Counseling is a preventive profession, typically working with issues and challenges that our clients face daily. However, client concerns often exist at deeper levels, and counseling process often shades into therapy. As counselors, you regularly encounter children and youth who may be at risk. Whether with a medicated child who has been deemed as having attention-deficit/hyperactivity disorder or a depressed teenager whose family is unable to afford private treatment, counselors often end up being the key mental health resource. Of necessity, we often work with clients who have no other realistic source of treatment. For example, a teenager may return to high school after a stay in a psychiatric or drug treatment facility. A child or adult may need specialized care, but no referral sources are available.
The impact and effect of your work is vital not only with the “normal” issues that young people face, but also with the issues posed by potentially more disturbed youth. The National Institute of Mental Health estimates that 26 percent of the U.S. population ages 18 and older has a diagnosable mental disorder during any given year, while 6 percent face diagnosis of serious mental illness. Sixty-five percent of serious mental conditions such as anxiety and affective disorders appear before age 21, thus emphasizing the importance of early counseling intervention. Children and adolescents are increasingly being diagnosed with mental disorders and prescribed medications that can sometimes be dangerous. In 2012, the website ScienceDaily reported a 62 percent increase in the use of antipsychotic drugs with publicly insured children, with two-thirds of these potentially dangerous drugs being off-label prescriptions. In 2010, the Archives of General Psychiatry reported evidence that these medications shrink the amount of gray matter in children.
Professor Patrick McGorry, an Australian psychiatrist and world expert on young people at risk for psychosis, is challenging the very concept of diagnosis for conditions such as borderline personality disorder, major depression and schizophrenia. He asserts that the diagnostic categories in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) are “endpoints” with little or no attention paid to etiology and developmental issues. For example, subclinical youth may show signs of decreased functioning. Although we may see affective dysregulation and other signs, clear diagnosis is usually impossible. “Persistence and severity are key dimensions setting the bar for care, irrespective of the specific set of features,” McGorry has said. He speaks of a “soft entry” to treatment rather than arbitrary categories that all too often lead to overmedication and overtreatment.
CLICK HERE TO VIEW PDF IN FULL SIZE: McGorry Clinical Staging Table
McGorry makes it clear that all “disorders” have early clinical features or prodromes — early symptoms that might indicate the onset of a disease. Prodrome is the term ascribed to at-risk youth whose functioning is decreasing significantly. It has been found that one-third or more of these youth will become psychotic within three years. However, it is important to separate those youth who have a true prodrome from those who may be suffering from grief or trauma, the major effects of which pass over time.
The research appendix of the DSM-5 names the prodrome as attenuated psychosis syndrome. There is evidence that preventive treatment programs can significantly reduce later reversion to psychosis. Rather than one-third of these youth becoming psychotic, a 2012 review written by McGorry and colleagues in the journal Clinical Practice found that early intervention preventive programs reduce that figure to 5 to 10 percent. Even if psychosis does not appear, however, those considered at risk continue to have significant life challenges, often requiring some form of counseling throughout the life span.
This is an important issue, and the question remains — how can we work effectively to prevent psychosis in young people? In hopes of finding the answer, we visited Australia to meet McGorry. There we saw programs in operation that make a significant difference in preventing serious disturbance in youth. Rather than applying the potentially damaging label of attenuated psychosis syndrome to these youth, McGorry uses the terms high risk and ultra high risk. His program focuses on early prevention and avoids medication as much as possible. He worries that the attenuated psychosis syndrome label being used in the United States will lead to overuse of unnecessary medications because psychiatry does not give much attention to prevention or early intervention. If the attenuated psychosis syndrome diagnosis as formulated in the DSM-5 is accepted in isolation, we can expect preventive research to be ignored, while seeing a vast increase in potentially dangerous medications for youth.
A practical framework
Counselors often are the first professionals to observe when a young person’s behaviors indicate high risk of continuing and future major behavioral and emotional issues. Thankfully, effective counseling and systematic programs can make a difference, and the need for further help, or even institutionalization, may be prevented.
Diagnostic risk factors include, first of all, a noticeable decrease in functioning. The endpoint features of attenuated psychosis syndrome in the DSM-5 include symptoms that may appear only occasionally; most of the time, these youth will function normally in society. The attenuated psychosis syndrome diagnosis looks for odd beliefs or magical thinking, perceptual disturbance or some paranoid ideation, along with occasional disconnections from reality. Depression, anxiety or explosive outbursts may increase. The youth’s appearance may change in terms of clothing, self-care or significant gain/loss of weight.
McGorry’s clinical staging model is designed to work for patients, clinicians, families and researchers. It is rooted in the model of normalization and prevention. Clinical staging is the method used in McGorry’s Early Psychosis Prevention and Intervention Centre (EPPIC), which focuses on youth at risk with specific recommendations for treatment at each clinical level (see the accompanying table). The diagnosis is for level of need and treatment, not for a specific category.
Clients are first placed in two general categories — those who appear to be working with “normal” difficulties and those who may be at risk, high risk or even ultra high risk for becoming constantly depressed, bipolar or schizophrenic. Typically, the first group represents Clinical Stages 0 and 1. This group is treated using concepts that are well known and integral to the counseling movement. It is here that we see the counseling profession overlapping with in-depth psychiatry. Furthermore, it is obvious that counselors have an important role in working with at-risk youth. While traditional diagnostic endpoints do not lead to treatment recommendations, clinical staging does. The scaling and normalization of youth concerns leads to a newly integrated form of counseling and therapy.
