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An Evaluation of the Psychotherapeutic Milieu Therapy Programme of the William Slater Centre for Adolescents and Young Adults

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An Evaluation of the Psychotherapeutic Milieu Therapy Programme of the William Slater Centre for Adolescents and Young Adults AN EVALUATION OF THE PSYCHOTHERAPEUTIC MILIEU THERAPY PROGRAMME OF THE WILLIAM SLATER CENTRE FOR ADOLESCENTS AND YOUNG ADULTS A dissertation submitted in partial fulfillment of the degree Master of Arts (Research Psychology), in the Faculty of Social Science and Humanities, University of Cape Town. 1997 UniversityNazeema Ahmed of Cape Town Supervisor: Professor Johann Louw - -, , on 1 ; ...' The copyright of this thesis vests in the author. No quotation from it or information derived from it is to be published without full acknowledgement of the source. The thesis is to be used for private study or non- commercial research purposes only. Published by the University of Cape Town (UCT) in terms of the non-exclusive license granted to UCT by the author. University of Cape Town Acknowledgements My sincere thanks to: Johann Louw, my supervisor, for all his encouragement, patience and assistance. The William Slater Centre's research team, namely, Ray Berard, Frank Boenneester, Gary Read, Justin Sennett and Nigel Hartmann, for their support, interest and encouragement. Sheldon Brandt for assistance with the data collection. The staff and adolescents of the William Slater Centre, for their support, co-operation and contributions. My parents and my husband for all their patience and encouragement. Samad Adam and Samsodien Parker for entrusting me with their computers. My friends, for their encouragement and perseverance with me. The Medical Research Council and the William Slater Centre for financial assistance. Abstract In recent years there has been increasing recognition of the turmoil of the adolescent developmental period. This has primarily been the result of research demonstrating high morbidity, and at times mortality, for this age t,TToup. With the acknowledgement of adolescent mental health problems, and adolescent depression in particular, came the application of a range of treatments for adolescent problems and disorders. This in tum gave rise to a need, from funders and practitioners alike, to demonstrate the efficacy of the interventions. While traditional social science methods were utilised for this purpose, the rise of the field of evaluation brought new vigour to the area of efficacy of psychological treatments. It was this new approach that informed the structure and methodology for the present thesis. The aim of this thesis was to evaluate the William Slater Centre for Adolescents and Young Adults' psychotherapeutic milieu treatment programme. The efficacy of this milieu treatment programme was determined by analysing the following: (i) the structure of the programme; (ii) the process of the programme; and (iii) the short-term outcome of the programme. A combination of qualitative and quantitative methods were used. Results of the evaluation are manifold, with each chapter of the thesis providing insight into varying aspects of the Centre's therapeutic programme. Detailed descriptions of the structure and process of the William Slater Centre and its therapeutic programme is provided. This is followed by an in-depth account of the implementation of the therapeutic programme, where details of the day-to-day functioning of the programme is provided. The final part of the thesis is a brief examination of the short-term outcome of the programme and the staff and adolescent patients' perceptions of the strengths and limitations of the Centre's programme. The thesis provides a comprehensive overview of the structure and functioning of the William Slater Centre and its programme. Emphasis is placed on the concordance of the therapeutic programme with milieu therapy principles. The thesis demonstrates that while the Centre provides an essential service to the adolescent psychiatric population, significant organisational problems of the Centre and the programme require attention. CONTENTS Page Number Title Introduction 5 Chapter 1: Adolescent mental health 5 I. An overview of adolescent mental health 8 2. Adolescent mood disorders 8 2.1. Adolescent depression 9 2.2. Adolescent depressive symptoms 10 2.3. Co-morbidity factors 12 3. Interventions for adolescent depression 13 3.1. Pharmacotherapy 13 3.2. Psychotherapy 15 4. Conclusion 16 Chapter 2: Evaluation ofpsychotherapeutic treatments 16 1. An overview of programme evaluation 16 1.1. Definition 17 1.2. Evaluation approaches 18 2. The evaluation of psychotherapy 19 2.1 . Literature review 25 3. Methodological issues 25 3.1. Methodological limitations of psychotherapy studies 28 3.2. Further methodological difficulties with psychotherapy research 30 3.3. Methodological limitations of adolescent psychotherapy research 33 4. Future research in the evaluation of psychotherapeutic treatments 34 5. Conclusion 36 Chapter 3: An evaluation ofthe William Slater Centre for adolescents and young adults psychotherapeutic milieu treatment programme 36 1. Introduction 36 2. Aims 37 2.1. Programme structure 38 2.2. Programme process 40 2.3. Programme