Manju Mehta and Rajesh Sagar (eds.)A Practical Approach to Cognitive Behaviour Therapy for Adolescents10.1007/978-81-322-2241-5_3

3. Community-Based Mental Health Interventions in Adolescents

M. Manjula¹

(1)

Department of Clinical Psychology, NIMHANS, Bangalore, 560029, India

M. Manjula

Email: drmanjula71@gmail.com

Keywords

Community-based interventionsMental health problemsEarly intervention and prevention

3.1 Need for Community-Based Interventions

Unaddressed mental health problems in adolescents are found to have serious implications. About 24–39 % of them are known to experience such consequences as discontinuation of the education, risky sexual behaviors, substance abuse, unemployment and involving in antisocial activities; poor interpersonal relationships, and lack of skills to cope with problems (Kjelsberg and Dahl 1999). Though most of the mental health problems of the adults have their onset in the adolescence and often are not identified as psychological in nature, help is not sought till it becomes entrenched and disabled in nature. There are strong perceived and actual barriers in seeking help, and the percentages of those who seek help are as less as 10–15 % (McGorry and Purcell 2009; Rickwood et al. 2007). These figures are largely based on young adult population; thus, the adolescents seeking help may even be lesser. If the problems have their onset in young age, interventions should follow suit, before they become ingrained, because shorter duration and reduced severity of symptoms are associated with better outcomes (Kessler et al. 2005). The mental health interventions offered are largely child or adult focused, neither the setting nor the types of interventions are appropriate for the adolescents’ needs. Since most often the problems are sub-syndromal in nature, the early intervention and preventive/promotive interventions can go a long way in early recovery and prevention.

The community-based interventions are carried out on the premise that the psychological problems experienced by the adolescents are determined by the interaction of individual, environmental, family, and parental factors. Thus, community-based approaches focus on (a) promoting positive mental health by educating the community to recognize the early signs of mental illness, without stigmatizing or discriminating; (b) addressing the risk factors in the whole population (universal prevention, e.g., anti-stigma campaign); (c) targeting young people at risk for developing mental health problems; and (d) providing early intervention/prevention services for people with mild emerging mental health difficulties (Catalano et al. 2004).

When the interventions are carried out in the community (schools, community mental health clinics, hospitals, and residential treatment programs, and work places), it is easy to access without fear of stigma since the professionals reach to young people facilitating trusting relationships (Rickwood et al. 2007). Also, that the responsibility for intervention is shared (by individuals, families, parents, carers, teachers, policy makers, professional organizations etc.), makes the enforcement and maintenance of gains easy.

The current scenario is such that, even in the countries having programs for young people are at the best fragmented, not well integrated resulting in negative experiences and young people struggling to seek help (Vision for Change 2006). In India, mental health needs of the youth are largely unmet leading to poorer clinical outcomes and chronic mental health problems as they become adults (Murthy 2011; Farooq et al. 2009). Also, there is severe lack of community-based interventions designed specifically for adolescents. Given the current status of mental health systems, the requirement of the day is a community-based system comprising of integrated, youth-focused, evidence-based, prevention, and early intervention services which takes into account the setting, timing, kind, and the intensity of the intervention required when they need it the most (Patel et al. 2007).

3.2 Community-Based Interventions for Adolescents

The chapter attempts to give an overview of the community-based, early and preventive interventions carried out across the countries. This chapter is not all inclusive; however, an attempt is made to focus on large-scale studies and major interventions for mental health problems. There is substantial work in the area of juvenile delinquency/violence prevention and substance abuse; however, the paper does not cover the literature and programs on the same. Similarly, though promotive interventions lie on a continuum of preventive interventions with a universal focus, and largely aiming at enhancing resilience, for the lack of space, it is not covered.

