Community intensive therapy

Community based treatment for psychiatric illness is available in many countries. Kimberly Kendall and Ahmed Darwish consider the options for children and adolescents

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Being admitted as an inpatient to a psychiatric unit either voluntarily or involuntarily can be a terrifying experience for an adult. Imagine how it feels for a child.

Historically, the provision of mental health care for children and adolescents in most rich countries has been patchy at best. In fact, the number of beds provided at a local level is tiny. In 2004, 9.6% of children in Great Britain aged 5-15 years were estimated to have a mental disorder.^w1 Of course, not all of these children need admission to hospital, which can be an isolating experience. Admission to hospital can be disruptive for the child and his or her family. Also, parents can often feel unable to help and worry that their child will be negatively affected by other patients.^w2

In the past decade or so, the treatment of children and adolescents with psychiatric disorders in the community has become more common. More professionals have questioned the usefulness of inpatient treatment, and the use of inpatient beds for these patients has decreased.^w3

Defining the term

Community intensive therapy is an often vaguely defined term that describes a model of service delivery. However, its principles are given away in its name. The approach allows patients to stay at home for most if not all of their treatment, and treatment takes place at home, at school, and anywhere else that is considered the patient's normal environment.

Examples of the types of treatment are cognitive behaviour therapy and family therapy. Usually the same therapist or therapists will visit each time, allowing a relationship of trust to develop. The programme of treatment is more intensive than if patients attended a clinic as outpatients—for example, they have more appointments a week.

Benefits

Community intensive therapy has many benefits. Primarily it allows the patient to stay at home during treatment.^w4 This aims to prevent isolation of the patient from his or her family, peer, and school environments, which might have happened were the child admitted as an inpatient to a psychiatric unit. The child's own strengths are used to support him or her, and the family's relationship with health professionals is developed to empower the family.^w4 Importantly, the patient maintains his or her place in the community, and the approach also goes some way towards protecting the patient from the stigma of admission as an inpatient.

Community intensive therapy can help in some of the most complex and challenging cases, which often consist of multiple diagnoses—for example, a girl with anorexia nervosa is likely to also have depression and possibly an anxiety disorder. Evidence shows that community intensive therapy results in higher patient satisfaction, which is something very important in encouraging patients to engage with their therapist.^w5

From an economics point of view, the community approach makes the most of input from child and adolescent mental health services; reduces the need for patients to be sent out of the area for treatment (which is very expensive); and has been shown to be as cheap as standard treatment.^w6

Disadvantages

Disorders such as psychosis, for example, can make patients difficult to live with, and for this reason parents can find it difficult to have their child stay at home during treatment. Because appointments are quite regular, they can sometimes interfere with school and the child's day to day activities. The types of patients and their disorders and the high pressured working environment may also increase stress in staff.

An international perspective

Awareness of community intensive therapy seems to be increasing, but this is mainly among mental health professionals. Most of the public and even doctors from other specialties are not familiar with the concept, and this needs to be improved.

A diverse range of services has applied the community intensive therapy service model. Even within countries, the configuration of services is varied. Here are some examples from around the world.

South Wales

The community intensive therapy team, based at the Child and Family Centre, Tonteg, was set up in 1998 to provide for the needs of young people with complex psychiatric difficulties. The philosophy of the team is that the mental health needs of all young people and their families can be met within the school, home, and community environments. Using the strengths of the people involved and supporting them along the way, the community intensive therapy team empowers the patient and his or her family. The team liaises with other agencies and measures out its therapeutic input—individual therapy and family therapy—according to the ability of the patient and family to make use of that therapy.

The cases that the community intensive therapy team take on are comparable with cases that would otherwise be referred for admission to an inpatient psychiatric unit and include patients with eating disorders, psychosis, affective disorders, complex cases of autistism, and repetitive self harm.

Melbourne, Australia

The adolescent intensive management team is a multidisciplinary team consisting of a social worker team leader, a consultant psychiatrist, three clinical psychologists, a psychiatric nurse, and a youth worker. The team is based at the Austin Hospital and treats patients aged 12-18 with extreme risk and behaviour that is difficult to manage. Examples of when a referral to the adolescent intensive management team may be made are when outpatient teams have failed to engage a young person in treatment or when the patient's condition demands a high degree of intervention.

The aim of the team is to produce a therapeutic response from the systems and people surrounding the young person. Most interventions by the adolescent intensive management team take place in the patient's environment—for example, at home, at school, and in other places in the community—and may involve schools, working with the family, and supporting and training parents. Although techniques such as cognitive behaviour therapy and family therapy are used, the adolescent intensive management team has named its diverse approach "intensive system therapy."

Auckland, New Zealand

Youth Horizons is a non-profit organisation based in Auckland, New Zealand. It offers intensive clinical support services in the community as well as residential and foster care programmes, Youth Horizons works with families and young people affected by complex behavioural and mental health problems. The organisation's philosophy is that young people should be empowered to fully participate in family and community activities. In an attempt to ensure that this happens Youth Horizons uses multisystemic therapy (see box) to work with young people, their families, and the communities they live in.^w7

Connecticut, United States

The adolescent intensive outpatient programme is a structured after school programme run at the Yale-New Haven Psychiatric Hospital. The programme provides assessment, supervision, structure, and support in the context of group therapy, and offers therapies that build skill in cognitive behaviour. The focus is on the management of feelings and the development of social and problem solving skills. The programme offers a number of methods of treatment, including group psychotherapy, family therapy, case management, and skill teaching.^w8

California, United States

The Loma Linda University Behavioral Medicine Center, at Redlands, California offers an intensive programme for outpatients and a partial hospitalisation programme. The intensive outpatient programme is for treating adolescents who do not need admittance to hospital but need more than one or two outpatient appointments a week. It offers specialised groups for adolescent therapy, adolescent education, multifamily therapy, parent support, and aftercare. There are distinct paths for patients with chemical dependency and dual diagnosis.^w9

Conclusion

The intensive community approach to treating children and young people with psychiatric and behavioural problems has enjoyed a lot of success and high degrees of patient satisfaction.^w5 It is cost effective and its benefits outweigh its disadvantages.^w6 It can only be a matter of time before it is used more widely in mental health services.

Competing interests: None declared.

References w1-w10 are on student.bmj.com.

       

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