Evaluation of brief outpatient services in a children's mental health community clinic

In the past two decades, increased emphasis has been placed on the use of brief treatment services in clinical practice with youth. However, despite the common use of such services, there is a lack of research evaluating the effectiveness of this treatment approach, especially pertaining to brief services that are four sessions or less. The current study addressed this gap in the literature by evaluating the effectiveness of a Brief Service program consisting of four treatment sessions or less. It also investigated how therapeutic alliance, client satisfaction, youth and parent psychopathology, and caregiver strain were related to treatment effectiveness. A pre/post-treatment design was used in order to determine if successful treatment outcomes could be attributed to the Brief Services. Specifically, families with children under 18 years of age who would normally be assigned to Brief Services within a local children’s mental health centre were invited to participate. Participants (N = 33) received brief outpatient treatment at the Children's Centre Thunder Bay (CCTB), which involved one to four sessions over a maximum of six weeks. The CCTB Brief Service program was found to be effective in reducing child and parent mental health issues and caregiver strain. Clients were satisfied overall with their experiences at CCTB as well. Client ratings of therapeutic alliance were associated with treatment satisfaction for sessions one and two, and changes in youth mental health for session two. Parent and youth depression, anxiety, and stress were not associated with treatment outcomes in youth or caregiver strain. EVALUATION OF BRIEF 1 Evaluation of Brief Outpatient Services in a Children’s Mental Health Community Clinic The distribution of limited mental health resources in community-based settings plays an important role in the type and quality of services made available for children and adolescents. While many evidence-based treatments require lengthy involvements of youth and their families in services (i.e., 10 to 20 sessions), the actual attendance for treatment often involves significantly fewer sessions (Mueller & Pekarik, 2000). For instance, Weisz and Weiss (1989) reported that the majority of children and their families attended fewer than 10 sessions before terminating or dropping out. Given the reality of limited treatment attendance and often long waitlist for services, the use of shorter outpatient treatments has become an increasingly popular method of intervention (Girling-Butcher & Ronan, 2009; Mireau & Inch, 2009). However, in comparison to longer treatment services, the effectiveness of these services has received little attention or empirical study. Defining Brief Services One of the primary defining characteristics of brief services, also known as time-limited or short-term treatment, is that goals are quickly and mutually defined by both the client and clinician (Dziegeilewski, 2008; see also Searle, Lyon, Young, Wiseman, & Foster-Davis, 2011). Above all, the main goal of brief therapy is to promote positive changes in the client’s current functioning and life (Dziegeilewski, 2008). Another characteristic of brief therapy is that homework is given to complement what is taught during the sessions (Dziegeilewski, 2008). The pacing of the therapy is also important due to the limited number of sessions available. Furthermore, paper-and-pencil, self report measures are frequently distributed to the client before the start of treatment to provide a summary of the presenting issues and direct goal development (Dziegeilewski, 2008). Termination is discussed earlier in treatment in comparison to long-term EVALUATION OF BRIEF 2 interventions as well (Dziegeilewski, 2008). For instance, Bloom (2001) posits that brief therapy should be seen as a self-contained unit, with each session providing a plan for intervention so that additional sessions may not be necessary. In this case, termination is taken into consideration at the end of every session. In general, brief service is best suited for clients who are motivated to participate in therapy (Searle et al., 2011; Welfel, 2004). In addition, brief service is typically inappropriate for individuals with severe, chronic problems or co-morbid disorders (Welfel, 2004). Finally, an additional session can be planned one to four months after the last session as a maintenance strategy if needed (Dziegeilewski, 2008). The current literature on brief therapy in a mental health setting was influenced by early research on the dose-response relationship in the 1980s. For instance, Howard, Kopta, Krause, and Orlinsky (1986) challenged the previous idea of a positive relationship between the amount treatment received and the therapeutic benefit. In their meta-analysis, 15 studies were included from 1951 to 1983. Over 2,400 participants were included and the number of treatment sessions ranged from four to 33 sessions. Over