Adm Policy Ment Health DOI 10.1007/s10488-014-0563-3
ORIGINAL ARTICLE
Brief Intervention: A Promising Framework for Child and Youth Mental Health? Donna Gee • Helen Mildred • Peter Brann Mandy Taylor
•
Springer Science+Business Media New York 2014
Abstract There is a discrepancy between the demand for mental health treatment amongst children, young people and their carers, and the capacity of the current service system to provide evidence based interventions. Innovative models of care are required to redress this discrepancy. One such model is the single session model, which provides a single or small number of solution focused sessions targeting one or two identified problems. Single session interventions have been trialled across a range of presenting concerns including child and youth mental health services. This paper provides a rationale for offering a brief focused intervention as part of a broader Child and Youth Mental Health Service, and introduces a model of how brief intervention fits within a broader system of care. Keywords Brief Intervention Child and youth mental health Service design Single session intervention Service frameworks Mental health problems have become the major health and well-being issue amongst children and young adults in developed countries. This is highlighted in Australian figures of burden of disease showing that mental health problems occur in approximately 14% of young people aged 4–17 years, and 27 % in the 18–24 year old age range
D. Gee (&) H. Mildred M. Taylor Deakin University, School of Psychology, Eastern Health Child and Youth Mental Health Service, 221 Burwood Highway, Burwood Vic 3125, Australia e-mail: [email protected] P. Brann Monash University, School of Psychology and Psychiatry, Eastern Health Child and Youth Mental Health Service (EH-CYMHS), Clayton, Australia
(Sawyer 2000; Zubrick et al. 2000). Childhood and young adulthood are the foremost developmental stages for onset of mental health problems. The National Comorbidity Survey replication in the United States reported that roughly 50 % of all life time mental disorders commenced prior to age 14, with 75 % of incident cases commencing before the age of 25 (Kessler et al. 2005). Despite recent advances in evidence-based interventions, there remains a significant health gap between the numbers of people requiring versus the number receiving treatment (Andrews et al. 2001). For example, in an Australian survey of those identified as having significant levels of mental health problems through the Child Behaviour Checklist (CBCL), only 25 % had received treatment from a health or counselling service, typically a doctor, paediatrician or school counsellor. Of perhaps greater concern is that, of those children with elevated scores on the CBCL, who met criteria for a depressive, conduct or attentional disorder, and those whose parents perceived a need for professional help, only 50 % had received any professional assistance (Sawyer 2000). There are a number of factors which affect why it can be difficult for people to access and maintain engagement with appropriate mental health care. These have been reported elsewhere (Sawyer 2000; Thornicroft 2012; Wilson & Deane 2001) and include: •
•
System factors, such as funding and the lack of availability of mental health services and service providers (Kazdin & Blase 2011). Client factors, including younger age of onset (Christiana et al. 2000; Kessler et al. 1998; Thompson et al. 2008); a difficulty distinguishing mental health symptoms from ‘normal’ difficulties and a lack of knowledge about where to seek help (Sawyer 2000).
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•
•
Parental factors, including help being too expensive, not knowing where to get help, asking for help and not receiving it or having to wait too long for an appointment (Sawyer 2000). Perceived stigma associated with mental health problems, as well as expectations that families can or should manage their own problems (Sawyer 2000; Wilson & Deane 2001).
As a result of these factors, for many young people there are delays in accessing appropriate treatment. This can result in: prolonged personal suffering; secondary morbidities; significant impact on social, vocational and family functioning; interruptions in developmental progression; potential for symptoms to escalate. Furthermore, there is evidence that childhood mental health difficulties are associated with increased levels of adult mental illness and greater service use (Fryers & Brugha 2013; Knapp et al. 2002) Whilst there are efficacious interventions for children and young people with diagnosed mental health problems (Silverman & Hinshaw 2008; Weisz & Kazdin 2010; Weisz & Weiss 1993), these interventions have often been established within a research framework with clear inclusion and exclusion criteria, or they have been developed to treat specific diagnostic groups with limited applicability across diagnoses (McShane et al. 2007). Clients attending child and youth mental health services tend to present with a complex array of symptoms, and the therapist must utilise their clinical judgement to determine the applicability of evidence based treatments. Translating evidence-based interventions into routine clinical care has proved difficult, with recent evaluations of community-based child and youth mental health services in the US suggesting limited clinical improvement (Garland et al. 2013; Warren et al. 2010).
