BRIEF PSYCHOTHERAPY IN YOUTH MENTAL

HEALTH, A LITERATURE REVIEW

BY FRANCESCA PALAZZOLO
APA Style Paper for Masters of Counselling & Psychotherapy, Australian College of Applied
Psychology

KEYWORDS
Adolescents, Young People, Young Adults, Youth Mental Health, Brief Intervention, Brief
Psychotherapy, Counselling, Counseling, Anxiety, Depression, Youth, Review

AIM
Young people are notoriously difficult to engage in therapy, especially long term therapy.

Dropout rates for group therapy are high and for one on one therapy it is even higher.

According to the headspace report, The services provided to young people by headspace

centres in Australia, (Rickwood et al, 2015) the majority of headspace clients (35.4%) attend

only one session of therapy, somewhat less (25.6%) attend for only three to five sessions.

Only 10 per cent attend 10 or more sessions. This literature review aims to examine what

evidence there is for the efficacy of brief psychotherapy (in many cases ultra-brief ) for

young people and adolescents in a youth mental health setting.

DATABASES SEARCHED

PSYCHOLOGY AND BEHAVIOURAL SCIENCES COLLECTION, PSYCHINFO, PSYCHBOOKS,

PSYCHARTICLES, ACADEMIC SEARCH COMPLETE, GOOGLE

METHOD
A search was conducted using above databases as well as Google search. Google search was

used to include relevant websites related to youth mental health. Only studies post 2000 were

selected for review. A search of youth specific mental health services and online resources

were also searched. This literature review will examine some of the key research that

currently exists in the field of youth and adolescent brief psychotherapy, and will seek to

answer the following questions; What does the research say about the effectiveness of

evidence based practice in the youth mental health field, and what works best to improve

youth mental health outcomes in the context of brief intervention.

YOUNG people are notoriously difficult to engage in therapy, especially longer term

therapy. In fact, according to the headspace article, The services provided to young people by

headspace centres in Australia (Rickwood et al., 2015), the majority of headspace clients

(35.4%) attend only one session of therapy, somewhat less (25.6%) attend for only three to

five sessions and only 10 per cent attend 10 or more sessions. A recent international study

stated that factors such as ethnic background, socioeconomic status and problem severity

account for some of the main reasons for adolescents dropping out of therapy (Haan et al.,

2015). The authors go on to state that children and adolescents with untreated mental health

disorders are more likely to drop out of school, engage in drug and alcohol abuse and be

unemployed.

This author aims to examine what data exists that supports the efficacy of evidence

based brief interventions for young people and adolescents in a youth mental health setting.

A search was conducted using the multi-search function available through the

NAVITAS online library portal using the following keywords: adolescents, youth, young

people, young adults, youth mental health, brief Intervention, brief psychotherapy,
counselling, counseling, anxiety, depression, review, best practice, evidence based, common

factors and mechanisms of change. Databases such as Psychology and Behavioural Sciences

Collection, PsychINFO, PsychBOOKS, PsychARTICLES were searched. Google search was

used to include relevant websites related to youth mental health. Only articles published post

2000 in peer reviewed journals were selected for review. A preference was given for articles

which included the most prevalent of adolescent disorders; depression, anxiety, conduct

disorders, and attention-deficit disorder (Kazdin, 2004)." A search of youth specific mental

health services and online resources was also conducted, particularly headspace.org.

Headspace is a government funded youth mental health service focussing on early and brief

intervention and mental health support for young people aged 12 - 25.

A total of ten systematic and/or meta analytic reviews were examined by the author as

well as one very recent overview of systematic reviews relating to youth interventions,

published in 2016 (Kai et al.). Two stand-alone studies on specific interventions were chosen,

partly because of their recent publication date and for their relevance. Most of the reviews

targeted youth and adolescents, with a noticeable variety of ages classed as "youth" or

"adolescent". Ages as low as 10 were included as 'adolescents' in some of the studies cited in

some of the reviews. One meta-analysis included studies with young adults up to 30-years-

old. It is worth mentioning that despite Kazdin's (2003) call for further investigation into the

mechanisms of change within youth psychotherapy, this author could find little literature that

focused on this aspect of psychotherapy in the youth specific literature, apart from

Spielmans, Pasek & McFall (2007).

