some participants in this study, the reason for referral included factors other than mental health concerns alone. In interview some talked about problems which they were experiencing at home and in their relationships with family. Some acknowledged depression and self-harming behaviour, while for others, more pervasive mental health concerns were evident. Therefore, any further study should collect relevant demographic and diagnostic information, as the latter, in particular, informs the development of individual treatment planning. Limitations of the Current Study As highlighted, the prime limitation of the current study was the small sample size. Future research would benefit from an extended data collection timeframe to maximise the sample size in order to gain further perspectives from residents about their experience of the STEPS program. Secondly, the STEPS program did not offer a standardised intervention for all residents, and consequently staff members work with residents to develop individual treatment plans. Length of residence therefore varies and is dependent on each resident’s plan. Consequently, residents may reside at the program for varying periods from 1 week to 3 months, providing each participant with a different experience at STEPS. While important as a way of tailoring intervention and care to the needs of the individual,
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these factors may also contribute to each person’s perspectives on the STEPS program. Strengths of Current Study This study provided the opportunity to pilot a process which included gathering information on the lived experiences of a small group of young people undertaking a treatment program within a subacute mental health facility. As there is little literature evaluating stepped-care programs amongst a youth population, this study provides the opportunity for further research development and most importantly, provides a report of the phenomenological experience of young people experiencing mental health concerns. Results indicated there were some residents who benefited from their time at the STEPS program. Aspects of the program that were endorsed by the residents as beneficial included relationships with staff and fellow residents, being taught life skills to cope with mental illness and interpersonal relationships, and being in an environment that facilitated change.
Conclusion Research indicates that the onset of many psychological disorders from depression to psychosis, begin in youth (Frojd et al. 2007; Hickie et al. 2005). However, research also shows that youth are a population that are the least likely to seek help when they experience mental illness symptoms (Ciarrocchi et al. 2002). Consequently, new models of care focussed on early intervention with youth with mental illness are now being developed, with the STEPS Program in the ACT pioneering a residential stepped-care model in Australia. Results of this pilot study indicate some support for the stepped-care model and provide some direction for further research studies. Acknowledgments The authors acknowledge the support of CatholicCare Canberra and Goulburn (Australia), and ACT Health in the development of this study.
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