Background
Youth mental ill health is a significant issue worldwide, affecting individuals, families and communities. The ‘global burden’ of mental and substance use disorders is estimated to have increased by 37.6% between 1990 and 2010 [
1], and is one of the main contributors to disability in young people [
2‐
4]. Researchers estimate that a quarter of mental disorders emerge before the age of 12 years and about three-quarters before the age of 25 [
5]. The impact on social, educational, vocational and developmental milestones can be severe [
6] and often persist into adulthood.
Despite this high level of need, engagement with mental health services by young people aged 12–25 years is the poorest of all age groups [
5]. Experts have advocated for systemic change to improve the care provided to children and young people and boost the inclusion of families/significant others [
7‐
9]. In particular, there has been emphasis on early identification and engagement of children and young people experiencing mental ill health, increased availability of specialist mental health care and improved coordination of care [
3,
7,
9]. A key issue identified in numerous studies is that the difficulties involved in transitioning between child and adult health care systems often result in disengagement [
10‐
13].
In Australia, there has been a longstanding recognition of the importance of improving transitions and continuity of mental health care [
14,
15]. Nevertheless, fragmentation and lack of coordination of mental health care are ongoing service system issues [
16]. Researchers have argued that ‘sub-acute’ residential programs are needed to fill an important gap in the system [
17,
18], providing more intensive support than the community (‘step-up’ care) and assisting with transitions back into the community following hospital admission (‘step-down’) [
19].
Provision of sub-acute residential services for adults has become increasingly common in Australia [
17,
20,
21]. Recovery-oriented models of care are embedded into many of these [
19,
22‐
24]. Recovery-oriented mental health services are generally understood to feature the following: consideration of individual needs and wants; empowerment and promotion of self-care; embracing individual strengths and resilience; acknowledgment that the path to recovery is unique and varied; enabling those affected to benefit from one another; and promoting greater acceptance of people with mental health issues in the community [
22,
23,
25‐
27]. An evaluation of an adult step-up step-down recovery-oriented service in Australia found that clients had significant improvement in symptoms and levels of impairment at exit [
21]. Clients placed value on the following recovery-focused features: support to reduce symptoms, the opportunity to practice development of social relationships, and the opportunity to develop self-care skills [
21]. However, researchers have noted that therapeutic models within sub-acute residential mental health care services are not well described or evaluated [
24,
28]. This is more so the case for youth-focused sub-acute residential services, which are a more recent innovation [
28,
29].
The relatively modest amount of recent literature investigating models of therapeutic care for young people in residential settings is framed by an overall decline in use of residential care settings such as ‘group homes’ with vulnerable children and young people [
30,
31] and shift toward ‘least restrictive’ community-based mental health care [
32]. Despite these shifts, the potential efficacy of short-term, structured, needs-based, therapeutic residential care has gained recognition [
32]. For example, a U.S. study [
33] reported that intensive short-term residential treatment can effectively treat adolescents with severe psychiatric problems, finding that adolescents had sustained improvements in the year following discharge. Evaluation of a secure, residential treatment program in the U.S., focusing on “ecological outcomes” and utilising “a systems approach to emotional and behavioral problems”, found that, for those young people with more severe and persistent mental health issues, the program functioned to “deflect” the need for more intensive or restrictive intervention ( [
34], p499).
The general literature on effective mental health service provision to young people shows provision of holistic care tailored to individual needs, flexible delivery [
15] and therapeutic alliance between the practitioner and young person [
35‐
37] are critical. Carer/family involvement in residential care settings is acknowledged as being important where possible [
23,
38], with psychotherapeutic approaches involving families being supported by a strong evidence base [
39]. Provision of developmentally appropriate care is emphasised. For example, one evaluation found that young people who are grouped in the 16–25 year age range have different developmental needs that should be accounted for in practice [
28]. Three priority areas for young people in residential services were highlighted in the same study: employment and education, physical health and housing needs.
Consistently, the provision of ‘youth friendly’ care has been shown to be critical to improving engagement and retention of young people in services [
40‐
42]. A scoping review identified that principles of ‘youth friendly’ care must be embedded across the following characteristics: organisation and policy; environment; service provider, and treatment/service [
43]. Emphasis was placed on the importance of young people having a voice and being engaged in planning, development, implementation and service delivery [
43]. A qualitative study seeking young people’s perspectives on psychiatric inpatient care found that the support of peers was frequently regarded as one of the most helpful aspects of hospitalisation, as were group therapy and the opportunity for ‘time out’ [
44]. Participants also particularly valued interpersonal interactions with staff and the opportunity to learn coping strategies. Nevertheless, studies drawing on experiences of young consumers in residential therapeutic settings are uncommon.