outcome 40 3. Methodological orientation 42 3.1. Strengths and I imitations of methods 43 4. Conclusion 44 PROGRAMME STRUCTURE 45 Chapter 4: A description ofthe William Slater Centre for Adolescents and its therapeutic programme 45 I. Introduction 46 2. The William Slater Centre for Adolescents 46 2.1. Historical evolution of the William Slater Centre and the therapeutic programme 46 2.2. The location of the William Slater Centre 48 2.3 . Personnel 49 3. The therapeutic programme of the William Slater Centre 49 3.1. History of the programme 50 3.2. The referral and assessment process 53 3.3. Programme participants 53 3.4. The psychotherapeutic milieu treatment programme 55 4. Education and training 56 5. The research unit 56 6. The budget of the William Slater Centre 58 7. Conclusion 59 PROGRAMME PROCESS 60 Chapter 5: Profile ofpatients assessed at the William Slater Centre for Adolescents 60 1. Aim 60 2. Method 60 3. Results 61 3.1. Suitability 62 3.2. Outcome 63 3.3. Suitability and Outcome 65 3.3.1. Suitable patients completing the pro!:,rramme 65 3.3.2. Suitable patients not admitted to the programme 66 3.3.3. Defaulting patients 68 3.3.4. Suitable patients, but not motivated 68 3.3.5. Suitable patients, preadmission programme 70 4. Demographic data 77 5. Demographic and diagnostic data 81 6. Conclusion 83 Chapter 6: A description and critique of milieu therapy 83 1. Introduction 83 2. Definition of milieu therapy 84 3. Principles of milieu therapy 87 4. History of milieu therapy 89 5. The decline of milieu therapy 92 6. Milieu therapy at present 93 Chapter 7: Monitoring the implementation ofthe psychotherapeutic milieu treatment programme of the William Slater Centre 93 1. Introduction 94 2. Aim 94 3. Method 95 4. Results 142 5. Discussion 150 6. Conclusion 151 PROGRAMME OUTCOME Chapter 8: Depression rating scales as a measure of adolescent depression 152 1. Introduction 153 2. Aim 153 3. Measures 155 4. Method 156 5. Results 156 5.1. Means and standard deviations of rating scales 157 5.2. Comparison of BDI scores at four time periods 158 5.2.1. Further analysis of the BDI scores 160 5.3. Comparison ofHDRS scores at three time periods 161 5.3.1. Further analysis of the HDRS scores 164 6.3. Comparison ofMADRS at four time periods 165 6.4. Summary 165 7. Discussion 171 Chapter 9: Staffperceptions of the milieu programme 167 I. Introduction 168 2. Method 168 3. Results 169 4. Conclusion 187 Chapter 10: Discussion and Conclusion 187 1. Introduction 187 2. Aim 188 3. Discussion 188 3.1. Structure, process and outcome of the Centre's programme 189 3.2. Drawbacks of the William Slater Centre 189 3.2.1. Lack ofknowledge of milieu therapy 190 3.2.2. Lack of open communication 190 3.2.3. Authority and leadership 192 4. Conclusion 194 References Index of tables Page Table 1: Sliding scale for initial assessment, follow-up 57 visits, admissions and post-discharge visits to the William Slater Centre Table 2: Decision taken at assessment interview( s) on the 61 suitability of patients for the William Slater Centre's therapeutic programme (n=988) Table 3: Outcome of patients assessed at the William Slater 62 Centre (n=988) Table 4: Decisions regarding suitability of patients at 64 assessment versus the outcome of patients Table 5: Time periods at which patients were prematurely 66 discharged from the 12-week programme Table 6: Means, standard deviations and ttest for BDl scores 69 at assessment and at week one (n=37) Table 7: Demographic data of four categories of patients 71 assessed at the William Slater Centre Table 8: A comparison of adolescent patients' 'race groups' 73 by year of assessment at the William Slater Centre Table 9: A comparison of adolescent patients' 'race groups' 75 by year of admission to the William Slater Centre Table 10: Demographic and diagnostic data of four categories 78 of patients assessed at the William Slater Centre Table 11: Means and standard deviations (SD) of the BDI, 157 HDRS and MADRS at four time periods Table 12: Repeated measure, one-way ANOVA, fixed effects 158 Table 13: Number of patients with BDI scores of 24+ 159 Table 14: Repeated measure, one-way ANOV A, fixed effects 160 Table 15: Means and paired two-sample t-test for HDRS and 161 BDI scores (n=104) Table 16: Repeated measure, one-way ANOV A, fixed effects 164 Table 17: Number of clinical staff employed at the Centre 175 1994-1996 Index of figures Page Figure 1: 'Racial groups' of adolescent patients assessed at 74 the William Slater Centre 1991-1995 Figure 2: 'Racial groups' of adolescent patients admitted to 75 the William Slater Centre 1991-1995 Figure 3: Time-series graph for the BDI at four time periods 157 (n=189) Figure 4: Time-series graph for the HDRS at three time periods 160 (n=252) Figure 5: Comparison of ratings ofthe BDI and HDRS ofthe same 162 cohort of patients (n=220) Figure 6: Time-series graph for the MADRS at four time periods 164 (n=39) Index of appendices Page Appendix A: Budget of the William Slater Centre 228 Appendix B: Weekly time table of the William Slater Centre 230 Appendix C: Brochure of the William Slater Centre for Adolescents 231 INTRODUCTION Adolescence brings with it a range of significant and challenging situations affecting almost all aspects of an individual.
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