One approach that may have merit as a component of the mental health suite of service delivery is the single session framework. Single session approaches have been offered as a solution to lengthy wait times for specialist services, and there is emerging evidence that they are efficacious (Campbell 2012). Furthermore, they may offer a step-wise model within specialist services for clients who may benefit from a focussed brief intervention to overcome stressors or reset them on their developmental trajectory. The remainder of this paper focuses on how a single session approach may have a range of benefits for young people experiencing emerging mental health issues, and their families.
The Single Session Model Single session therapy is usually conceptualised as a framework that aims to maximise the therapeutic encounter by identifying and addressing one or two key goals within the context of one 90-minute session. Within a single session model, the therapist seeks to promote change by assisting the client to identify specific problems, explore possible solutions and consider how these would be utilised after the session (Campbell 1999). Furthermore, (Bloom 2001) suggests that there are four fundamental principles related to single session interventions. These are: 1. 2.
3. Single Session Interventions To address the challenges in providing responsive, flexible and effective mental health services, a range of innovations are currently being trialled: ehealth services that offer therapy or information either online or by phone (Christensen & Hickie 2010); self-help packages (Norcross et al. 2013);increasing primary care resources (Hickie & Groom 2002). Kazdin & Blase (2011) argue that a range of interventions are required to meet the divergent needs of people experiencing mental illness and these interventions should be multi-faceted including information-based mental health promotion and problem prevention programs, targeted strategies to assist vulnerable individuals to prevent and better manage their health problems, and specialist services for treating consumers with mental health problems.
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4.
Improvement is accelerated in the initial sessions and then slows with ongoing treatment. Each contact is treated as a singular session focusing on a clearly identified issue, with the therapist encouraging the client to identify strategies to modify this issue and utilise these strategies in the future. The therapist takes on a more active role in ‘‘establishing therapeutic goals, conducting the therapeutic episode, and bringing it to an agreed-upon conclusion’’ (p. 77). The therapeutic foci is not on the face to face contact but rather the time after the session and how the client will enact their alternative strategies.
Evidence for the effectiveness of single session interventions has been growing, however much of it is in the form of small case studies or client self report of outcome. Single session interventions have been utilised across a range of issues including family problems (Campbell 1999), substance abuse (Miller 2000), and adolescent mental health issues (Perkins 2006; Slaff 1995). In addition, there have been three review papers outlining the literature on single session interventions (Bloom 2001; Cameron 2007; Campbell 2012). The most rigorous evaluation of the single session approach to date was undertaken by (Perkins 2006) within
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a Child and Adolescent Mental Health Service in Metropolitan Melbourne. This study compared a ‘treatment group’ (clients who received Single Session Work (SSW) within 2 weeks of entry to the service) with a ‘control group’ who were on a 6-week waitlist before receiving SSW. At 1 month follow up, the treatment group reported significant improvement in the frequency and severity of their identified problem, a reduction in parent and teacher reports of psychopathology, and improved functioning as measured by the Health of The Nations Outcome Scale for Children and Adolescents (Honosca). Furthermore, 95 % of clients reported satisfaction with the service immediately after the single session and 88 % reported satisfaction at the 4-week follow-up. These results were sustained at 18-month follow-up and there was no difference between the group who received treatment within 2 weeks and those who received the delayed intervention (Perkins & Scarlett 2008). A more recent study of brief intervention compared the effectiveness of a walk-in single session approach with usual care in a child and family centre, including clients on a waitlist for this service (Barwick et al. 2013). Clients attending the walk-in service reported improvement across a range of social and emotional measures. Improvements were significantly greater on total mental health problems and internalizing behaviours when compared to the usual care group. These improvements were maintained at 3-month follow-up and the walk-in group continued to show significant improvement compared to usual care (Barwick et al. 2013).