The combined evidence from research with young people in both residential and non-residential settings indicates that there is a strong overlap between practice that is youth focused and features of recovery-oriented care. Examples include emphasis on individualised care, the instrumental nature of social support from family and peers and the relational aspects of treatment, including interaction with staff [
45‐
47]. However, there is a gap in research that explore of features of recovery-oriented practice within the youth-focused community-based residential care service context. This is significant given the potential of sub-acute models of care in creating a more seamless service system and use of recovery-oriented principles in supporting therapeutic pathways to wellness for young people experiencing mental distress.
This paper reports the findings from an independent evaluation of one Y-PARC service located in an outer metropolitan area of Melbourne conducted in 2015–2017. Prevention and Recovery Care (PARC) services have sought to fill a gap in the continuum of mental health treatment and care by enhancing consumer access and options required for their individual needs [
48]. These services initially targeted adults (over 18 years), providing short term (up to 28 days) mental health residential support and have been described elsewhere [
20,
24]. In Victoria, this service has now been extended through the more recent establishment of Youth PARCs (Y-PARCs). Y-PARCs are tailored to the needs of young people between the ages of 16 and 25 [
49]. Y-PARCs are explicitly recovery-oriented and operate using a blended service model, which involves a partnership between Mental Health Community Support Services (MHCSS) and public area mental health services, commonly referred to as clinical services. The short length of stay and therapeutic focus on mental health goals using a recovery framework are distinguishing features of the Y-PARC, with existing youth residential models in Victoria being for longer term stays (e.g., 1–2 years) and primarily focused on housing needs or education [
50]. At the time of writing there were 21 adult PARCs located in Victoria but there were only three Y-PARCs.
In addition to gaining a better understanding of the reach of the service and characteristics of residents, the evaluation sought to identify ways to: 1) improve provision of therapeutic, recovery-oriented treatment and care; 2) strengthen family engagement and involvement; 3) understand and evidence the impact of Y-PARC on residents’ mental health status and on reducing demand at other acute medical and other mental health services; and 4) improve the service’s partnering arrangement. Analysis presented in this paper outlines identified key strengths of the service model as well as limitations and challenges experienced in service delivery that may be considered in development and improvement of youth mental health services both in Australia and elsewhere. Furthermore, this study contributes to a scant body of research in this area that draws on the perspectives of consumers and their family members/carers.
Methods
This study draws on data collected during a mixed methods evaluation of the Y-PARC service, 2015–17 (Mitchell, Green et al. 2018).
1 The evaluation aims were informed by a service ‘logic model’ describing the aims of the service. Development of key research questions was a collaborative process overseen by a Governance Group representing the four agencies involved in the evaluation (the clinical service, two MHCSS and the university-based research team). The Governance Group also oversaw the data collection process, analysis and development of recommendations.
While this study utilised data ‘about’ young people who accessed the service (e.g., analysis of the service’s database), particular value was placed on the experiences of service users. The perspectives of Y-PARC users and their carers were gained in in-depth interviews and analysed alongside information given by staff and stakeholders to enrich understanding of the service model, practice elements and impact. Interpreted within a hierarchy of user participation [
51], the evaluation approach was informed by an understanding of the value of seeking contribution from young service users in active, empowering and capacity-building roles [
52] and disruption of hierarchical relationships characterising research interviews. Therefore, young people who have been consumers of mental health services were engaged as co-researchers and contributed to the design of research questions, co-facilitation of qualitative interviews, data analysis, development of recommendations, writing of an evaluation report and this manuscript.
2 The involvement of youth co-researchers in a genuine collegiate relationship has been ensured to avoid ‘tokenism’ [
53]. The findings reported here follow the analysis of quantitative and qualitative data sources, described below.
Resident characteristics
Secondary analysis of resident characteristics and outcomes data was conducted using data routinely collected and recorded on the mental health database and medical client information management systems. These de-identified and aggregated data describe age, gender, employment/education status, diagnosis grouping/s of residents who accessed the service across 3 years, 2012–15. Data were collated and basic descriptive analysis was conducted (involving calculation of percentages and proportions). Analysis contributes to understanding of the user group, patterns of access and reach of the service (presented under the “Characteristics of Y-PARC residents” heading below).
Semi-structured interviews
Qualitative interview data were collected from four groups:
a)
Young people who have had an admission at the service (n = 14).
b)
Carers nominated by group a) (in this case all family members) (n = 5).
c)
Service providers who interact and liaise with the Y-PARC (key stakeholders) (n = 9).
d)
Y-PARC staff (3 group interviews conducted with n = 10 respondents).
