AICAFMHA:
promoting mental health for young Australians
Australian Infant, Child, Adolescent and Family Mental Health Association Ltd
ABN 87 093 479 022

Building Bridges or Walking the Plank: creating positive outcomes for young people with serious mental health issues
Eleni Stathoulis & Chris Yelland, Hospital to Home Transition Team, WCH, SA

(Slide 1. Heading)

We’ll be talking today about the program we both work on which is called the "Hospital to Home Transition Team" or HHTT for short.

HHTT is a part of Northern Child and Adolescent Mental Health Services (CAMHS), Women’s and Children’s Hospital, in South Australia.

Slide 2. Overview

Overview

• HHTT program
• Theoretical model
• Nature of the client group
• Structure of program
• Overview of program
• Therapeutic approaches

This is an overview of what we’ll be presenting today. Just briefly, we’ll be talking about the HHTT program in general; it’s therapeutic underpinnings; the specific types of issues experienced by the young people who attend; the structure of the group program and an overview of it, and specific therapeutic approaches taken with young people presenting with particular issues.

We’ll start by talking generally about the HHTT program.

Slide 3. HHTT overview

HHTT

• Statewide service for adolescents with severe mental health issues
• Aims to optimise mental health and reintegration into family and wider community
• Emphasis on first episode psychosis
• Continuum of care
• Group program
• Case management

The Hospital to Home Transition Team (HHTT) is a statewide service which works with young people who are likely to have required a hospital admission as a result of severe mental health issues. The program is based at Adolescent Services – Enfield Campus (ASEC) which provides two other adolescent day programs.

The program aims to optimise the mental health of adolescents aged between 12 and 18 years and assist with their reintegration into family and the wider community. It targets those with severe mental health issues with a particular emphasis on first episode psychosis, and is closely linked with Boylan Ward, South Australia’s only child and adolescent mental health inpatient facility. This enables young people to engage with HHTT while an inpatient thus ensuring a continuum of care for adolescents with severe mental health issues.

HHTT provides a therapeutic group program run over 4 days, which is largely activity based. The program also provides clinical case management with each young person assigned a case manager, and also offers individual and family counselling / support where appropriate.

Model/Theoretical Underpinnings

The clinical model used by HHTT is the Transitional Rehabilitation Model of practice. It is an eclectic model drawn from the fields of Occupational Therapy, Psychology and Nursing. This model is based extensively on the Model of Human Occupation, the psychiatric rehabilitation approach (Heras, Dion & Walsh, 1993) and from the EPPIC model of early intervention (McGorry, Edwards, Mihalopoulos, Harrigan & Jackson, 1996).
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Slide 4. Transitional Rehab Model

Transitional Rehabilitation Model

• Early involvement in day to day activities
• Individuals viewed as part of a system
• Individuals possess ability to be in control and make choices
• Development of skills and supports to generate sense of accomplishment

The transitional rehabilitation model is based on four main underpinnings:

1. That early involvement in day-to-day activities assists in the recovery process.

2) Secondly, that individuals are viewed as part of a system and operate in an interactive way within that system. Continuity of care, rehabilitation and supported transition back into an individual’s system therefore assists the recovery process.

3) That individuals possess the ability to be in control of and make choices about their lives. They are therefore as active, as they are able, in decision making and planning within the treatment process.

4) That development of skills and appropriate environmental supports generates a sense of accomplishment and organization of daily life and assists in the acquisition of adaptive behaviours.

The transitional rehabilitation model’s general goals are to assist in the maintenance, recovery, development and acquisition of skills for young people with severe mental health issues. It addresses individual’s needs across the continuum of care from pre-admission and admission to hospital, to the gradual return to their wider system. It values the involvement of individual’s in their recovery process and aims to reduce the impact of mental health issues through early intervention. This model recognises the importance of the therapeutic relationship in rehabilitation and the need for this relationship to be established early in the assessment and treatment phase in order to provide consistent care across the continuum from hospital, to home and the young person’s wider systems. The use of purposeful and meaningful activity across a variety of modalities and settings is recognised as assisting in the development of skill and of adaptive behaviours in order to meet identified needs.

Nature of the client group

Slide 5. HHTT Referrals – 2000

This table shows the number of clients referred to the HHTT program last year, and the types of issues that they were experiencing. As can be seen, the clients who attend our program have experienced a range of difficulties, although in general they fall into two basic categories:

• Those who have experienced a psychosis (which also includes some who may have been diagnosed with a bipolar disorder – a number of these clients have often tended to experience psychotic symptoms at the time of experiencing a manic episode).

