Centrele de sănătate mintală și intervenția în criza de viață – experiența Centrului de Sănătate Mintală pentru Copii și Adolescenți Cluj-Napoca

Introduction

What is a crisis? According to the American Psychological Association⁽¹⁾, a life crisis is a period of significant distress and effort to adapt to major life events. People in crisis are at risk of suffering significant physical or mental health alterations.

In recent years, there has been an increase in the number of adverse events that can be associated with crisis, as well as a deterioration in mental health among children. This is reflected in empirical data that quantitatively and qualitatively attest to the worsening of psychopathology with an alarming increase in the pediatric and youth suicide rate⁽²⁾.

In this context, efforts are being made to find the best methods of prevention and intervention in the crisis⁽³⁾.

Crisis and associated psychopathological categories have been classified according to various criteria^(4,5) into acute stress reactions, chronic stress states subsumed under the concept of complex trauma, adjustment disorders to various significant life events (divorce, death of a significant person, change of school, emigration, etc.), and persistent affective reactions related to how the child adjusts to primary attachment figures (reactive attachment disorder and disinhibited attachment disorder).

There are also types of crises, such as those related to maturation, which do not always require a psychopathological diagnosis but can nevertheless cause significant suffering and require external support to be optimally resolved.

Given the complexity of situations that cannot be reduced to circumscribed psychiatric implications and complications, there is a global trend towards outpatient and community-based services, which have proven to be more effective in alleviating crises than measures involving hospitalization⁽⁶⁾. There is also empirical evidence that intensive interventions carried out over a longer period in the family environment have positive results, superior to programs involving short-term crisis interventions⁽⁷⁾.

Advantages of non-hospital management in crisis:

• Maintaining the child’s social, family and school integration by not disturbing the natural course and rhythm of daily activities.
• Better adapting of measures to a specific life and personal context by maintaining the involvement of the family, school or other partners, depending on the type of crisis.
• The intervention is more naturalistic, acting not only to overcome the crisis, but also to prevent it at all levels.
• It involves lower costs, by avoiding hospitalization and treatment expenses during the acute period or in the long term due to the effects and sequelae of the crisis.

Consequently, mental health centers are optimal structures for initiating and handling crisis interventions.

The Children and Adolescents Mental Health Center in Cluj-Napoca – our experience in recent years 

The Children and Adolescents Mental Health Center (Centrul de Sănătate Mintală pentru Copii și Adolescenți –CSM) in Cluj-Napoca, Romania, is one of the outpatient structures in the country, subordinate to the National Center for Mental Health and Anti-Drug Abuse. We treat patients from Cluj County, but on several occasions, we have also received requests from other counties. The team currently consists of a psychiatrist, psychologists, speech therapists, a social worker and nurses.

We strive to carry out our work with a focus on the well-being and health of our patients, as well as their families and community. We resort, as much as possible, to integrated therapeutic methods that have been proven effective empirically, but adapted to the specific or unique needs.

Crisis intervention is often necessary, and, actually, the majority of new cases have a crisis component due to the fact that the individual or group’s ability to adjust to adverse external or internal events or situations has been exceeded.

In recent years, we have observed some quantitative and qualitative changes with significant consequences for our work, requiring professional and organizational adjustments. Overall, we have noticed an increasing trend of life crises among children and families, resulting in more frequent requests for specialized help, putting pressure on CSM staff and requiring quick and effective solutions.

Increasing complexity of life situations

Special needs for children institutionalized in state or private centers within nongovernmental organizations, family-type homes. For example, we have children in our care from centers built near monasteries. Both boys and girls are housed there, in some cases several children from the same family. We face crisis situations related to adaptation to the institutional environment, compliance with the center’s rules, collaboration with staff who are sometimes overwhelmed by the children’s aggressive or risky behavior, serious physical conflicts, unwanted pregnancies in adolescents and the danger of accidents.

Children in foster care – a situation in which we care for children with mental health problems and, also, work with the foster parent to foster a good relationship between the two, without which the crisis cannot be resolved. In some situations, foster parents face the dilemma of whether to keep or give up the foster child. This happens when the children’s behavior exceeds the foster parents’ ability to manage it. For example, children who use drugs; children or adolescents with marked physical aggression who hit and threaten foster parents or members of their family; serious behavioral issues at home such as defecating in inappropriate places; school problems like violence towards peers; self-harm and suicide attempts. If the caregiver has given up caring for the child, the crisis continues and becomes more complicated, because it is necessary for the child to adapt to a new living environment, mitigate the effects of repeated abandonment, and correct dysfunctional behaviors.

Adopted children with difficulties adapting to their new family, with tension arising between the desire to make a good impression and to assert their personal autonomy, as well as the crisis of the adoptive family struggling to integrate the child, a process which sometimes proves very difficult, to the disappointment and regret of the parents.

Atypical families, single-parent families due to parental separation, or families with children conceived through sperm donation, without a known biological father. In these cases, the role of the absent parent is performed with difficulty and extra effort by the one who remained with the child, and we try to support a normalization of the parent-child relationship to avoid overly rigid disciplinary, excessively permissive, or overprotective parenting styles.

Children with parents who have mental illnesses. In this situation, we try to support both the child and the parent, and identify other family members or close friends who could help with care and supervision. The goal is to avoid institutionalization, if possible, but also to avoid exposing the child to major care deficiencies or abuse.