Procedure
A list of young people (over 18 years) who were residents of Y-PARC in the calendar years of 2014–16 was compiled. All young people on this list had been previously assessed by a psychiatrist on admission for ability to give informed consent. A letter was sent to a random sample of 150 young people from this sampling pool inviting them to contact the research team via telephone or email to volunteer their participation. The young people who were interviewed were also asked to nominate a family member or carer and these individuals were then invited to participate via a letter. Interviews were conducted face-to-face by a member of the research team and co-facilitated by youth researchers where possible. The average length of interviews was one hour. Young people and family member respondents were each reimbursed with a $40 shopping voucher for their contribution.
Service providers who interact and liaise with the Y-PARC were identified by the Governance Group. This list was supplemented by a local area scan conducted by the research team and a snowball method, which involved contacting stakeholders mentioned by interviewees via telephone or email. Individual interviews were conducted face-to-face or by telephone. Staff members with roles in managing the Y-PARC and delivering services in 2016 were invited to participate in one of two semi-structured group interviews.
Consistent with a constructivist approach [
54] in-depth interviews were used to explore the subjective lived experience of four groups. All interviews were semi-structured using an interview guide that was tailored to each group as appropriate with a general focus across each on: exploring adherence of the service to its general aims, impacts (both in relation to individual outcomes and contribution to the system, depending on the perspective of the respondent), and identification of strengths and weaknesses of the service. Informed written consent was obtained and interviews were digitally voice-recorded.
All interviews were transcribed verbatim and personally identifying information was deleted from transcripts. Content analysis of the transcripts was undertaken, with this technique being “a careful, detailed, systematic examination and interpretation of a particular body of material in an effort to identify patterns, themes, assumptions, and meanings” ( [
55], p183). Computer software NVivo version 11 (QSR International) was used to assist with the analysis, which involved ‘coding’ and interpreting of data [
56]. The pragmatic aims of the evaluation study guided deductive or ‘a priori’ reasoning [
57] whereby the questions and prompts in each semi-structured interview guide were used to develop a categorical scheme. Informed by a grounded theory approach, further sub-themes or ‘lower level codes’ were then identified inductively (derived from the data rather than from pre-established categories) [
55] within each theme as the diversity of answers to the questions and prompts were discerned. Data were analysed separately for each respondent group. Because the higher-level themes were derived from the semi-structured interview schedule, similarities and differences between respondent groups on these themes could be discerned. Validation of the interpretive analysis was pursued in an iterative or ‘cyclical’ [
58] process of seeking feedback from research team members as various drafts of the analysis were prepared. The initial draft was highly comprehensive and detailed, with subsequent drafts seeking to refine themes while reducing detail and length. The research team members included Y-PARC managers, youth co-researchers and academics. From these varied perspectives the research team discussed and edited numerous drafts in pursuit of a final agreed version.
Ethics approval for the analysis and reporting of the administrative data and the qualitative interview component of the research was gained through the Peninsula Health Human Research Ethics Committee (QA/15/PH/18 and LRR/16/PH/3). Reporting in this manuscript adheres to the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines [
59].
Discussion
The evaluation identified that, over the three-year evaluation period, a total of 288 young people ages 16–25 years were resident at the Y-PARC service. Twice as many females accessed the service compared to males over the evaluation period (n = 194 to n = 94) and residents stayed for an average length of 19.6 days. Overall, this evaluation found that principles of recovery-oriented practice are embedded in the service, with young people, family and stakeholder respondents discussing how they valued and benefited from provision of person-centred care, promotion of autonomy and self-help, and time spent in an environment with other young people where they could focus on their mental health.
There was a high level of satisfaction reported by former Y-PARC residents and family members overall. Their accounts demonstrated that there is a strong emphasis on ensuring that residents feel safe and comfortable in the environment and it appeared that these elements were the building blocks of the therapeutic environment at Y-PARC. This is consistent with principles of ‘youth-friendly’ service design [
43]. Being able to return for multiple stays at the service was an important service feature. This enabled young people to progress through several stages including stabilisation after a period of mental distress, gaining self-management skills, engagement and building of trusting relationships with staff over time. A flexible, self-paced, long term approach to care is also consistent with a recovery-oriented approach, which emphasises person-centred and user-led care [
23].
Respondents also commonly reported that young people benefited from forming naturalistic, friendship-like relationships with staff and that the opportunity to do so was a key driver of engagement with other aspects of the service. It has been well established that the therapeutic relationship is an important facilitator of recovery for both young people and adults with aspects such as trust, respect and ‘caring’ being important to both [
17,
18,
60]. However, the value placed on a friendship-like relational experience with staff among young people tends to be less prominent in studies with adults [
20].