Outcomes of the various reviews and studies were heterogeneous at best. For

example, Jai et al., conducted a broad and ambitious overview of systematic reviews to 2015

on interventions for youth mental health which "aimed to systematically review the

effectiveness of interventions to prevent and manage mental health disorders among

adolescents and youth," (2016, p.1). A total of 38 reviews were selected based on criteria

such as relevance to topic (reviews were selected that targeted studies of interventions for

youth mental health) and age relevant reviews, (reviews that classified adolescents as 11-19

years but also included reviews that targeted adolescents and youth up to 25 years). Reviews

were separated into four categories; school based interventions, community based

interventions, online interventions and individual and family interventions. A variety of

psychological interventions were used in the chosen studies; CBT and behavioural

interventions, solutions focused therapy, as well as exercise and creative arts used as

interventions. Some reviews also compared psychological interventions with

pharmacological interventions and variations of both. However, due to the heterogeneity of

the majority of the reviews and studies, meta-analysis could not be conducted for most of the

reviews as noted by the authors in their concluding remarks.

Many of the reviews and studies in the above overview favoured CBT and

behavioural interventions, including a review by Kavanagh et al. (2009) of CBT based mental

health promotion interventions conducted in schools on adolescents aged 11 - 19 years old.

The meta-analysis showed that CBT was an effective intervention for reducing depressive

symptoms in the short term and at 6 months post intervention. Interestingly, greater effect

sizes were shown in participants that showed more clinical symptoms and who were from

higher socioeconomic backgrounds.

Conversely, Farahmand et al. (2012) reviewed 33 studies and 41 independent samples

on the effectiveness of community based mental health interventions for at-risk children and

youth from low socioeconomic backgrounds and status. Only 12 of the studies involved

youth with average ages older than 12 years and the majority of the interventions were

community based programs, many of which involved home visits and family/environmental

interventions. Only one of the studies involved a specific therapeutic modality, (attachment
based family therapy) and interestingly this study showed one of the greater effect sizes

(0.48) second only to an intervention for young adolescent teenage mothers providing

practical and emotional support over a 24 month period, which had an effect size of 0.60,

(Diamond et al., 2002). It is perhaps not surprising, then, that this review noted that those

interventions that included environmental factors showed a greater effect size than those

interventions that did not target environmental factors (namely home environment). Overall,

the review indicated positive effects for these types of interventions (0.25), which shows that

including context can sometimes account for a significant difference in research outcomes.

Likewise, Weisz, Jensen-Doss & Hawley (2006) conducted a meta-analysis of 32

randomized trials which directly compared evidence based treatments to "usual care".

However on closer examination, the sample studies did not hold up very well in terms of the

quality of the evidence base. Only three out of the 32 studies focused on 'internalizing

problems,' such as anxiety and depression. The remainder of the 29 presentations focused on

in this meta-analysis were conduct problems and delinquent adolescents. This makes sense

when it is noticed that most of the studies were conducted in youth correctional or detention

centres. Further limiting this review's universality is that most of the participants in the

selected studies were male (80%) and the UC conditions included 28.6% of the "usual

intervention" (p. 679) specific to youth correctional /detention facilities, detail of which is

also not specified in the literature. The authors themselves have pointed out the lack of detail

regarding what constitutes usual care as something that needs further investigation.

In spite of these limitations, the authors were able to report an overall positive effect

size (0.30) for EBT over UC in this analysis of direct, randomized comparisons, Duncan et

al., 2010.) Twenty seven of the EBT's studied were behavioural interventions including CBT,

problem solving therapy and behavioural family systems therapy. However, as also noted in
Duncan et al., (2010) when therapist allegiance factors were taken into consideration, the

effect size was largely diminished.

A similar finding was noted by the authors of another similar meta-analysis from

(Miller, Wampold, & Varhely, (2008) The authors stated that, "The purpose of the present

study was to determine whether differences in effectiveness exist among treatment

approaches applied to the youth by (a) conducting a meta-analysis of studies involving direct

comparisons of bona fide psychological therapies and (b) examining the effects of researcher

allegiance and whether allegiance explains any difference between treatments that might be

found," (p.6). They found that effect sizes varied greatly between interventions, however,

more significantly, they also discovered that when therapist allegiance factors were taken into

consideration the differences between therapies were no longer significant.

Bearing this in mind, The APS publication, Evidence Based Psychological

Interventions, published in 2010 is worth mentioning here. Its aim is to evaluate and identify

the best evidence based treatments or interventions for particular disorders. To do this it uses

guidelines published by The National Health and Medical Research Council (NHMRC)

which grades the quality of studies based on certain criteria.