The Single Session Model and ‘Therapeutic Dose’ The single session model emerged from data showing that many clients attend services for only one session or for brief periods (Hansen et al. 2002; Talmon 1990; Weir et al. 2008). Importantly many of these clients reported improvement in their wellbeing after one session, which was sustained in the short to medium term (Bloom 2001; Campbell 1999). Furthermore, there is evidence to suggest that much of the improvement in therapy occurs in the initial session, with therapeutic gains slowing in subsequent sessions (Battino 2006; Howard et al. 1986; Hubble et al. 2010; Seligman 1995). It should be noted that the name single session does not necessarily refer to a one and only session, but rather the premise that the first session is approached as a discrete treatment package. The term ‘Brief Intervention’ then refers to a short-term treatment package of one or more single sessions. Services are continually adapting to meet the needs of their clients. Brief intervention may be a more acceptable first stage intervention providing a flexible and accessible
service to many clients. Some clients, in conjunction with their treating team, may choose further ‘doses’ of therapy depending upon their individual needs. Some clients may only wish to attend for a brief number of sessions (Wierzbicki & Pekarik 1993). There are also a range of clients who are either ambivalent about treatment or have difficulty with regularly attending appointments. Some only require strategies to enhance their existing resources.
The Potential of the Brief Intervention Approach Given the prevalence of mental health problems amongst young people and difficulties with access and resources, the single session approach may present an opportunity to develop services that are more available and attractive to young people. Indeed, Young et al. (2012) argue that the single session model can contribute to providing an accessible and responsive service to a diverse range of clients and across a range of service systems. Fry (2012) reports that of 144 families seen in their single session program, 78 % attended for 1-3 sessions and 77 % reported that these sessions had been helpful in dealing with their mental health problem. Certainly there is evidence to suggest that single session approaches are satisfactory to clients (Miller 2008) and that clients report a single session approach is helpful in addressing their problems (Miller & Slive 2004). Single session approaches aim to utilise the young person’s existing resources to help overcome obstacles. This approach is consistent with young peoples’ beliefs about trying to ‘deal with problems on their own’ (Sawyer 2000) and fits within a more recovery and resilience based treatment philosophy. Young people with a diagnosed mental illness have shown a preference for self-management strategies compared to more formal support services (Olesen et al. 2010). These strategies included doing ‘more of the things you enjoy’, increased physical activity, accessing alternative supports, talking with family and friends or utilising internet chat-rooms (Olesen et al. 2010). These strategies could be enhanced with a single session approach, encouraging young people to fine-tune existing skills and resources to better manage their problems.
Current and Future Mental Health Responses Single session interventions support young people and their carers to access effective treatment, in a timely manner that is flexible enough to meet the needs of a range of individuals. The brief intervention model offers a stepped approach to treatment, by providing a short term service as a first point of contact with the goal of focusing on
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strengths and trying to redirect and assist the young person along on their developmental pathway. In addition to offering a responsive service and shortening waitlists, single session interventions can assist in the allocation of resources to those clients requiring longerterm therapy (Talmon 2012). From a broader service system perspective, the single session or brief intervention model may help to ameliorate the overwhelming demand for tertiary mental health treatment. Providing a focused and responsive intervention could reduce delays for young people and their carers who are attempting to access treatment. We propose that a single session service is an important addition to the current range of treatment options and should be seen as a valid component on a continuum of mental health care. Despite the attractiveness of brief interventions, evaluation of these models has been limited; research undertaken so far generally involves small case studies, and methodologically limited research utilising non-standardised measures. Future research is required to fully examine whether single session interventions are an acceptable model of care for young people and their families, as well as to determine it’s effectiveness in reducing symptomatology, improving functioning and applicability of the model across a spectrum of mental health symptoms, severity and age groups. Brief intervention is a promising model of treatment for mental health problems affecting children, young people and their carers. It also has the potential to assist health service providers to utilise scarce resources across the spectrum of care, respond in a more timely and efficient manner and may met the needs of a large number of clients and their families.