Findings from the current study suggested that provision of holistic, developmentally appropriate care was also critical, with one of the most widely discussed benefits being the opportunity to experience independent group living and to form new friendships with young people who shared similar experiences. This is consistent with recovery literature, which emphasises the importance of social connection and peer support, particularly in relation to skill development [
21,
61].
There were some areas of challenge or tension identified in this evaluation. The data indicate that relationship-building and ‘the basics’ (e.g. independent living skills and social skills) were prioritised over the provision of structured formal interventions at the Y-PARC. There is evidence that some therapeutic techniques drawn from evidence-based models such as cognitive behaviour therapy may have been used by some staff members but none of our respondents across the four interview groups referred to consistent use of evidence-based psychosocial interventions. The delivery of evidence-based psychosocial interventions in residential youth settings is an under-developed area of the literature [
62]. James et al. [
39] argue that, while there is evidence to support use of several therapeutic interventions in youth residential settings, implementation is complex. Identified barriers include general receptivity among staff and clients, treatment factors and organisational/structural barriers [
39]. Delivery of evidence-based psychosocial interventions was an area for continued investigation within this service with feedback from young people indicating that employment of a clinical psychologist, and structured group sessions may facilitate the delivery of more formalised interventions.
It was evident that family inclusive practice was a priority at the Y-PARC, with young people and family members giving numerous examples of how family and significant others (including children and friends) were included and welcomed by the service. The service also employed a specialist family engagement worker to support practice in this area. However, there was no evidence of implementation of evidence-based therapeutic family-focused interventions such as multi systemic therapy and functional family therapy [
39,
62]. The difficulty of working therapeutically within the milieu of young people’s support networks including with family/carers is well-recognised in the mental health literature [
63,
64], and was reflected in the data. Evaluation of an adult PARC service in Queensland found that involvement and engagement of informal carers was a challenge in that context; whereas, in this study, negotiating the appropriate level of involvement of family in care (e.g., decision making) was a more prominent issue. The issues associated with consent have been noted in both contexts [
24,
28]. Moreover, the combined feedback from young people, family and staff reaffirmed that a continued emphasis on supporting staff to achieve family-inclusive practice was important.
One of the key innovative features of the Y-PARC and other emerging recovery-oriented residential environments is the provision of blended care (e.g. from clinical and non-clinical practitioners) through a partnership between multiple services. This arrangement was understood by Y-PARC staff and stakeholders as both a significant strength and a challenge. They described how, while negotiating different ‘languages’ was a challenge, they learned from one another and ultimately this arrangement contributed to a more holistic and seamless service.
The integration of psychiatric care into the model was a specific area of concern for many young people and parents. The psychiatric treatment model was experienced as inconsistent with the person-focused, recovery-oriented principles underpinning the broader Y-PARC model. There was also a perceived lack of continuity of care, with frequent changes in psychiatric personnel disrupting the capacity to build a therapeutic relationship. Young people who had a prior relationship with a private psychiatric practitioner preferred to maintain their existing relationship and many discussed issues associated with transfer of care.
When asked about service impacts, the majority of young people reported that they discerned improvements in their mental health due to their stay(s) at the Y-PARC and this was supported by family members. Stakeholders provided extensive feedback on the contribution that the Y-PARC makes to the system, with all reporting how it filled a ‘gap’ between community services and acute inpatient mental health hospital wards. There was some evidence that a stay at Y-PARC supplemented the need for hospital admission for some young people in this study. Family members and young people commonly contrasted the Y-PARC with hospital units, speaking about how the service focused on long term wellness rather than medication and risk management. While it is not possible to comment on long term outcomes for these young people, many spoke about improved resilience, better understanding of their mental health, an understanding of the importance of seeking help and stronger connections to therapeutic services moving forward – all of which are consistent with personal recovery [
23,
26].
Limitations
Although efforts were made to use a randomised sampling strategy, the number of qualitative interviews were small and still based primarily upon an opt-in strategy. The opt-in strategy is likely to bias the sample towards research participants who feel more strongly, either positively or negatively, about their experiences at the Y-PARC. The potential for biases in staff-reported practice is also acknowledged. In this respect it is important to note that staff accounts were only drawn upon in the current report when they were consistent with data collected from other sources. Finally, the evaluation was conducted very shortly after the first 3 years of establishment of the Y-PARC. It is well understood that community services undergo a period of rapid evolution and development following establishment. Follow-up research could be potentially conducted to investigate the progress of the service and to investigate changes that have been made following the first evaluation.
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