Extended Inpatient Treatment

AN ADOLESCENT EXTENDED TREATMENT CENTRE (AETC) IS AN ESSENTIAL PART OF THE FULL SUITE OF YOUTH SERVICES

An Expert Clinical Reference Group comprised of clinical and education professionals, health bureaucrats and individuals with consumer/carer lived experience outlined what was necessary to meet the needs of the group they described as:

characterised by severity and persistence of illness, very limited or absent community supports and engagement, and significant risk to self and/or others(ECRG Report, 08/05/2013; BACCOI Exhibit 216)

The criteria included:

  • For young people whose needs could not be met in an acute setting or another environment due to risk, severity or need and when all other appropriate and less restrictive interventions have been considered/tested first.
  • For young people aged 13 – 17 years, with flexibility in upper age limit depending on presenting issues and developmental capacity (as opposed to chronological age).

(For expanded information on WHO young people with severe and complex mental health issues are, go to our Young People page.)

  • In an in-patient therapeutic milieu, with capacity for family/carer admissions (i.e. family rooms)
  • For medium term admissions (approximately up to 12 months; however, length of stay will be guided by individual consumer need and will therefore vary).
  • Delivering integrated care with the local Child and Youth Mental Health Service of the young person
  • Providing individualised, family and group rehabilitation programs delivered through day and evening sessions, available 7 days/week. These must include activity based programs that enhance self esteem and self efficacy of young people to aid in their rehabilitation. As symptoms reduce, there is a focus on assisting young people to return to a typical developmental trajectory.
  • Including programs that maintain family engagement with the young person, and wherever possible young people will remain closely connected with their families and their own community
  • Providing young people with access to a range of educational or vocational support services delivered by on-site school teachers and will be able to continue their current education option. [The provision of education at this level requires focused consideration; an on-site school and education program is a priority.] There is an intentional goal that young people are integrated back to mainstream community and educational/vocational activities.
  • Providing flexible and targeted programs delivered across a range of contexts including individual, school, community, group and family.

HOW …

An AETC should operate in a facility and grounds with accommodation/treatment facilities and dedicated area for education/school. It should incorporate environments that allow for physical activity and a range of outdoor experiences along with space for a garden, outdoor vegetation and inviting community areas. The balance between the needs for security and privacy and an environment that speaks of flexibility, approachability and community is vital.

Services would be provided by staff specially trained in adolescent mental heatlh:

  • Psychiatrists
  • Psychologists
  • Mental Healthcare Nurses
  • Teachers/Teacher Aides
  • Occupational Therapists
  • Social Workers

as well as administrative, maintenance and catering personnel.

Additional visiting professionals would provide training in a range of areas, with many of these organised through the school for inclusion in the weekly/monthly education program. These could include development of skills in the areas of independent living, self-defence, cooking, creative/artistic expression (including writing, music, art, filmmaking etc.), sporting or physical pursuits etc. A number of activities would also be held off-site in order to have access to appropriate facilities/experts and to maintain a connection to the wider community wherever possible. Participation in any of these activities would be according to professional assessment of individual appropriateness.

CONCERNS

Contemporary practice understandably is to treat young people in their own community wherever possible. And because of historical institutionalisation, the majority of clinicians are resistant to the concept of extended inpatient care. However, offered through an appropriate program in an appropriate environment by expert practitioners with the goal from the outset to facilitate a young person’s meaningful integration into a community beyond that within the inpatient milieu, such a service can mean the difference between ongoing social isolation with reliance on welfare and high level support AND a life of productive independence. The key is that such an extended inpatient program should be for young people with severe and complex mental health issues for whom other treatment options have failed.

Where the risk of institutionalisation is concerned, it should be acknowledged that that can be considered greater if the young person receives medium-term care in an acute unit (versus a design-specific extended care unit) and that prolonged admissions of young people with severe and complex mental health issues to acute units can have an adverse impact on other young people admitted for acute treatment. It has also been found that “managing this target group predominantly in the community is associated with complexities of risk to self and others, and also the risk of disengaging from therapeutic services.” (ECRG Report, 08/05/2013; BACCOI Exhibit 216) And in fact, the right program will enable a previously socially isolated and developmentally delayed young person to become an engaged, functional and productive member of society.

But this will only happen at the rate it takes each individual to first develop trust, then observe and then trial social behaviours within the stability of the AETC. The capacity to build resilience and to acquire the skills and understanding will happen at a unique pace. But the micro-community that exists within the centre allows for the transitionthrough this learning curve at a rate that engenders growth that isn’t short-lived particularly because it starts without the overwhelming impact of repeated trauma that has existed for the young person in the wider community. Once experts can assess that foundation development indicates readiness, experiences in that wider community have a  chance of achieving positive outcomes. So the AETC is not an isolated place. It is a first step but one that cannot be rushed to meet academic parameters but one through which the consistency of care and understanding from the expert staff will be the scaffolding that enables valuable change on which more advancements can continue to be made and built upon.

A considerable amount of the practical activity that assists in this area tends to be planned and implemented by the education staff.  Not only because it is learning opportunities that the young people have lacked but also because of the frequency – and therefore continuity – of the engagement that the education team will have with the young people in the inpatient centre. An in-house school program and those providing that are involved and available each weekday whereas treating practitioners (psychiatrists, psychologists, occupational therapists … etc.) are unlikely to have daily consultations with patients. So, in real terms, it is the nursing staff and the school staff who are  consistently present and the school staff whose focus will be on expanding the skills and knowledge of their students from a foundation of trust and hope. Together with the clinical professionals, the full integrated approach of this multidisciplinary team can be life-changed for many young people and their families.