The Mental Health Social Worker

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New Look at Data Confirms Strong Association between Depression and Stressful Life Events

Stressful life events are strongly associated with a person’s risk for major depression, but a certain gene variation long thought to increase risk in conjunction with stressful life events actually may have no effect, according to researchers funded by the National Institute of Mental Health (NIMH), part of the National Institutes of Health. The study, published in the June 17, 2009, issue of the Journal of the American Medical Association, challenges a widely accepted approach to studying risk factors for depression.

“Rigorous re-evaluations of published studies provide the checks and balances necessary for scientific progress,” said Thomas R. Insel, M.D., director of NIMH. “We are still in the early days of understanding how genes and environment interact to increase the risk for depression.”

Most mental disorders are thought to be caused by a combination of many genetic risk factors interacting with environmental triggers. However, finding the exact combinations continues to present significant challenges to research.

Advances in scientific understanding and technologies during the past decade have led to powerful tools for studying how genetic and environmental factors can affect a person’s risk for disease. Such advances allowed mental health researchers in 2003 to show that a gene involved in serotonin activity increased the risk of major depression in people who had a number of stressful life events over a five-year period (see “More About the Science” below for more information about this gene and serotonin). Coming at a time of heightened research interest in these gene-environment interactions and the relative lack of progress in the field for mental disorders, this study received wide acclaim and had a far-reaching influence. Not only have considerable resources been invested in subsequent studies that built on this finding, but also some researchers have proposed marketing the gene test to the public, claiming to be able to predict a person’s risk for depression.

However, efforts to replicate the 2003 study’s findings—a key step in scientific progress that helps show whether a particular finding was a chance event—have had inconsistent results.

To examine whether the 2003 study’s finding had been confirmed, a group of scientists from NIMH and six universities with expertise in epidemiology, biostatistics, genetics, and psychiatry reviewed the status of relevant replication studies. Led by Kathleen Merikangas, Ph.D., of the NIMH Intramural Research Program, the workgroup did a meta-analysis, re-analyzing data on 14,250 participants in 14 studies published from 2003 through March 2009. Of these, the researchers also re-analyzed original data, including unpublished information, on 10,943 participants from 10 studies published before 2008. The workgroup analyzed these original data to see whether there were gender differences in the associations between the serotonin genotype, stressful life events, and depression.

By applying the same definitions of study variables and data analysis methods used in the 2003 study, the workgroup found a strong association between the number of stressful life events and risk of depression across the studies. However, the presumed high-risk version of the serotonin transporter gene did not show a relationship to increased risk for major depression, alone or in interaction with stressful life events, in the analysis of the 14 studies. Their findings were the same in men and women alone in the analysis of original data from 10 studies.

The workgroup noted that their analysis had some limitations. Individual level data were available for only 10 of the 14 studies published before 2008. However, these limitations would have had little effect on the overall findings because the number of participants in the studies not included was only a small proportion of the total sample.

These findings may account for the difficulty many researchers have faced in attempting to replicate the 2003 study. This analysis confirms some earlier reviews that had also questioned the validity of the gene’s effect on depression risk. However, the workgroup emphasized that the intent of its analysis was not to deter research on gene-environment interactions for mental disorders.

“Identifying gene-environment interactions is most successful when studies can focus on a single gene with a major effect, or when the environmental exposure has a strong effect,” said lead author Neil Risch, Ph.D., University of California, San Francisco and Kaiser Permanente Northern California. “In the case of modest gene effects or environmental impacts, the statistical power to detect an interaction will be low, and thus weak positive results should be interpreted carefully.”

The authors concluded that incorporating environmental exposures in candidate gene studies (those that study a particular gene) may be as likely to yield false positive findings as the candidate gene studies themselves. Therefore, the results of other studies using the same approach as the 2003 study also deserve thorough review and meta-analysis.

“Even though our re-analysis did not confirm an association between the serotonin gene and depression, the finding that the environmental factor was strongly associated with depression in several studies reminds us that environmental factors are also involved in the complex pathways leading to mental disorders,” noted Merikangas. “Future progress will require thoughtful integration of the tools of genetics, epidemiology, and clinical and behavioral sciences.”

