Transitions are a natural part of life, but they can present many challenges, even for those of us who are psychologically robust. Adolescence is the developmental phase when young people move towards adulthood. There are a number of associated changes and demands that occur during this time which can be particularly difficult to manage if the young person has a developmental disability. The process is complicated further with the addition of social or psychological problems.
Young people in mental health services may also have to transition between adolescent and adult mental heath services. Factors that may complicate this transition include the nature of the mental health difficulties and the effect on functioning, previous experiences of traumatic endings and/or multiple transitions, and the nature and severity of the developmental disability and learning disability. A number of recently published reports have highlighted the difficulties that can occur when young people transition to adult mental health services (Lavis and Hewson 2011). Young people in hospital can become invisible if their placement is stable or out of area. When young people do transition it is often not well planned and young people are not kept informed or involved. It has been highlighted that transitioning between adolescent and adult mental health services can be particularly difficult for those with Autistic Spectrum Disorder, Attention Deficit Hyperactivity Disorder, and those without a firm medical diagnosis such as young people with conduct disorder or emerging personality disorder.
Young people say that they want to be kept informed about the plans and they want transitions to happen at a pace that suits them. Young people report that negative experiences around transition can lead to disengagement with services and they are disappointed when adult mental health services cannot provide ‘a miracle cure’. Consistently young people said that they wanted one specific person who will stick with them and not lots of different people passing them on (Lavis and Hewson 2011).
Drawing on psychological theory, particularly attachment theory, is very important when thinking about transitions (Bowlby 1998; Holmes 2001). Young people may be in the service for a considerable amount of time, often years, meaning they may have developed important relationship with other young people and staff. The service may have provided their first experience of feeling safe and contained. Considering this, and the fact that young people often enter the service with a history of being a looked-after child and/or multiple placement breakdown, careful consideration needs to be given to transitions. The prospect of an ending can evoke powerful feelings related to past losses, especially if previous losses were traumatic or overwhelming. Transitions can also evoke feelings linked with past experiences such as anger, rejection and abandonment.
As mentioned earlier, transitions are not always well managed and young people with developmental disabilities may not be given enough time or the correct forum to communicate their hopes and fears about leaving.
Funding decisions can mean that a young person may quickly have another placement identified and move within weeks, or they may be waiting for a placement for over a year. This can lead to significant anxiety and associated deteriorations in mental state and behaviour. Anxieties may be expressed through behaviour (acting out), including sabotaging their new placement: ‘If I’m risky I’ll stay here.’ Sudden, high levels of stress and anxiety can also trigger a relapse of mental illness. This can have profound real effects on the young person’s future placement and cause conflict between the service and families who lose faith in the ‘system’.
Staff may also have to deal with difficult feelings regarding letting a young person go or when they feel they have invested a lot into helping a young person’s recovery but have not made a lot of progress. It can be helpful to support the team in viewing the young person’s stay in the service as one part of their recovery journey, and the cumulative effects of the multi-modal treatment programme may not become apparent until after the person has left the service.
Although transitions can create the potential for high anxiety and ‘acting out’ entrenched patterns of behaviour, transitions can also present an opportunity for the young person to experience feelings of achievement and success. They may also be able to create a different narrative relating to moving on and for the first time have a positive experience of an ending.
In terms of good practice, transition planning should start at least six months in advance, coordinated by a consistent proactive lead professional. Structured peer support can be very helpful and consideration should be given to facilitating a group for young people who may shortly be making a transition. Outcomes should be monitored and services should seek feedback from the young people so that services can make improvements (Brodie, Goldman and Clapton 2011). Barriers to successful, well managed transitions may include the ‘invisibility’ issue, funding difficulties, meeting referral criteria ( particularly for those with borderline intellectual disability or no MH diagnosis) and a lack of adult services for individuals with complex/unusual presentations.
Malcolm Arnold House (MAH) is a 40-bed medium-secure service for young people with developmental disabilities. At MAH the clinical psychologist and art therapist have worked together to facilitate a group for young people who may shortly be leaving the service, called the ‘leavers’ group. Young men with learning disabilities, some of whom are on the autistic spectrum, meet to think about their transition. The group has a structured framework within which they can speak or use the art materials to express different themes which relate to moving on. The group is non-directive, which is quite unusual in the service.
The benefits of image making are that imagery can express things that are difficult to verbalise and this can be especially useful for the less verbal members of the group. Imagery can also express and communicate unconscious fears and anxieties; the facilitators can then support the young person to identify something apparent in the art work that the young person has not yet put into words.
The potential benefits of the group format are that this context can create a different dynamic to that experienced on the ward environment. Young people have something in common, shared hopes and concerns about moving on. The group can encourage support and be a safe place to express feelings, perhaps feelings of rage, that young people are worried about expressing in the ward environment, for fear of consequences in terms of perceived risk.
Many young people express that they are both excited and nervous about moving on from their current placement, however their main feeling at the start of the group tends to be fear. Themes that the young people identified as important at the start of the group have included;
■ Keeping in touch with people
■ Freedom, Independence, more choices and fewer restrictions
■ Doing ‘normal things’—opening windows, proper mattress, proper toilet with soft toilet paper
■ Being near family and friends and seeing or having pets
■ It’s hard to think about leaving. It can be scary and frustrating and this can affect behaviour
■ Concerns about the amount of support they will receive in their new placement
■ Meeting new people and leaving the people they know
■ Not knowing when they are leaving
■ Telling people about their past, developing trust.
It has been noticed by the facilitators that during the check-in at the start of the group, young people can focus on concrete real life experiences that happen day to day, including problems such as peer conflict, difficulties coping, fear of losing things (their progress, section 17 leave). This is especially so for those in the group who may be slightly less able and therefore struggle more with reflective skills. Not knowing what is happening regarding their transition and being told different things are also common issues.
The facilitators are currently in the process of evaluating this group, however preliminary outcomes demonstrate that young people want to attend, that they share similar hopes and fears about moving on and that they benefit from hearing how others are feeling and by sharing their own concerns.
Services need to ensure that psychological thinking, planning and service user involvement does not cease at the transition. The way a young person experiences a transition is really important in terms of how they will cope with the changes and how they will engage with future services. What has been highlighted is that in-patient services for young people, particularly those with developmental disorder, should give more emphasis to how transitions are managed, both within and between services. The young person’s views should be taken into account and the relevant literature should be consulted and included in the relevant local policies and guidance.