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

Aims
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.
Methods
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.

Findings
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.

Use of Findings
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. 

References
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.