The authors on the paper include Neil Risch, Ph.D., University of California at San Francisco and Kaiser Permanente Northern California; Richard Herrell, Ph.D., NIMH; Thomas Lehner, Ph.D., NIMH; Kung-Yee Liang, Ph.D., Johns Hopkins University; Lindon Eaves, Ph.D., Virginia Commonwealth University; Josephine Hoh, Ph.D., Yale University; Andrea Griem, NIMH; Maria Kovacs, Ph.D., University of Pittsburgh; Jurg Ott, Ph.D., Rockefeller University; Kathleen Ries Merikangas, Ph.D., NIMH.

Reference

Risch N, Herrell R, Lehner T, Liang KY, Eaves L, Hoh J, Griem A, Kovacs M, Ott J, Merikangas KR. Interaction between the Serotonin Transporter Gene, Stressful Life Events and Risk of Depression: A Meta-Analysis. JAMA. 2009 Jun 17;301(23):2462-71.

Rarity Makes Definitive Assessment Elusive

A study examining stimulant use among children and adolescents found an association between stimulants and sudden unexplained death in youth with no evidence of pre-existing heart disease. The finding draws attention to the potential risks of stimulant medication, according to the study’s authors; an accompanying editorial notes that the rarity of sudden unexplained death and the lack of long-term data on the effectiveness of these medications for reducing other health risks make a full benefit/risk assessment difficult.

Background

Stimulant medications are widely used to treat children with attention deficit hyperactivity disorder (ADHD). The medications help reduce hyperactivity and impulsivity and improve the ability of affected children to focus and learn. Research has shown that stimulants can also have effects on the cardiovascular system, for example, raising blood pressure and heart rate. There have also been reports of sudden deaths in children receiving the medications, prompting the U.S. Food and Drug Administration (FDA) to direct drug manufacturers to inform consumers of possible risks of stimulant medications in children and adolescents with known pre-existing heart problems. In order to assess the association between stimulants and risk of death in young people, the National Institute of Mental Health and the FDA jointly funded a study looking at records of children and adolescents who died suddenly and unexpectedly.

This Study

Madelyn Gould, Ph.D., and colleagues at Columbia University College of Physicians & Surgeons and the New York State Psychiatric Institute identified 564 children and adolescents who had died suddenly for unexplained reasons. These youth had no known structural heart defects or other co-existing physical disorders known or suspected to be associated with sudden death. Each of these young people was then matched with a comparison young person who had also died suddenly, but in a motor vehicle accident. Information from family, medical, and autopsy records were systematically reviewed. The results revealed that stimulants were used by 10 of the young people whose deaths were unexplained and by 2 who died in crashes. (The stimulant found in each case was methylphenidate [Ritalin]. This study examined deaths that occurred between 1985 and 1996, before mixed amphetamine preparations [Adderall] became commonly used).

Because sudden death is extremely rare in childhood, randomized controlled studies—the ideal approach to studying health effects in populations—cannot be conducted to investigate such events. The authors employed a case-control design in which child or adolescent with the condition of interest—in this case sudden unexplained death—was matched with someone who died suddenly as a passenger in a motor vehicle accident. Using this approach, the authors were able to control for many relevant factors other than those being studied, such as asthma and other conditions associated with sudden death, although it was not possible to control for all potentially confounding factors.

Significance

According to the authors, the results of this study draw attention to concerns that stimulant medications increase the risk of sudden unexplained death in children and adolescents. The accompanying editorial, by coauthors Benedetto Vitiello, M.D. and Kenneth Towbin, M.D., both at NIMH, points out that the study, though rigorous in its approach, could not provide information on whether ADHD itself could increase the risk of sudden death, given its association with high-risk behaviors such as substance abuse.

The editorial went on to note that while randomized prospective studies are not practical—given the large numbers of subjects needed to detect such rare events—additional case/control studies would still be informative. In addition, research to improve screening methods for heart conditions that raise the risk of sudden death is essential.

Finally, the editorial notes that “1) sudden unexplained death is a rare event, 2) this is only the first such study, 3) it relies on small numbers, and 4) it is not possible to quantify the risk beyond estimating that it is very small.”

Reference

Gould, M.S., Walsh, T., Munfakh, J.L., Kleinman, M., Duan, N., Olfson, M., Greenhill, L, and Cooper, T. Sudden death and use of stimulant medications in youth. American Journal of Psychiatry AIA:1-10, 2009.