References Andrews, G., Henderson, S., & Hall, W. (2001). Prevalence, comorbidity, disability and service utilisation: Overview of the Australian National Mental Health Survey British Journal of Psychiatry, 178, 145-153. Barwick, M., Urajnik, D., Sumner, L., Cohen, S., Reid, G., Engel, K., et al. (2013). Profiles and service utilization for children accessing a mental health walk-in clinic versus usual care. Journal Of Evidence-Based Social Work, 10(4), 338–352. Battino, R. (2006). Expectation: The very brief therapy book. Norwalk: Crown House Publishing Limited. Bloom, B. L. (2001). Focused Single-Session Psychotherapy: A Review of the Clinical and Research Literature. Brief Treatment and Crisis Intervention, 1(1), 75–86. Cameron, C. (2007). Single session and walk-in psychotherapy: A descriptive account of the literature. Counselling and Psychotherapy Research, 74(2), 245–249. Campbell, A. (1999). Single Session Interventions: An example of clinical research in practice. Australian and New Zealand Journal of Family Therapy, 20(4), 183–194.
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Campbell, A. (2012). Single-Session Approaches to Therapy: Time to Review. Australian and New Zealand Journal of Family Therapy, 33(1), 15–26. Christensen, H., & Hickie, I. (2010). Using e-health applications to deliver new mental health services. Medical Journal of Australia, 192(11), S53. Christiana, J. M., Gilman, S. E., Guardino, M., Mickelson, K., Morselli, P. L., Olfson, M., et al. (2000). Duration between onset and time of obtaining initial treatment among people with anxiety and mood disorders: An international survey of members of mental health patient advocate groups. Psychological Medicine, 30(3), 693–703. Fry, D. (2012). Implementing Single Session Family Consultation: A Reflective Team Approach. The Australian and New Zealand Journal; of Family Therapy, 33(1), 54-69. Fryers, T., & Brugha, T. (2013). Childhood Determinants of Adult Psychiatric Disorder. Clinical Practice & Epidemiology in Mental Health, 9, 1–50. Garland, A. F., Haine-Schlagel, R., Brookman-Frazee, L., BakerEriczen, M., Trask, E., & Fawley-King, K. (2013). Improving community-based mental health care for children: Translating knowledge into action. Administration and Policy in Mental Health and Mental Health Services Research, 40(1), 6–22. Hansen, N. B., Lambert, M. J., & Forman, E. M. (2002). The psychotherapy dose-response effect and its implications for treatment delivery services. Clinical Psychology: Science and Practice, 9(3), 329–343. Hickie, I., & Groom, G. (2002). Primary care-led mental health service reform: an outline of the Better Outcomes in Mental Health Care initiative. Australasian Psychiatry, 10(4), 376-38. Howard, K. I., Kopta, M., Krause, M. S., & Orlinsky, D. E. (1986). The dose–effect relationship in psychotherapy. American Psychologist, 41(2), 159–164. Hubble, M. A., Duncan, B. L., Miller, S. D., & Wampold, B. E. (2010). Introduction. In B. L. Duncan, S. D. Miller, B. E. Wampold, & M. A. Hubble (Eds.), The heart and soul of change: Delivering what works in therapy (2nd ed., pp. 23–46). Washington: American Psychological Association. Kazdin, A. E., & Blase, S. E. (2011). Rebooting Psychotherapy Research and Practice to Reduce the Burden of Mental Illness. Perspectives on Psychological Science, 6(1), 21–37. Kessler, R. C., Berglund, P., Demler, O., Jin, R., & Walters, E. E. (2005). Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62(6), 593. Kessler, R. C., Olfson, M., & Berglund, P. A. (1998). Patterns and predictors of treatment contact after first onset of psychiatric disorders. The American Journal of Psychiatry, 155(1), 62–69. Knapp, M., Mccrone, P., Fombonne, E., Beecham, J., & Wostear, G. (2002). The Maudsely long-term follow-up of child and adolescent depression 3: Impact of comorbid conduct disorder on service use and costs in adulthood. The British Journal of Psychiatry, 180, 19–23. McShane, G., Bazzano, C., Walter, G., & Barton, G. (2007). Outcome of patients attending a specialist educational and mental health service for social anxiety disorders. Clinical Child Psychology & Psychiatry, 12(1), 117–124. Miller, W. R. (2000). Rediscovering Fire: Small interventions, large effects. Psychology of Addictive Behaviours, 14(1), 6–18. Miller, J. K. (2008). Walk-in Single session team therapy: A study of client satisfaction. Journal of Systemic Therapies, 27(3), 78–94. Miller, J. K., & Slive, A. (2004). Breaking down the barriers to clinical service delivery: Walk-in family therapy. Journal of Marital and Family Therapy, 30(1), 95–103. Norcross, J. C., Campbell, L. F., Grohol, J. M., Santrock, J. W., Selagea, F., & Sommer, R. (2013). Self-help that works:
