Kathryn Godfrey on an innovatory approach to young people's mental health services

Published: 15/01/2004, Volume II4, No. 5888 Page 31

East London and the City Mental Health trust's Coborn adolescent service in St Clement's Hospital, Bow, covers 700,000 inhabitants in three east-London boroughs.

Young people admitted to the unit are aged 12-18 and suffer from complex mental health difficulties, including psychosis, severe depression, anxiety disorders, obsessive compulsive disorder and attachment disorder.

The 2000 report Whose Crisis?

by children's mental health charity YoungMinds found that children and young people with mental illness were being admitted to the unsuitable environments of paediatric and adult psychiatry wards.

Before Coborn, there was only one other adolescent inpatient facility in inner London, with most teenagers cared for out of area.Working with religious and community leaders from the ethnically diverse area is key.

'The service is geared to an ethnic population, ' explains consultant psychiatrist Dr Rafiq Refaat. 'We work hard to find out what is available in the community from the same culture as the patient, and make links with these services so we can support the young person and their parents.'

Within the area - which has a significantly higher rate of mental illness than the national average - established ethnic populations of Bangladeshis, Hasidic Jews and West Africans are being joined by an increasing number of refugees, including those of Turkish and Kurdish origin. The unit is also treating an increasing number of unaccompanied minors; children as young as 14 who are living and working in this country without their parents and constitute a particularly vulnerable group.

'The deprivation and socioeconomic factors associated with these groups make them more vulnerable to mental illness. Refugees have often suffered traumatic experiences at home and then have to adjust to the cultural differences of the host country, ' says Dr Refaat.

Cultural and religious beliefs are considered throughout the child's treatment, with staff and parents meeting regularly.

Patients from an orthodox Jewish or Muslim background need reassurance about their child being cared for in a mixed unit, with mixed staff.How beliefs can be accommodated within the limitations of the unit may need to be continually renegotiated between staff and parents.

Staff have found that forming relationships with local rabbis and imams helps provide reassurance. Families feel more confident entrusting their children to the unIt is care when it has been given sanction by a respected community leader.

The unit stresses that young people are only admitted to the unit when options for caring for them in the community have been exhausted. In the initial acute phase of the young person's illness, they are often in a distressed and agitated state so parents are initially allowed to stay overnight.

The average length of stay is 52 days, with the aim to discharge the young person as soon as possible. The inpatient stay may be followed up with day care.

The unIt is large multidisciplinary team is made up of doctors, nurses, clinical psychologists, occupational therapists, social workers, art therapists, family therapists and a teacher. The teacher has to work sensitively, as the patient's school experience may not have been positive and they may have been bullied.

Single-sex and mixed groups meet each week. They include a cooking group, a discussion group, a group which looks at relapse prevention strategies and another which focuses on the relationship between physical and mental health.

As well as the inpatient beds, there are three day-care places whose users attend two or three times a week for groups or therapy.

Currently in a refurbished area of the hospital, the unit will be rehoused in a purpose-built unit in 2005. The increase in mental illness in young people has been acknowledged by the doubling of inpatient beds to 12, along with a three-bed intensive care unit and an increased day care facility from three to six.

Whose Crisis? also reported that it often takes more than three days to find a bed for an adolescent emergency admission - it can take as long as three weeks. Unit clinical service manager Andrew Cruickshank says the strong emphasis on accessibility means it is easy for young people to be admitted to Coborn.

'Community teams will alert us to a young person who may need admission and who may turn up at accident and emergency out of hours.We meet the demand at the time.We do not go through a lengthy assessment process.'

Flexibility is the other essential. 'We have to be flexible and work around issues, ' explains Mr Cruickshank. 'You can't dictate a model of care to such a diverse group.'

Coborn unit staff aim to prevent users'mental health crisis severely affecting their selfesteem, so diverting them away from a long 'career' in mental health services.

'We encourage the young person to use their psychological distress in a developmental way, ' says Mr Cruickshank. 'If they can take something from their distress, it can make a difference and stop the cycle.'

Further information

www. youngminds. org. uk/ whosecrisis

For information on contributing to HSJ's fortnightly mental health page, e-mail emma. forrest@emap. com