Vitiello, B. and Towbin, K. Stimulant treatment of ADHD and risk of sudden death in children. American Journal of Psychiatry AIA:1-10, 2009.

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Cognitive Prevention Program Trumps Usual Care in “Real World” Trial

At-risk teens exposed to a program that teaches them to counteract their unrealistic and overly negative thoughts experienced significantly less depression than their peers who received usual care, NIMH-funded researchers have found. However, the cognitive behavioral prevention program failed to similarly help adolescents prone to the mood disorder if their parents were currently depressed.

NIMH grantee Judy Garber, Ph.D., of Vanderbilt University, and colleagues, report on the findings of their multi-site clinical trial in the June 3, 2009 issue of the Journal of the American Medical Association.

Background

Only a fourth of depressed youth receive any treatment and at least 20 percent develop a chronic, difficult-to-treat form of the illness. Having a history of the illness substantially increases risk for depression, which soars two to three times among children of depressed parents. An initial study had supported the efficacy of a cognitive behavioral prevention program in reducing risk in such depression-prone teens, but it was unknown whether this would hold up across diverse “real world” settings.

To find out, Garber and Drs. David Brent, the University of Pittsburgh, William Beardslee, Boston Children’s Hospital and Judge Baker Children’s Center, and Gregory Clarke, Kaiser Permanente Center for Health Research in Portland, OR, randomly assigned 316 at-risk adolescents (aged 13-17) to either the cognitive behavioral program or usual care.

Teens in the cognitive behavioral program received eight weekly 90-minute group cognitive behavioral sessions. Masters or doctoral-level therapists helped them learn to restructure dysfunctional thinking patterns and practice problem solving skills. This was followed by six monthly continuation sessions in which they reviewed the cognitive and problem-solving skills and also learned relaxation, assertiveness and behavioral activation techniques.

Teens in the usual care condition as well as those in the cognitive behavior program were allowed to begin or continue with any mental health or other healthcare services available in their communities.

Results of This Study

Over a 9-month follow-up period, the rate of depression in the cognitive behavioral program group was 11 percent lower than for those in the usual care condition — 21.4 percent vs. 32.7 percent. Adolescents in the prevention program also self-reported lower levels of depression symptoms than those in usual care. Among teens whose parents were not depressed at the beginning of the study, the program was more effective in preventing onset of depression than usual care — 11.7 percent vs. 40.5 percent. However, this advantage did not hold for youth in the cognitive behavioral program if they had a parent who was depressed at the start of the study. Such teens had significantly higher rates of depression than those without a currently depressed parent.

Significance

The results demonstrate that the prevention program can be effectively delivered in a variety of “real world” settings, say the researchers.

“For every 9 adolescents who received the cognitive intervention, we would expect to prevent one from developing a depressive episode,” explained Garber. “This is comparable to what is seen with treatment response to medication.”

Moreover, preventing recurrence of a depressive episode may arguably bring even greater benefits than treating an episode after it has already produced other negative consequences. This suggests that the program may be useful for maintaining recovery, once achieved, she noted.

What’s Next?

“Our results also underscore the link between changes in parent and youth depression. Future investigations might explore combining or sequencing parental depression and prevention programs for at-risk teens.”

Reference

Prevention of depression in at-risk adolescents: a randomized controlled trial. Garber J, Clarke GN, Weersing VR, Beardslee WR, Brent DA, Gladstone TR, DeBar LL, Lynch FL, D’Angelo E, Hollon SD, Shamseddeen W, Iyengar S. JAMA. 2009 Jun 3;301(21):2215-24.PMID: 19491183

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Citalopram, a medication commonly prescribed to children with autism spectrum disorders (ASD), was no more effective than a placebo at reducing repetitive behaviors, according to researchers funded by the National Institute of Mental Health (NIMH) and other NIH institutes. The study was published in the June 2009 issue of Archives of General Psychiatry.

“Parents of children with autism spectrum disorders face an enormous number of treatment options, not all of which are research-based,” said NIMH Director Thomas R. Insel, M.D. “Studies like this help us to better understand which treatments are likely to be beneficial and safe.”

The researchers say their findings do not support using citalopram to treat repetitive behaviors in children with ASD. Also, the greater frequency of side effects from this particular medication compared to placebo illustrates the importance of placebo-controlled trials in evaluating medications currently prescribed to this population.