The APS introduction clearly explains the process of how evidence is selected; "The

level and quality of evidence refers to the study design and methods used to eliminate

bias. Level 1, the highest level, is given to a systematic review of high quality randomised

clinical trials those trials that eliminate bias through the random allocation of subjects to

either a treatment or control group," (APS, 2010, p.2). However in the same introduction, the

APS also acknowledges that there are many psychological interventions which have yet to be

empirically tested as they do not lend themselves to current research methods. It may be

prudent to keep the above statement in mind when perusing the available evidence base.
 According to the above mentioned publication, for common child and adolescent

disorders, CBT and Family Therapies were the standouts as treatments of choice for

Depression, Anxiety disorders, ADHD and conduct disorders. However, there were no

evidence based treatments listed for Post-traumatic Stress Disorder, Panic, Psychotic,

Dissociative, Somatisation, Hypochondrias, Binge Eating or Adjustment Disorder. Clearly,

these disorders are treated in clinics and therapy rooms every day, but there are limited

studies that fit the NHMRC's criteria.

It is also worth noting that the majority of "evidence based treatments" in the

available literature for youth psychotherapies seem to favour CBT or behavioural based

treatments. An example is David-Ferdon & Kaslow's (2008) review of Evidence-Based

Psychosocial Treatments for Child and Adolescent Depression. Ten out of the 18 studies

focusing on adolescents and youth used CBT based interventions. Ishikawa et al (2007)

reviewed Cognitive Behavioural Therapy for Anxiety Disorders in Children and Adolescents

showing that overall CBT had a medium to large effect size compared to a control group. The

review and analysis included 20 studies on the efficacy of CBT interventions for children and

adolescents. The authors included studies that compared CBT groups to a control group, a no

treatment group and/or other treatment group. They compared settings and used a variety of

interventions that fall loosely under the banner of CBT. However, the average number of

sessions in the studies included were 12, which may account for the larger positive effect.

University students showed the largest effect size at 0.77. There are many studies and reviews

which attest to the effectiveness of CBT as an intervention.

Positive as this may be, the limitations of these findings are apparent. Certainly, CBT

is regarded as the stand out treatment of choice for adolescent presentations as it by far the

intervention model most tested in the literature. This significantly weakens the gene pool, so
to speak, and possibly excludes many other potentially efficacious treatments that don't fit the

'empirical mould' quite as well.

Another point of interest appears here. While many of the studies reviewed seemed to

test the efficacy of evidence based treatments (EBT) versus usual care (UC) or treatment as

usual (TAU) as noted by Kelly, Rickman & Norwood in Duncan et al., (2010) little emphasis

or detail is placed on the specifics of what is involved in the UC or TAU interventions. This

is especially significant as it was noticed that once therapist allegiance factors were adjusted

for, the effect sizes between the EBT and the UC treatments more or less disappeared as

already noted, (Miller, Wampold & Varhely, 2008).

Furthermore, Spielmans, Paske & McFall, (2007) conducted a meta-analysis on CBT

specific treatments which specifically asked the question, "What are the active ingredients in

cognitive and behavioural psychotherapy for anxious and depressed children?" The authors

reviewed studies that compared CBT interventions with non-CBT interventions and CBT

interventions with non "bona-fide" interventions and found that CBT specific interventions

were no more beneficial than other therapies. According to the authors, "CBT was no more

efficacious than bona fide non-CBT treatments," (Spielmans, Paske & McFall, 2007, p. 642).

There is certainly room for more research on youth specific therapeutic interventions

other than CBT or behavioural interventions, despite the evident efficacy of such

interventions, and for interventions that can be applied briefly. However, there appear to be

far less of these "high quality" studies on these non-CBT treatments to be found. There is

however, some research evidence on other therapies as discussed briefly below.

One notable intervention that is gaining traction as an efficacious brief intervention

for youth is Acceptance and Commitment Therapy (ACT). One 2014 study was found which

compared ACT based brief interventions on young people with depressive symptoms with
TAU in a school setting. Two comparative studies showed that ACT was an effective

treatment for mild depressive symptoms over TAU (usual care). Results of the studies

showed that depressive symptoms were significantly reduced and "psychological flexibility"

(an ACT specific outcome) increased. Conditions were that students were asked to participate

(suicidal, serious presentations and school avoidant children were excluded) and intervention

was delivered in groups over eight weeks using a manualized ACT based program.