The interventions based on cognitive-behavioral models, life skills, problem-solving and stress management techniques are known to decrease depressive and anxiety symptoms by more than 50 % and reduce the risk of anxiety and depression disorders by more than 2/3rds. They also lead to positive changes in psychological and behavioral adjustment, academic performance, and cognitive skills (Durlak et al. 2011). Improving mental health literacy is one of the most important strategies to facilitate early intervention; this is achieved through four categories of interventions: whole-of-community campaigns; community campaigns aimed at a youth audience; school-based interventions teaching help-seeking skills, mental health literacy, or resilience; and programs training individuals to intervene in a mental health crisis (Kelly et al. 2007).

Several interventions are identified as evidence based in the treatment of adolescent mental health problems. Therapies based on the behavioral, cognitive behavioral, models such as exposure therapy, modeling therapy, coping skills, communication skills, relaxation therapy, and anger coping therapy are used across disorders such as anxiety, autism, ADHD, schizophrenia, depression, bipolar disorder, and conduct/oppositional defiant disorder. Some of the well-established evidence-based practices are cognitive behavior therapies (CBT), trauma-focused CBT (TF-CBT), adolescent community reinforcement approach (A-CRA), aggression replacement training (ART), dialectical behavior therapy (DBT), seven challenges, for substance abuse; multisystemic therapy (MST)—a brief but intensive, clinician-provided, home-based treatment; preparing adolescents for adulthood (PAYA) and motivation interviewing (MI). Other evidence-based therapies are parent management training, family education and support, interpersonal therapy, multisystemic therapy, functional family therapy, brief strategic family therapy and mentoring (NAMI 2007). Both clinic- and community-based approaches use the same modules; however, the community-based programs are largely group based.

Apart from the diagnosable mental health problems, often parents of adolescents also are equally in need of knowing how to deal with the undesirable behavior of an adolescent. The behaviors included fighting with siblings, talking back to adults, moodiness, and school difficulties (Ralph et al. 2003). Similarly, adolescents enlist causes of stress as difficulties in academics, problems in interpersonal relationships with parents, friends, peers, heterosexual relationships, low self-esteem, and fears about sexuality-related issues (Das and Manjula 2009).¹

3.3 Interventions Carried Out in Community Health Clinics

Keeping in mind the prevalence of the psychiatric problems in the adolescents and feasibility of carrying out intervention in the primary care services and to facilitate referral to secondary care services, a briefer intervention (1–5 sessions) called SCREEN was developed. It included assessments as well as interventions specific to the problems. The brief intervention was sufficient for about 37 % (n = 2,071) of them resulting in improved psychosocial functioning implying the need for replicating the briefer intervention strategies at the primary care services (Laukkanen et al. 2010).

Preliminary attempts to examine efficacy of lifestyle interventions using a socio-ecological framework for such disorders as obesity and eating disorders is underway (Wilfley et al. 2010). In a community- and clinic-based RCT carried out in USA, Weisz et al. (2009) used CBT for youth aged 8–15 years (n = 57), who were selected based on the initial complaints of any internalizing symptoms by parents and then were evaluated for depressive spectrum disorders. CBT was found to be cost-effective, briefer, resulted in reduced usage of medication, and more parent engagement. In a similar attempt, RCT was carried out in community clinic setup to examine the feasibility of CBT in youth (8–15, n = 48) diagnosed with anxiety disorders. Though there was significant improvement in anxiety symptoms, there was no difference between CBT and usual clinical care (Southam-Gerow et al. 2010).

3.4 Early Intervention, Prevention, and Promotion Interventions Carried Out in the Community

3.4.1 Early Interventions

The early intervention modules typically include identifying early signs of distress, provide help on a first aid basis, prevent self-harm, ameliorate the course of mental illness, facilitate recovery, guide young people toward the right support, and reduce stigma (Clark et al. 2002). There is definitive evidence for early interventions in youth leading to reduction in prevalence and progression of illness (McGorry et al. 2007). A very good example of deployment and validation of early interventions are carried out under the leadership of McGorry and colleagues in Australia. Community-based youth mental health centers operated by Headspace, Orygen Youth Health, the National Youth Mental Health Foundation, (more than 60 such centers) operating across the country serve a large number of youth. They help young people with emerging serious mental health and substance disorders, and also conduct training programs to share knowledge and enhance service system functioning. Realizing the need for the early intervention and prevention and to facilitate help-seeking among adolescents, Australian Red Cross has formulated various culturally appropriate, youth centered, peer education support programs.