Citalopram is in a class of antidepressant medications called selective serotonin reuptake inhibitors (SSRIs) that is sometimes prescribed for children with ASD to reduce repetitive behaviors. These behaviors, a hallmark of ASD, include stereotypical hand flapping, repetitive complex whole body movements (such as spinning, swaying, or rocking over and over, with no clear purpose), repetitive play, and inflexible daily routines.

Past research suggested that some children with ASD have abnormalities in the brain system that makes serotonin, a brain chemical that, among many other functions, plays an important role in early brain development. Children with obsessive compulsive disorder (OCD) may also have serotonin abnormalities and have repetitive or inflexible behaviors. OCD is effectively treated with SSRIs, leading some researchers to wonder whether similar treatment may reduce repetitive behaviors in children with ASD. So far, studies have produced mixed results, but SSRIs remain among the most frequently prescribed medications for children with ASD.

Researchers in the Studies to Advance Autism Research and Treatment (STAART) network, funded by five NIH institutes, conducted a six-site, randomized controlled trial comparing the effectiveness and safety of using the SSRI citalopram (Celexa) versus placebo to treat repetitive behaviors in children with ASD. The study included 149 participants, ages 5–17, who had autism, Asperger disorder, or pervasive developmental disorder-not otherwise specified (PDD-NOS).

After 12 weeks of treatment, roughly 1 out of 3 children in both groups—32.9 percent of those treated with citalopram and 34.2 percent those treated with placebo—showed fewer or less severe repetitive symptoms.

“Adverse symptoms were common in both groups, probably reflecting common childhood ailments as well as the changing nature of symptoms associated with ASD,” according to Bryan King, M.D., director of child and adolescent psychiatry at Seattle Children’s Hospital and lead author on the study. “However, reports of increased energy, impulsiveness, decreased concentration, hyperactivity, diarrhea, insomnia, and dry skin were more common in the citalopram group.”

According to the researchers, the study results may challenge the underlying premise that repetitive behaviors in children with ASD are similar to repetitive and inflexible behaviors in OCD.

The authors on the paper include Bryan H. King, M.D., Seattle Children’s Hospital; Eric Hollander, M.D., Mount Sinai School of Medicine; Linmarie Sikich, M.D., University of North Carolina, Chapel Hill; James T. McCracken, M.D., University of California Los Angeles; Lawrence Scahill, M.S.N., Ph.D., Yale University; Joel D. Bregman, M.D., North Shore Long Island Jewish Health System; Craig L. Donnelly, M.D., Dartmouth Medical School; Evdokia Anagnostou, M.D., Mount Sinai School of Medicine (currently at the University of Toronto); Kimberly Dukes, Ph.D., DM-STAT; Lisa Sullivan, Ph.D., Boston University; Deborah Hirtz, M.D., National Institute of Neurological Disorders and Stroke (NINDS); Ann Wagner, Ph.D., NIMH; Louise Ritz, M.B.A., NIMH (currently at NINDS); and the STAART Psychopharmacology Network.

The STAART network is jointly funded by NIMH, NINDS, the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), the National Institute on Deafness and Other Communication Disorders (NIDCD), and the National Institute of Environmental Health Sciences (NIEHS), all part of the National Institutes of Health (NIH).

Use of medication did not trigger suicidal thinking among adolescents with depression, but those with persistent and severe depression were more at risk for suicidal events while undergoing treatment, according to a new analysis of data from the NIMH-funded Treatment for Adolescents with Depression Study (TADS). The analysis, which was published in the May 2009 issue of the Journal of Clinical Psychiatry, was conducted to better understand what may predict the development of suicidal events during treatment.

Background

Depression is a major risk factor for suicidal thinking and behavior (suicidality). Antidepressant medications, though effective in decreasing depression, may also increase the risk for suicidal thinking and attempts among adolescents. But scientists are unsure how these medications may prompt some teens to consider or attempt suicide. To add further complication, suicidality may emerge even when depression begins to lift and patients begin to improve. For these reasons, doctors treating teens with depression are strongly encouraged to closely monitor their patients for at least the first month of treatment.

Benedetto Vitiello, M.D., of NIMH, and colleagues analyzed data from the 36-week TADS to determine if they could identify possible predictors of suicidal events among the 439 participants. The primary results of TADS, which compared medication, psychotherapy, and their combination in treating teens with depression, have been previously reported.