And

• Those who have usually been diagnosed with "depression" or sometimes "anxiety" and who, in general, have demonstrated difficulty coping with issues that come up in their lives, often have very complex issues and family backgrounds with multiple psychosocial stressors, and often have limited personal resources (as well as social supports) to cope with these. They often have also demonstrated recurring maladaptive behaviours, such as ongoing self-harming or threats to self-harm, and often are not able to cope in mainstream settings such as school.

We also occasionally are referred young people who have been hospitalised for eating disorders, and we would also include those people in this second category.
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The two HHTT "Streams"

Until this year, regardless of the issues affecting the individual young people, all clients who attended the HHTT program were put into groups together. Although an effort was made to choose specific groups that would be relevant for a particular young person, the groups themselves were made up of individuals who were experiencing a wide range of problems.

This caused a number of difficulties that made it hard to plan activities that would be relevant to both of the client groups just described. For example, we couldn’t really as a group talk about early warning signs of psychosis when it wasn’t really relevant to those who had been referred for depression or anxiety; and similarly it wasn’t often appropriate to talk about self-harming in the group with some young people who had presented with a psychosis. In addition, sometimes just the ‘mix’ of the clients made it difficult to run groups given the very different issues and presentations that they came to us with.

In order to address these issues, this year we began to "stream" clients into two separate programs which we have called "Stepping Stones" and "Break Free" in order to be better able to provide groups with specific therapeutic focuses that are more relevant and useful to the young people who attend.

Client’s are therefore placed in one of the following two groups when they are referred to our program.

Slide 6. Streams

HHTT Streams

• "Stepping Stones": A group program for young people who have experienced a psychosis

• "Break Free": A group program for young people who have had difficulty coping with life stressors and who may have developed maladaptive coping strategies in response to these

And so now we are going to go on to talk more specifically about the programs that we run.

The HHTT group program

Our group program offers therapeutic and activity based groups to both streams, which are run by teaching (Department of Education Training and Employment) staff and clinical (Department of Human Services) staff including a Coordinator, Clinical Psychologist, Clinical Nurse and Occupational Therapist.

Each stream provides similar activity based groups. Our media and communication skills group took the following photographs depicting our resources to illustrate our activity based groups including cooking, art, and woodwork.

Slide 7-12. Photos
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Slide 13. Activity Group Program

Group Program

• Provide concrete tasks to engage young person
• Encourage interaction amongst peers and staff
• Low demand
• Immediate Outcomes
• Small achievable tasks
• Skills based
• Explore, create, have fun …
• Age appropriate
• Provide structure and routine

We find the following benefits of activity based groups:

• Provide concrete tasks to engage a young person into the program

• Encourage interaction amongst peers and staff as they negotiate their way around activities

• Can be low demand

• Have immediate outcomes

• Can be broken down into small, achievable tasks

• Have skills based components which can be transferred into the young person’s environment

• Provide opportunities to explore, create, and have fun

• Are age appropriate and reflect the sorts of activities that may be conducted in mainstream schools

• Provide structure and routine

The tasks, demands and processes of these activities are modified and tailored to the specific needs of the young people in each stream to enable them to participate successfully. Most importantly the group program offers young people a sense of belonging and continuity not only in the groups run but also in the faces they see on a weekly basis.

In addition, each stream provides a therapeutic component which addresses the specific mental health needs of the two distinct streams.
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The Stepping Stones Program

We’ll begin with the therapeutic components of Stepping Stones, our Early Psychosis group which include:

• Monitoring of mental state, medication and illness management

• Lifestyle management addressing accommodation, avocational and vocational or academic pursuits, finance, physical health

• Psychoeducation at both an individual and group level

• Family education and support

• (limited) crisis management support

We work in partnership with young people, their family, supports, psychiatrist (public and private), other health agencies and school or educational facility as appropriate. As that young person approaches 18 years, we liaise and work with the adult mental health service for a smooth handover and transition that we hope prevents further disruption in the young person’s life.

As we are able to track a young person throughout the course of their illness we are able to continue working with that young person when unwell or reconnect them to the program if recovering from a psychotic episode because the program offers them continuity and a sense of belonging in a safe and familiar environment.