Work of McGorry has been modeled after in many countries such as ‘headstrong’ program in Ireland originated by Prof. Hewitt B. Clark, which carries out such activities as research and support (education and training, communication, service evaluation, and fund raising). The uniqueness of the headstrong program has been youth engagement, enablement, and leadership across all areas of work such as local and national youth advisory panels (YAPS) and youth lead mental health promotion (Think Big). Recently, there has been considerable efforts in replicating the Australian model, in countries such as Canada, England, Scotland, and Wales targeting people who work with, live with or care for adolescents (11–18) (Kitchener and Jorm 2006). In US, the prominent evidence-based program for adolescents and young adults is the Transition to Independence Process (TIP) model developed by the National Network on Youth Transition (NNYT).

One of the most important community-integrated collaborative early intervention approach including the researchers, community/local therapists, community organizations, and family members has been carried out with respect to youth experiencing ongoing traumas (domestic, community and school violence; verbal, physical, sexual abuse, bullying). Series of projects were carried out such as the Children Recover after Family Trauma (CRAFT) Project; Women’s Center and Shelter of Greater Pittsburgh (WCS) (Cohen et al. 2011; Murray et al. 2010) at U.S. and Zambia using the trauma-focussed–cognitive behavior therapy (TF-CBT). TF-CBT includes components to enhance youth resiliency-based coping skills (enhancing safety), actively includes parents or caregivers in treatment, developing trauma narratives and addressing youths’ maladaptive cognitions about ongoing traumas and helping youth differentiate between real danger and generalized trauma reminders. The studies indicated significant improvement in the youth and the parents.

3.4.2 Preventive Interventions

The mental health promotion and prevention interventions typically are built upon strengthening the existing skills, the components of such programs are: Mental health literacy, Coping skills to cope with daily stressors, Self care and community connectedness, Improving access to social support, Strengthening community action for better understanding of illness to reducing stigma and discrimination and help-seeking. Examples of such programs are Beyondblue, Mindmatters, and Mental health first aid (Davis et al. 2000).

Lot of work has gone in terms of the suicide prevention intervention in youth, and there are various preventive models that are established as effective. In a systematic review study, Gould et al. (2003) examined the school-based suicide prevention programs (conducted over 10 years). The identified promising interventions included—school-based skills training for students, screening at-risk youths, media education and education of primary care physicians, and lethal means restriction. The psychological therapies that are effective included dialectical behavior therapy and cognitive behavior therapy. Direct education and awareness through pamphlet (‘Toughin’ it out’), to School Gatekeeper training model or signs of suicide (SOS) prevention programs have resulted in greater awareness, openness to discuss about suicide, more help-seeking, lower attempts and more adaptive attitudes about depression and suicide (Bridge et al. 2007; Kataoka et al. 2007; Aseltine et al. 2007). In contrary, the efficacy of national youth suicide prevention strategy (NYSPS) implemented in Australia from 1995–1998 and a subsequent period (1999–2002), did not show significant differences in decline in rates of suicides in areas which targeted the prevention and areas which were not targeted. Including the parents along with the adolescents in suicide prevention intervention is found to have significant impact in reducing the risk factors, enhancing the protective factors and greater sustainability of improvements (15 months) (Hooven et al. 2012). A suicide prevention program enhancing the sources of strength among the peer leaders (453) trained for conducting school-wide awareness program (18 schools and 2,675 students) was found to be beneficial both for the students and the peer leaders (Wyman et al. 2010).

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