Between Adolescence and
Adulthood: How Young Adults with Mental Illness Perceive Their Treatment Needs
Lisa V. Blitz, M.S.
André Ivanoff, Ph.D.
Between Adolescence and Adulthood:
How Young Adults with Mental Illness Perceive Their Treatment Needs is an
exploratory study designed to investigate how seriously mentally ill young
adults in a psychiatric rehabilitation and day treatment program perceive their
treatment needs. Specialized programming will be developed to meet those needs
based on the research results. The last phase will be an outcome study to
determine the effectiveness of these specialized services. This article
presents the study background, aims, and methods.
Seriously
mentally ill young adults between 18 and
25 years old are a vulnerable and little understood minority in the community
mental health system. An increasing
number of young adults with severe and persistent mental illness have been
referred to day treatment programs from hospitals, outpatient clinics, and
residential treatment facilities where they have “aged out”, and from
rehabilitation programs where they have “failed” treatment. These young adults
often have difficulty adapting to the milieu culture of a treatment program
which is designed for adults, but which does not provide specialized services
to meet the needs of young adults. Their
dissatisfaction with program services, their emotional reactions to the illness
and disability of older clients, and their difficulty in feeling a sense of
belonging are expressed verbally and behaviorally (e.g., acting out sexually or
with drugs or alcohol). Their drop out
and rehospitalization rates tend to be high.
These individuals hover between the last developmental
stages of adolescence and the beginnings of full adulthood, even as they are
treated by the mental health system as full adults. Since many of these clients never experienced
institutionalization and have benefited from improved medication therapy, their
needs frequently differ from those of older adults in day treatment programs.
Moreover, to a 20-year-old client entering the adult mental health system for
the first time, even a 35-year-old fellow patient seems old. The additional 15
years that this older adult has had struggling with his or her illness can be
frightening and intimidating to the younger person
This study is designed to investigate the problems and needs of mentally ill young people between 18 and 25 years old, a population that has received little attention from researchers and other writers in the field. A literature review revealed a wealth of articles about clinical treatment of disturbed adolescents in their teens as well as about mentally ill adults over the age of 18, but few articles regarding mentally ill young people between 18 and 25 years old.
The
study is being conducted at the Bronx REAL [Rehabilitation and Education in the
Art of Living], a Jewish Board of Family and Children’s Services therapeutic
community for seriously mentally ill adults, which uses group, individual, and
vocational treatment in the context of milieu therapy. Since the program’s
inception in 1985 until approximately 1997, the client population had typically
been between 30 and 50 years old. Beginning in early 1997, however, the program
experienced a sudden influx of referrals of young adults in their late teens
and early twenties, creating a significant shift in age distribution and mix.
It
became apparent that as these young adults were admitted to the program,
adjustments in treatment style and service delivery would be necessary in order
to meet their needs. Program clinicians
and case managers reported that the young adults were presenting unfamiliar issues. Program supervisors noted an increase in
aggressive energy in the therapeutic community and were being called upon more
frequently to intervene in potentially violent incidents. To better serve this
population, program administrators saw the need for modifications in service
delivery and treatment style. Adolescent
development theory, which typically interprets adolescence as a period of
development that extends into the mid-twenties (Balk, 1995), suggested to staff
that they were serving a population with different psychosocial and
developmental needs from the program’s typical population.
Accordingly,
this study was designed to address these program needs. All young adult clients (between the ages of
18 and 25) who were enrolled in the JBFCS Bronx REAL between December 1, 1997
and March 31, 1998 were interviewed. A
series of focus groups were held with the young adults to determine their
perceptions of their issues and treatment needs; their attitudes toward the
Bronx REAL program; and their impressions of how the program had been helpful
to themselves and their peers. These
focus groups led to the development of questionnaires used in subsequent
interviews.
Records
were kept of interactions between young adults and older adults; young adults
and young adults; young adults and staff; and staff and staff regarding the
young adult clients. Also, clients were
asked a set of questions to determine their current problems and issues. A second set of focus groups was held to
review the interview findings with the young adults.
The principal investigator and an administrative team at the JBFCS Bronx REAL conducted data analysis. This step consisted of analytic coding of the interview transcripts and field notes from the observations, focused coding to collapse and drop codes, and categorization to identify major themes, ideas and points.
The results of this analysis were used directly in the program development process, also conducted by this team. The findings were categorized into three groups: areas of need for service; treatment principles; and treatment and service priorities. The areas of need for service had three sub-themes: issues related to the developmental needs of young adulthood; interpersonal functioning in the program; and problems, coping skills, and service needs related to their illness and disability. The treatment principles were grouped into six prescriptive standards: provide direct feedback to clients; maintain real, genuine relationships; emphasize skill building; approximate a school learning environment in the program structure; make program rules and expectations of clients clear and consistent; and ensure that consequences for rule violation are clear, objectively fair, and geared toward learning and growth.
The
young adults’ five highest treatment priorities were found to be: (1) help
achieving a goal; (2) assistance with going to school or getting a job; (3)
help setting a goal; (4) being around others of their same age; and (5) help
resolving emotional problems. Their five
lowest treatment priorities were found to be pertaining to: (1) questions
regarding drugs or alcohol; (2) concerns about HIV/AIDS; (3) questions and
issues about sex; (4) relationships with peers; and (5) issues with a boyfriend
or girlfriend.
Program
development efforts continue to incorporate these findings in all areas of
service provision. Specialized psychoeducational and psychotherapeutic groups
have been established in response to these findings. Staff training and
development have been redesigned to extend the incorporation of these treatment
principles into clinical assessment and intervention. From the beginning of the
data analysis phase of the project, the principal investigator has worked with
a team of program staff to assess how the results impact program service
delivery and treatment. The input of key staff members, who know the Bronx REAL
system and program culture, was drawn upon to facilitate the integration of the
new program into the existing milieu, and to ensure the backing and support of
the treatment team of the program as specialized services began to be
implemented. In spite of these cautions,
however, implementation of the specialized services proceeded more slowly than
anticipated.
Several
incidents involving young adult clients participating in the program (e.g.,
thefts from staff, aggressive outbursts in the milieu, sexual contact in a
locked group room, and substance abuse issues) have led some staff to question
whether the program should expand its efforts to treat these young people. Effective implementation will require the
cooperation of the entire treatment team.
The principal investigator continues to work with the staff to provide
education and to address staff fears and concerns.
The study’s principal
investigator is Lisa V. Blitz, M.S. The
faculty consultant is André Ivanoff, Ph.D.
Balk, D. E. (1995). Adolescent development: Early through late adolescence. Pacific Grove, CA: Brooks/Cole Publishing Co.
Rothman, J., & Thomas, E. J. (1994). Intervention
research: Design and development for human services. Binghamton, NY: Haworth Press.