 Children who have changed their country of residence, left/returned to Romania with difficulties in adapting to the new school and social system or language.

Children with parents in prison or who use drugs, exposing the children to contact with illegal substances and the criminal environment.

Children who have committed crimes themselves in the recent past, who are currently under the supervision of the probation service and are closely monitored in terms of correcting antisocial behavior and consistency in following the remedial measures instituted.

Increased frequency and intensity of mental disorders, with the consequent appearance of more severe and recurrent crises. In the case of obvious mental illness, increased attention and active assessment of the risk of self-harm, suicide or violence is necessary.

We note in particular the increase in the incidence of neurodevelopmental disorders and the earlier and more frequent appearance of psychotic elements, even with episodic or chronic triggers from the schizophrenia spectrum. These are signs of a general trend of psychological destabilization and mental fragility among children and adolescents at risk of progressive psychological deterioration. In this context, crisis intervention often requires a combination of medication and close collaboration between therapists, the family and the school to support a harmonious and supportive environment adapted to the child’s difficulties.

Changes in the general sociocultural context

Intensive use of technology exposes children to numerous risks, such as unfiltered access to information and exposure to violent or pornographic content, or content promoting deviant behavior. In addition, it substantially changes the way in which the natural process of neuropsychological development takes place by restricting stimuli to those in the virtual environment, which are very easily accessible through strictly visual and auditory sensory modalities, in artificially staged contexts, thereby bypassing or restricting the mental work of representation, analysis and synthesis of information. It also encourages social isolation and increases helplessness in social-pragmatic situations by decreasing interaction with peers and reducing concrete experience, which is usually complex and unpredictable, requiring adjustment along the way.

Changes in lifestyle, with the weakening of interpersonal connections, reduced support offered by the community, family and school, and in general social fragmentation, with isolation, egocentrism and an excessively defensive or offensive attitude.

A state of alertness generated by the experience of the COVID-19 pandemic, the threat of war and general socio-political instability.

Relativization of hierarchies and fundamental universal categories, including the concepts of normality/illness, which has consequences for the assumption of identity, the delimitation of situations requiring active intervention and therapy, and the best way to intervene.

A great deal of diverse information, easily accessible but often superficial, reductionist, one-sided, contradictory, false or harmful.

Easy access to drugs and gambling.

Accelerated pace of life with high expectations but with a decreased ability to delay rewards, to be patient and to accumulate slowly, progressively and solidly through knowledge and activities that require time, consistency and a constant interest.

What do we do in a crisis?

The CSM team’s intervention is generally structured in several stages and correlated with the crisis characteristics. It usually involves the systematic intervention of at least three professionals: the psychiatrist, the psychologist and the social worker, to whom the speech therapist and medical assistant may be added, as appropriate:

1. Psychiatric assessment of the child – required for the evaluation of the mental state and, where appropriate, the nature and severity of mental disorders, paying attention to functional impairment and the risk of self-harm or harm to others.
2. Psychological assessment – to describe the current level of cognitive development, as well as the potential for progress and recovery. Psychological tests are also used to explore and quantify changes in emotional and behavioral aspects, including academic and social skills.
3. Assessment of the family situation and life context – performed with the social worker. Personal autonomy and support network are also assessed, as well as other resources available in the child’s and family’s life to facilitate crisis management and long-term stabilization.
4. An intervention plan is developed, tailored to the specific crisis, pathology and contextual factors,
5. Implementation of various therapeutic modalities – pharmacological measures, crisis counseling, concrete support, where necessary, for remediation, but also to prevent the crisis from worsening and avoid unfavorable consequences in the future.
6. Recommendations are also made for other community resources that could be accessed. We ensure that they have our contact details, including the phone number of the doctor who can be reached in difficult situations even outside working hours.
7. Where necessary, we contact the teachers, the care staff of institutionalized children, the social workers employed by local authorities and other mental health professionals, such as counselors, psychologists, occupational and art therapists.
8. Long term surveillance – we maintain long-term contact with the child and family for periodic reassessments, and often they are included in a form of therapy and support programs.

If measures beyond outpatient capabilities are necessary, if there is a significant risk of self-harm or harm to others, if the patient’s mental state is severely impaired, or if outpatient treatment cannot be administered safely, we refer patients for admission to the inpatient psychiatric ward.

In addition to the interventions specific to each case, we also carry out crisis assessment and prevention activities outside the CSM. Where necessary, we visit the locations where some of our patients live (foster care homes and other types of child protection institutions), or in some other occasions we meet and advise the staff who take care of the child or foster parents, or even the protection services representatives.

Conclusions

The intervention is complex, involving a large part of our team, and we address the entire family or a significant social group. We use the resources that are already available, and we try to develop them through collaborations with partners in various related fields.

We consider it essential to look and listen carefully and actively to the patient, to be lucid in our decisions, to provide concrete help where appropriate, immediate but also long-term support. We strive to avoid stigma and respect the dignity of each person by maintaining an objective, nonjudgemental stance, by adapting our style to the structure of the patients and their families, as well as to the nature of the problems, generally involving the family in decisions, collaborating with all parties to alleviate difficulties and surpass the crisis.

In addition, we do not forget that any crisis is also an opportunity for change and development for the individual, the community and institutions, including the Children and Adolescents Mental Health Center.