two thirds of the therapeutic benefit was evident in the first 25 sessions. In addition, 29-38% of clients displayed symptom improvement within the first three sessions no matter the total length of treatment. These findings introduced the idea that an important portion of treatment change occurred in the initial sessions of therapy and that clinicians should pay particular attention to what happens early on. Although the studies chosen greatly varied in therapeutic orientation, mental health setting, and outcome measures used, this meta-analysis nevertheless stimulated research aimed at defining brief service as a unique form of treatment. Furthermore, research has recently described a slight variation of brief therapy known as intermittent therapy (Dziegeilewski, 2008). Specifically, both traditional brief therapy and intermittent therapy focus on fast and effective service (Dziegeilewski, 2008). However, EVALUATION OF BRIEF 3 intermittent therapy does not include planning sessions ahead of time and thus sessions occur on an as-needed basis (Dziegeilewski, 2008). Thus, research continues to be conducted on this topic. In analyzing the literature on brief service interventions, there is much variability in the type of theoretical approaches used within a brief services model. For instance, the majority of literature describes brief services in terms of individual or group brief cognitive-behavioural therapy (CBT; e.g., Clark et al., 2001; Girling-Butcher & Ronan, 2009; March et al., 1998). With brief CBT, the relationship between thoughts and feelings and their influence on behaviours is stressed (Dziegeilewski, 2008). There is also literature describing brief psychodynamic therapy (e.g., Leichsenring et al., 2009; Searle et al., 2011). This type of brief therapy focuses on a client’s history and unconscious processes in developing current problemsolving techniques (Dziegeilewski, 2008). Solution-focused brief therapy (SFBT) is also a popular approach in treating mental health issues (e.g., Corcoran, 2006; Lee, 1997). In this type of therapy the client’s strengths are identified and used to develop a specific course of action, with minimal emphasis placed on deficits or pathology (Dziegeilewski, 2008). There is also much discrepancy in the literature in defining the length of brief services, even when comparing similar types of treatment and target populations. For instance, a study conducted by Girling-Butcher and Ronan (2009) described their short term cognitive behavioral therapy (CBT) for youth with anxiety disorders as having eight sessions, whereas March, Amaya-Jackson, Murray, & Schulte (1998) used 18 sessions for the same client group. According to the review article by Dziegeilewski (2008), brief services typically involves six to 10 sessions. However, some studies even consider 15 to 20 treatment sessions to be brief therapy. For instance, one randomized controlled study was interested in the effectiveness of a EVALUATION OF BRIEF 4 brief psychodynamic therapy in adults between the ages of 18 and 60 years with Dysthymic Disorder (Maina, Forner, & Bogetto, 2005). The therapy consisted of a minimum of 15 to 20 sessions, with a maximum of 30 possible sessions, and participants were assigned to either brief psychodynamic therapy, brief supportive therapy, or a control group. Both brief interventions were effective in reducing symptoms on measures of depression, anxiety, and overall functioning, with the psychodynamic therapy being more effective. Likewise, a randomized controlled study of adults with Generalized Anxiety Disorder involved participation in 30 sessions of either brief CBT or short-term psychodynamic psychotherapy (Leichsenring et al., 2009). Both CBT and psychodynamic therapy produced an equivalent reduction in symptoms on the Hamilton Anxiety Rating Scale (Hamilton, 1960), although other outcome measures of anxiety and depression determined that CBT was superior. Overall, these studies were limited by relatively small sample sizes of 30 and 57 respectively. More importantly, the majority of studies in the literature involving therapy greater than 15 sessions include adults as well as a psychodynamic orientation. Thus, these services may have been considered brief due to the fact that regular, long term psychodynamic psychotherapy can take more than six months to complete (Holmes, 1994). However, it may not be considered brief service in comparison with CBT, which is more commonly seen in children’s mental health clinics. In the past two decades, there has been an increased emphasis placed on the use of brief treatment for youth (Girling-Butcher & Ronan, 2009). Several reasons for this include brief services often being cost effective and reducing therapist time, which allows more clients to be taken into therapy (Girling-Butcher & Ronan, 2009). Furthermore, managed care often places a limit on the number of sessions a client is entitled to, which prevents certain manualized types of interventions from being conducted (Girling-But