Adm Policy Ment Health Resources to improve emotional health and strengthen relationships. New York: Oxford University Press. Olesen, S., Butterworth, P., & Leach, L. (2010). Prevalence of selfmanagement versus formal service use for common mental disorders in Australia: findings from the 2007 National Survey of Mental Health and Wellbeing. The Australian and New Zealand Journal of Psychiatry, 44(9), 823–830. Perkins, R. (2006). The effectiveness of one session of therapy using a single-session therapy approach for children and adolescents with mental health problems. Psychology and Psychotherapy: Theory, Research and Practice, 79(2), 215–227. Perkins, R., & Scarlett, G. (2008). The effectiveness of single session therapy in child and adolescent mental health. Part 2: An 18-month follow-up study. Psychology and Psychotherapy: Theory, Research and Practice, 81(2), 143–156. Sawyer, M. G. (2000). Mental health of young people in Australia: Child and adolescent component of the National Survey of Mental Health and Well-being. Seligman, M. E. P. (1995). The effectiveness of psychotherapy: The Consumer Reports study. American Psychologist, 50(12), 965–974. Silverman, W. K., & Hinshaw, S. P. (2008). The second special issue on evidence-based psychosocial treatments for children and adolescents: A 10-year update. Journal of Clinical Child and Adolescent Psychology, 37(1), 1–7. Slaff, B. (1995). Thoughts on short-term and single-session therapy. In R. C. Marohn & S. C. Feinstein (Eds.), Adolescent psychiatry: Developmental and clinical studies (Vol. 20, pp. 299–306). Hillsdale: Analytic Press Inc. Talmon, M. (1990). Single session therapy: Maximising the effect of the first (and often only) therapeutic encounter. San Francisco: Jossey-Bass. Talmon, M. (2012). When Less is More: Lessons from 25 Years of Attempting to Maximize the Effect of Each (and Often Only) Therapeutic Encounter. Australian & New Zealand Journal of Family Therapy, 33(1), 6–14.
Thompson, A., Issakidis, C., & Hunt, C. (2008). Delay to seek treatment for anxiety and mood disorders in an Australian clinical sample. Behaviour Change, 25(2), 71–84. Thornicroft, G. (2012). No time to lose: onset and treatment delay for mental disorders. Epidemiology and Psychiatric Services, 21(1), 59–61. Warren, J. S., Nelson, P. L., Mondragon, S. A., Baldwin, S. A., & Burlingame, G. M. (2010). Youth psychotherapy change trajectories and outcomes in usual care: Community mental health versus managed care settings. Journal of Consulting and Clinical Psychology, 78(2), 144-1. Weir, S., Wills, M., Young, J., & Perlesz, A. (2008). The implementation of single session work in community health. Brunswick: The Bouverie Centre. Weisz, J. R., & Kazdin, A. E. (2010). Evidence-based psychotherapies for children and adolescents (2nd ed.). New York, NY US: Guilford Press. Weisz, J. R., & Weiss, B. (1993). Effects of psychotherapy with children and adolescents. Thousand Oaks, CA US: Sage Publications, Inc. Wierzbicki, M., & Pekarik, G. (1993). A meta-analysis of psychotherapy dropout. Professional Psychology: Research and Practice, 24(2), 190–195. Wilson, C. J., & Deane, F. P. (2001). Adolescent Opinions About Reducing Help-Seeking Barriers and Increasing Appropriate Help Engagement. Journal of Educational and Psychological Consultation, 12(4), 345–364. Young, J., Weir, S., & Rycroft, P. (2012). Implementing Single Session Therapy. Australian & New Zealand Journal of Family Therapy, 33(1), 84–97. Zubrick, S. R., Silburn, S. R., Burton, P., & Blair, E. (2000). Mental health disorders in children and young people: scope, cause and prevention. Australian and New Zealand Journal of Psychiatry, 34(4), 570–578.