Slide 14. Stepping Stones – Aims of Psychoeducation group

Stepping Stones

• Recovery
• Understanding
• Safe structured environment
• Prevention of inactivity and boredom
• Range of social contacts
• Broad range of skills
• Opportunities for fun

The Psychoeducation group run in Stepping Stones is called Positive Health and aims to assist with :

• recovery from psychiatric symptoms and impairment

• recovery from secondary psychological effects of the psychotic experience

• help clients have an understanding of their experience

• providing a safe structured environment and comfortable atmosphere

• prevention of inactivity and boredom

• development of a range of opportunities for a range of social contacts

• maintenance and development of a broad range of skills

• opportunities for fun

Below is a list of topics covered within the Positive Health Group
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Slide 15. Positive Health Group

Topics covered in the group included

• What is psychosis
• Course and onset of illness
• Early warning signs
• Recognizing and dealing with stressors
• Positive and negative symptoms
• Medications
• Drugs and alcohol
• Being healthy
• Social / peer support
• Recovery
• Community supports

Young people attending this group have reported benefiting from the connection made with other young people having endured similar experiences.

One young person valued the group as she said it no longer made her feel like a "freak" and recognised her psychosis as a legitimate condition.

The Break Free Program

Similarly to our work with the young people involved in "Stepping Stones", we also work in partnership with young people, their families, and a range of other agencies in order to optimise outcomes for those referred to our "Break Free" group.

The therapeutic aims of the Break Free program are to:

• assist the young person in overcoming issues in their lives which are preventing them from being able to move forward in a positive direction

• to help them find constructive and safe ways of dealing with their issues

• and then to help them access mainstream opportunities such as education or employment options once they have developed the personal resources to manage these

We do this in a number of ways. Firstly, each young person is allocated a case manager who provides individual support and counselling, as well as family support. We also liaise with other services and assist young people in accessing agencies who are able to provide support in areas such as mental and physical health, education and employment, financial support, and accommodation, as appropriate.

We also provide specific therapeutic groups to those referred to our "Break Free" program in addition to the activity based groups that have already been discussed earlier. More specific information about the therapeutic group content offered to those involved in "Break Free" is provided below.
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Slide 16. Break Free Groups

Break Free Group

Self-esteem Problem Solving

Communication Relationships / Friendships

Body Image Thoughts & Feelings

Peer Group Pressure Assertiveness

Personal Safety Drug and alcohol issues

Sexual Health Stress Management

 

This is a list of the types of sessions that we tend to run with our "Break Free" clients. As can be seen they are fairly general topics, and what we choose to offer at any one time varies depending on specific needs that may be evident within the group, as well as the sorts of things that the young people themselves may identify wanting to work on.

Slide 17. Aims of Break Free Groups

Break Free

• Enhance positive mental health
• Expand repertoire of skills
• Group process, relationships and interactions
• Structured and self-contained

The aim of the group is to enhance positive mental health; the rationale being that if you have more positive mental health, then you are better able to manage and deal with issues that invariably arise in life. In addition we are also aiming to increase the young person’s repertoire in terms of the choices they are able to make when faced with difficult situations or emotions. So by providing young people with skills such as assertiveness and stress management they may be able to utilise these instead of falling back into maladaptive patterns such as self-harming at times of distress.

Other benefits of the group include the relationships that they form with each other and staff, and how they work through particular issues or conflicts that arise as well as their own issues within the group setting. They also benefit by

experiencing a sense of belonging, success and fun; the types of benefits that were discussed earlier.

Another general point is that the groups we run (and this refers both to "Stepping Stones" and "Break Free") tend to be very structured as we find that the young people referred to us may often be unable to provide their own structure for a number of reasons. Also, each session is fairly self-contained as we often have people moving in and out of the group and so we are unable to carry topics over from one session to the next.
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Slide 18. Contact details

Hospital to Home Transition Team

55 Watson Ave

Enfield, SA

5085

ph: (08) 8269 3844

e-mail: asec@wch-camhs.sa.gov.au

 

In summary, HHTT works in partnership with young people on both an individual level through clinical casemanagement and on a group level via the therapeutic group program.

We also work in partnership with families and other agencies involved with young people in order to optimise positive mental health outcomes, functioning and quality of life.

Our aim is to provide young people with the tools and support they may need in order to ensure they don’t feel like they are walking the plank alone, but rather that they are equipped to build bridges towards a positive future.
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Acknowledgements

We would like to acknowledge that much of the content of this paper regarding the HHTT philosophical and therapeutic underpinnings is taken from the conceptualisations made by all HHTT staff, both past and present, as well as key stakeholders.

References

Heras, C.; Dion, G., & Walsh, D. (1993). Application of Rehabilitation Models in a State Psychiatric Hospital. Occupational Therapy in Mental Health, 12(3), 1-31.

McGorry, P.; Edwards, J.; Mihalopoulos, C.; Harrigan, S., & Jackson, H. (1996). The Early Psychosis Prevention and Intervention Centre (EPPIC). An Evolving System of Early Detection and Optimal Management. Unpublished.

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Last Modified: 27-11-2002 10:11:55