Limitations were the sample size was relatively small, there was no long term follow

up, the participants were volunteers (not randomized) and mostly girls. While the authors of

this pilot study declared no conflict of interest, Stephen C. Hayes (who is listed as one of the

contributing authors) is the founder of Relational Frame Theory which forms the theoretical

frame work for the ACT model so one must consider that some level of researcher allegiance

would be indicated. Despite this, ACT shows promise as an alternate intervention for young

people which can be delivered over short periods and in group settings which is worth further

research.

There is also some recent evidence for the effectiveness of simple, brief psychological

and behavioural interventions in young people with emerging or threshold mental health

disorders. In 2011 headspace national began a random controlled trial testing the

effectiveness of simple psychological interventions and physical exercise on young people

visiting a headspace centre in Victoria (Parker et al., 2011). The final report of this trial,

available on the Beyond Blue website, showed that those young people who engaged in the

exercise interventions showed the greatest improvement in outcome, "Although there were

significant improvements in depression and anxiety symptoms overall in the young people

who participated in the Simple Interventions Trial, those who received the physical activity

intervention, regardless of the type of psychological intervention received, showed

significantly greater improvement in depression scores." (Beyond Blue, p.9). The trial
involved a total of 176 young people aged 15 - 25 (randomly selected from an initial group of

346 who were screened as suitable) and was conducted over a 6 week period. The results of

the study seem to indicate, any intervention is better than no intervention, even something as

simple as getting more exercise.

This author noted a distinct lack or reviews of note located between the years of 2010

and 2016, apart from Tanner-Smith & Lipsey's (2014) meta-analysis of brief alcohol

interventions for adolescents which showed that brief interventions were significantly

effective across modalities (especially CBT and Motivational Enhancement Therapy)

regardless of number of sessions. Brief interventions were delivered in as few as one session

in some cases. One interesting finding in this meta-analysis is that the effect sizes benefiting

CBT and MET showed both were similarly effective however interventions combining the

two modalities, CBT and MET, were as statistically insignificant as were a 21st birthday card

intervention (Bendtsen et al., 2012). This intervention basically involved sending students

turning 21-years-old a birthday card with alcohol consumption related psycho-education and

general health information. The authors had little understanding of the reason for this odd

outcome, which highlights the caution that ought to be placed when attempting to make sense

of statistical analysis in the context of humanistic pursuits, such as counselling and

psychotherapy. To quote Jung, "The statistical method shows the facts in the light of the ideal

average but it does not give us a picture of their empirical reality. While reflecting an

indisputable aspect of reality, it can falsify the actual truth in a most misleading way," (Jung,

1957).

CONCLUSION

This review sought to answer the question of what evidence exists for the

effectiveness of evidence based practice in youth psychotherapy and what works to achieve
the best outcomes for youth mental health and wellbeing. The following tentative conclusions

can be drawn from the preceding review.

There seems to be significant amount of empirical evidence for the efficacy of CBT

based therapies as an intervention for common youth and adolescent presentations, mainly

depression and anxiety disorders, as noted in the APS (2010) publication, but significantly

less on what is considered "evidence based" for other disorders. Most of the research on

evidence based therapies seem to use CBT which leaves many 'bona-fide' therapies and

modalities out in the cold when it comes to evidence based practice recommendations. In fact

Duncan et al., (2010) recommend, "Given the apparent lack of demonstrated differential

efficacy of approaches to child and adolescent problems, the field should no longer only

promote specific approaches for specific disorders..." At least one meta-analysis found that

there is little to no difference in efficacy between CBT and other therapeutic treatments,

(Spielmans, Paske & McFall, 2007) however, this does not discount CBT's proven efficacy

overall. Yet other reviews found that once therapist factors such as therapist allegiance or

bias to modality were accounted for, little to no difference could be discerned between the

evidence based practice and the TAU or UC groups, (Miller et al., 2008; Weisz, Jensen-Doss

& Hawley, 2006.)

In 2003, Kazdin acknowledged that a lot of progress had been made in the research

on evidence based therapies for children and adolescents however highlighted key gaps in the

research which he felt needed addressing; "Prominent among these areas of neglect is

research on the mechanisms of change, the moderators of treatment outcome, and the

generality of research findings to the conditions of clinical practice," (p.543). It appears that

these areas are still in need of further research, some 13 years later.
 In short, more research is recommended in the areas of mechanisms of change and

common factors in regards to the youth psychotherapy field and perhaps a re-focusing of the

lens from which the field views what is considered as "evidence based practice" -so as to take

in a more broader view.

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