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ORIGINAL ARTICLE
Brief Intervention: A Promising Framework for Child and Youth Mental Health? Donna Gee • Helen Mildred • Peter Brann Mandy Taylor
•
Springer Science+Business Media New York 2014
Abstract There is a discrepancy between the demand for mental health treatment amongst children, young people and their carers, and the capacity of the current service system to provide evidence based interventions. Innovative models of care are required to redress this discrepancy. One such model is the single session model, which provides a single or small number of solution focused sessions targeting one or two identified problems. Single session interventions have been trialled across a range of presenting concerns including child and youth mental health services. This paper provides a rationale for offering a brief focused intervention as part of a broader Child and Youth Mental Health Service, and introduces a model of how brief intervention fits within a broader system of care. Keywords Brief Intervention Child and youth mental health Service design Single session intervention Service frameworks Mental health problems have become the major health and well-being issue amongst children and young adults in developed countries. This is highlighted in Australian figures of burden of disease showing that mental health problems occur in approximately 14% of young people aged 4–17 years, and 27 % in the 18–24 year old age range
D. Gee (&) H. Mildred M. Taylor Deakin University, School of Psychology, Eastern Health Child and Youth Mental Health Service, 221 Burwood Highway, Burwood Vic 3125, Australia e-mail: [email protected] P. Brann Monash University, School of Psychology and Psychiatry, Eastern Health Child and Youth Mental Health Service (EH-CYMHS), Clayton, Australia
(Sawyer 2000; Zubrick et al. 2000). Childhood and young adulthood are the foremost developmental stages for onset of mental health problems. The National Comorbidity Survey replication in the United States reported that roughly 50 % of all life time mental disorders commenced prior to age 14, with 75 % of incident cases commencing before the age of 25 (Kessler et al. 2005). Despite recent advances in evidence-based interventions, there remains a significant health gap between the numbers of people requiring versus the number receiving treatment (Andrews et al. 2001). For example, in an Australian survey of those identified as having significant levels of mental health problems through the Child Behaviour Checklist (CBCL), only 25 % had received treatment from a health or counselling service, typically a doctor, paediatrician or school counsellor. Of perhaps greater concern is that, of those children with elevated scores on the CBCL, who met criteria for a depressive, conduct or attentional disorder, and those whose parents perceived a need for professional help, only 50 % had received any professional assistance (Sawyer 2000). There are a number of factors which affect why it can be difficult for people to access and maintain engagement with appropriate mental health care. These have been reported elsewhere (Sawyer 2000; Thornicroft 2012; Wilson & Deane 2001) and include: •
•
System factors, such as funding and the lack of availability of mental health services and service providers (Kazdin & Blase 2011). Client factors, including younger age of onset (Christiana et al. 2000; Kessler et al. 1998; Thompson et al. 2008); a difficulty distinguishing mental health symptoms from ‘normal’ difficulties and a lack of knowledge about where to seek help (Sawyer 2000).
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•
•
Parental factors, including help being too expensive, not knowing where to get help, asking for help and not receiving it or having to wait too long for an appointment (Sawyer 2000). Perceived stigma associated with mental health problems, as well as expectations that families can or should manage their own problems (Sawyer 2000; Wilson & Deane 2001).
As a result of these factors, for many young people there are delays in accessing appropriate treatment. This can result in: prolonged personal suffering; secondary morbidities; significant impact on social, vocational and family functioning; interruptions in developmental progression; potential for symptoms to escalate. Furthermore, there is evidence that childhood mental health difficulties are associated with increased levels of adult mental illness and greater service use (Fryers & Brugha 2013; Knapp et al. 2002) Whilst there are efficacious interventions for children and young people with diagnosed mental health problems (Silverman & Hinshaw 2008; Weisz & Kazdin 2010; Weisz & Weiss 1993), these interventions have often been established within a research framework with clear inclusion and exclusion criteria, or they have been developed to treat specific diagnostic groups with limited applicability across diagnoses (McShane et al. 2007). Clients attending child and youth mental health services tend to present with a complex array of symptoms, and the therapist must utilise their clinical judgement to determine the applicability of evidence based treatments. Translating evidence-based interventions into routine clinical care has proved difficult, with recent evaluations of community-based child and youth mental health services in the US suggesting limited clinical improvement (Garland et al. 2013; Warren et al. 2010).