McGorry’s original research has been replicated in many settings, internationally and in the United States. There is clear short- and long-term evidence that the clinical staging framework (or variations on that theme) reduces the chances of youth reverting to psychosis. Those youth who may never revert to psychosis receive the benefit of quality treatment without being labeled as suffering from attenuated psychosis syndrome.
Why are counselors so important in this process? Take a look at the mental health workforce in the United States. The Occupational Outlook Handbook shows more than 1 million helping professionals but lists only 24,210 psychiatrists, although other estimates range as high as 36,000. Even if we take the larger figure, psychiatry represents approximately 3.6 percent of professionals able to meet the mental health needs of the nation. From these data, it is patently clear that members of the American Counseling Association will continue to play a major role. The primary and secondary treatment options listed in the accompanying table have long been considered major roles. Not only are counselors needed, but they have the skills and experience to work with these youth.
Coordination of mental health services is key to the EPPIC model — infants, children, adolescents and adults in individual, family, group, school and community contexts. Furthermore, all mental health issues, from typical daily concerns to serious issues such as autism and schizophrenia, fall within this framework. McGorry seeks to avoid the use of medications with clients as much as possible, while focusing on psychoeducation and cognitive behavior therapy. The model includes typical counseling interventions such as stress management, anger management, family counseling and job placement with support, all with an extensive emphasis on relapse prevention.
The clinical staging model in a high school
The counseling and guidance program at Massachusetts Wellesley High School illustrates how the clinical staging model is related to counseling practice. Under the leadership of principal Andrew Keough, Wellesley High School states that “schools are more like families than like business, and every member needs a voice.” To build that family community, students have brief daily meetings and a half-hour meeting once per month in advisory groups of eight to 10 members. This ensures that every teen has personal contact with a teacher, counselor or administrator. Groups are randomly chosen to enlarge the students’ circle of acquaintance in the large school. There is a daily check-in, typically followed by short discussions on topics such as “what was the highlight of the weekend” or a school issue. There is often enough time for brief trivia contests or discussion of personal issues as well.
Additional student contact is made twice weekly through small group guidance seminars taught by counseling staff. The small groups are limited to 12 to 15 students and take place for all four years of the students’ high school experience. Groups in the first year cover study skills and school adjustment issues. In ensuing years, the groups tackle decision-making skills, positive mental health and symptoms of anxiety and depression. These programs make it possible to know all of the school’s students, and they also encourage self-referrals to counseling staff. They are important components of the first two clinical stages of McGorry’s model. Counseling, of course, covers the full range of academic and personal issues, including the ability to support students who are more challenged.
A student support team meets weekly to discuss student issues, with special attention paid to Stages 2 and 3, but always with awareness of Stage 1. For students at Clinical Stage 3 who are more distressed and may have been released from a hospital or drug treatment program, small groups ranging from three to five people provide support, while the leader often works in concert with the treatment facility. These groups also serve as transition teams to gradually return these students to their regular classrooms.
Another preventive effort designed to further community is an after-school enrichment/recreation program that caters primarily (but not exclusively) to students who are not involved in the many formal school groups or athletic teams. Students are encouraged to define their own desires for a group experience, supported by an interested teacher. Examples include time in the gym or on the athletic field for those who did not make school teams, a computer group that is taught how to develop apps, karate and boxing groups, clay and art workshops, and many others.
Somewhat parallel to the Wellesley program, McGorry has originated the Headspace program, which seeks to work with youth when “things are not quite right.” These centers offer similar services to those provided by Wellesley, but in a separate setting. There are currently 45 Headspace centers throughout Australia, with 90 planned by 2015. They function as combination community centers with a counseling focus for young people. Supportive counseling is available, and a major effort is made to get parents involved. Headspace emphasizes positive mental health and therapeutic lifestyle changes such as exercise, socialization skills, meditation and relaxation, drug prevention, adequate sleep and nutrition as personally and multiculturally appropriate. Headspace also includes access to medical and psychotherapy services and interface with crisis teams (24/7 mental health teams). The central function of these programs is to enable at-risk youth to stay in the community, to prevent more serious issues and to provide counseling support as appropriate.
Visit the EPPIC website at eppic.org.au or the Orygen Youth Health website at oyh.org.au for additional information, including the outpatient programs where methods, systems and practices can be downloaded. We also recommend EPPIC’s 2010 Cognitive-Behavioural Case Management in Early Psychosis: A Handbook (oyh.org.au/online-store/cognitive-behavioural-case-management-early-psychosis-handbook). Extensive information on Headspace can be found by conducting a Google search. In addition, many useful videos are available, often presenting real clients and counselors discussing matters such as bullying, depression and gay/lesbian issues. These can be found on youtube.com/playlist?list=PL8C639D508E0A4B3C or by searching Headspace Ambassadors on YouTube. Information on Wellesley High School is available at wellesley.k12.ma.us/wellesley-high-school.
Allen E. Ivey is distinguished university professor emeritus at the University of Massachusetts, Amherst and courtesy professor at the University of South Florida. Contact him at firstname.lastname@example.org.
Mary Bradford Ivey is a courtesy professor at the University of South Florida. Contact her at email@example.com.