One approach that may have merit as a component of the mental health suite of service delivery is the single session framework. Single session approaches have been offered as a solution to lengthy wait times for specialist services, and there is emerging evidence that they are efficacious (Campbell 2012). Furthermore, they may offer a step-wise model within specialist services for clients who may benefit from a focussed brief intervention to overcome stressors or reset them on their developmental trajectory. The remainder of this paper focuses on how a single session approach may have a range of benefits for young people experiencing emerging mental health issues, and their families.
The Single Session Model Single session therapy is usually conceptualised as a framework that aims to maximise the therapeutic encounter by identifying and addressing one or two key goals within the context of one 90-minute session. Within a single session model, the therapist seeks to promote change by assisting the client to identify specific problems, explore possible solutions and consider how these would be utilised after the session (Campbell 1999). Furthermore, (Bloom 2001) suggests that there are four fundamental principles related to single session interventions. These are: 1. 2.
3. Single Session Interventions To address the challenges in providing responsive, flexible and effective mental health services, a range of innovations are currently being trialled: ehealth services that offer therapy or information either online or by phone (Christensen & Hickie 2010); self-help packages (Norcross et al. 2013);increasing primary care resources (Hickie & Groom 2002). Kazdin & Blase (2011) argue that a range of interventions are required to meet the divergent needs of people experiencing mental illness and these interventions should be multi-faceted including information-based mental health promotion and problem prevention programs, targeted strategies to assist vulnerable individuals to prevent and better manage their health problems, and specialist services for treating consumers with mental health problems.
123
4.
Improvement is accelerated in the initial sessions and then slows with ongoing treatment. Each contact is treated as a singular session focusing on a clearly identified issue, with the therapist encouraging the client to identify strategies to modify this issue and utilise these strategies in the future. The therapist takes on a more active role in ‘‘establishing therapeutic goals, conducting the therapeutic episode, and bringing it to an agreed-upon conclusion’’ (p. 77). The therapeutic foci is not on the face to face contact but rather the time after the session and how the client will enact their alternative strategies.
Evidence for the effectiveness of single session interventions has been growing, however much of it is in the form of small case studies or client self report of outcome. Single session interventions have been utilised across a range of issues including family problems (Campbell 1999), substance abuse (Miller 2000), and adolescent mental health issues (Perkins 2006; Slaff 1995). In addition, there have been three review papers outlining the literature on single session interventions (Bloom 2001; Cameron 2007; Campbell 2012). The most rigorous evaluation of the single session approach to date was undertaken by (Perkins 2006) within
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a Child and Adolescent Mental Health Service in Metropolitan Melbourne. This study compared a ‘treatment group’ (clients who received Single Session Work (SSW) within 2 weeks of entry to the service) with a ‘control group’ who were on a 6-week waitlist before receiving SSW. At 1 month follow up, the treatment group reported significant improvement in the frequency and severity of their identified problem, a reduction in parent and teacher reports of psychopathology, and improved functioning as measured by the Health of The Nations Outcome Scale for Children and Adolescents (Honosca). Furthermore, 95 % of clients reported satisfaction with the service immediately after the single session and 88 % reported satisfaction at the 4-week follow-up. These results were sustained at 18-month follow-up and there was no difference between the group who received treatment within 2 weeks and those who received the delayed intervention (Perkins & Scarlett 2008). A more recent study of brief intervention compared the effectiveness of a walk-in single session approach with usual care in a child and family centre, including clients on a waitlist for this service (Barwick et al. 2013). Clients attending the walk-in service reported improvement across a range of social and emotional measures. Improvements were significantly greater on total mental health problems and internalizing behaviours when compared to the usual care group. These improvements were maintained at 3-month follow-up and the walk-in group continued to show significant improvement compared to usual care (Barwick et al. 2013).
The Single Session Model and ‘Therapeutic Dose’ The single session model emerged from data showing that many clients attend services for only one session or for brief periods (Hansen et al. 2002; Talmon 1990; Weir et al. 2008). Importantly many of these clients reported improvement in their wellbeing after one session, which was sustained in the short to medium term (Bloom 2001; Campbell 1999). Furthermore, there is evidence to suggest that much of the improvement in therapy occurs in the initial session, with therapeutic gains slowing in subsequent sessions (Battino 2006; Howard et al. 1986; Hubble et al. 2010; Seligman 1995). It should be noted that the name single session does not necessarily refer to a one and only session, but rather the premise that the first session is approached as a discrete treatment package. The term ‘Brief Intervention’ then refers to a short-term treatment package of one or more single sessions. Services are continually adapting to meet the needs of their clients. Brief intervention may be a more acceptable first stage intervention providing a flexible and accessible
service to many clients. Some clients, in conjunction with their treating team, may choose further ‘doses’ of therapy depending upon their individual needs. Some clients may only wish to attend for a brief number of sessions (Wierzbicki & Pekarik 1993). There are also a range of clients who are either ambivalent about treatment or have difficulty with regularly attending appointments. Some only require strategies to enhance their existing resources.
The Potential of the Brief Intervention Approach Given the prevalence of mental health problems amongst young people and difficulties with access and resources, the single session approach may present an opportunity to develop services that are more available and attractive to young people. Indeed, Young et al. (2012) argue that the single session model can contribute to providing an accessible and responsive service to a diverse range of clients and across a range of service systems. Fry (2012) reports that of 144 families seen in their single session program, 78 % attended for 1-3 sessions and 77 % reported that these sessions had been helpful in dealing with their mental health problem. Certainly there is evidence to suggest that single session approaches are satisfactory to clients (Miller 2008) and that clients report a single session approach is helpful in addressing their problems (Miller & Slive 2004). Single session approaches aim to utilise the young person’s existing resources to help overcome obstacles. This approach is consistent with young peoples’ beliefs about trying to ‘deal with problems on their own’ (Sawyer 2000) and fits within a more recovery and resilience based treatment philosophy. Young people with a diagnosed mental illness have shown a preference for self-management strategies compared to more formal support services (Olesen et al. 2010). These strategies included doing ‘more of the things you enjoy’, increased physical activity, accessing alternative supports, talking with family and friends or utilising internet chat-rooms (Olesen et al. 2010). These strategies could be enhanced with a single session approach, encouraging young people to fine-tune existing skills and resources to better manage their problems.
Current and Future Mental Health Responses Single session interventions support young people and their carers to access effective treatment, in a timely manner that is flexible enough to meet the needs of a range of individuals. The brief intervention model offers a stepped approach to treatment, by providing a short term service as a first point of contact with the goal of focusing on
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strengths and trying to redirect and assist the young person along on their developmental pathway. In addition to offering a responsive service and shortening waitlists, single session interventions can assist in the allocation of resources to those clients requiring longerterm therapy (Talmon 2012). From a broader service system perspective, the single session or brief intervention model may help to ameliorate the overwhelming demand for tertiary mental health treatment. Providing a focused and responsive intervention could reduce delays for young people and their carers who are attempting to access treatment. We propose that a single session service is an important addition to the current range of treatment options and should be seen as a valid component on a continuum of mental health care. Despite the attractiveness of brief interventions, evaluation of these models has been limited; research undertaken so far generally involves small case studies, and methodologically limited research utilising non-standardised measures. Future research is required to fully examine whether single session interventions are an acceptable model of care for young people and their families, as well as to determine it’s effectiveness in reducing symptomatology, improving functioning and applicability of the model across a spectrum of mental health symptoms, severity and age groups. Brief intervention is a promising model of treatment for mental health problems affecting children, young people and their carers. It also has the potential to assist health service providers to utilise scarce resources across the spectrum of care, respond in a more timely and efficient manner and may met the needs of a large number of clients and their families.
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