Results of the Study

Although no suicides occurred during the study, about 10 percent of participants experienced at least one suicidal event, defined as serious suicidal thinking or a suicide attempt. In addition, events occurred anywhere between the first week and the 31st week of the trial, indicating that the risk for suicidal events did not decrease after the first month of treatment. The researchers also found no differences in suicidal event timing among participants receiving antidepressant medications compared to participants not receiving medication.

Rather, participants who showed serious suicidal thinking and severe depressive symptoms prior to study treatment were more likely to have a suicidal event during treatment. In addition, interpersonal stressors, such as conflicts with family members, preceded suicidal events in 73 percent of cases.

Significance

Because the timing of suicidal events varied, the researchers suggest that careful clinical monitoring should continue past the first month of treatment. In addition, because the teens typically did not show increased irritability, insomnia or agitation before an event—common signs prior to a suicide attempt—the researchers concluded that suicidality was likely not triggered by medication. Rather, the analysis showed that the teens that experienced a suicidal event tended to do so in the context of persistent depression and difficult interpersonal problems.

What’s Next

More research is needed to better understand individual characteristics and identify specific predictors of suicidal actions, especially among adolescents with no history of suicidal thinking or behavior.

Reference

Vitiello B, Silva S, Rohde P, Kratochvil C, Kennard B, Reinecke M, Mayes T, Posner K, May D, March J. Suicidal events in the Treatment for Adolescents with Depression Study (TADS). Journal of Clinical Psychiatry. 2009 May;70(5):741-747.

t may not be as easy A,B, C and 1,2,3, but proponents of solution-focused counseling agree that the approach can be extremely effective when used in school environments

By Jim Paterson

School counselors and school counseling educators typically agree on three things when it comes to solution-focused counseling.

A) The approach makes perfect sense because it works with a student’s strengths and successes.

B) It is often more effective in getting challenging students to change than other approaches typically used in schools — namely, diagnosing problems and doling out punishment.

C) It is easier said than done.

“It sounds so easy in a book and makes so much sense, but it is harder than one might think to implement. We tend to slip back to the default — focusing on the problems,” says Leslie Cooley, a former school psychologist and author of a new book, The Power of Groups , which focuses on using solution-focused counseling in groups. “We’ve all seen All About Bob, Good Will Hunting and The Prince of Tides. That seems to be what works, and that is the default.”

John Murphy, a professor of psychology and counseling at the University of Central Arkansas and the author of Solution-Focused Counseling in Schools , published by the American Counseling Association, agrees. “Solution-focused counseling is simple to understand but harder to do because we have been socialized to seek out and eradicate problems,” he says. “When something isn’t working, there is an implied belief that we have to figure out what it is and call in someone to fix it.”

In practice, the solution-focused approach validates the struggles and perceptions of the client while building on their strengths and resources, encouraging their involvement, recognizing any change (no matter how small) and focusing on the future. To apply the approach effectively, Murphy says, counselors must develop a cooperative relationship that examines the client’s goals and the issues that concern the client.

According to Murphy, solution-focused counseling grew out of the work of Milton Erickson, who believed therapeutic solutions could be found separate from the problems that clients displayed, and Steve de Shazer and the Brief Family Therapy Center, where the solution-focused counseling name arose. “Historically, psychotherapy has concerned itself with problems (variously defined) and solutions (seldom defined at all), with problems receiving the major share of the effort,” de Shazer wrote in 1988. Solution-focused counseling also taps into Martin Seligman’s positive psychology approach, which examines healthy states of mind and how therapists and counselors can study, promote and use them.

“There is a seismic philosophical shift that many have to make (in using solution-focused counseling),” says former teacher and counselor Patrick Akos, now an associate professor of school counseling at the University of North Carolina. “You have to be intensely curious and focused on the assets kids have and the ideas that they believe will work for them — as focused on that as you are their problems.” Akos, a member of ACA and a past American School Counselor Association Educator of the Year, adds that counselors have to be “willing to give up the power of the expert role and understand that the student standing in front of you has the culturally and contextually relevant answers needed to move them toward positive change.”

In spite of the challenges, Akos, Cooley, Murphy and other experts insist that new and veteran school counselors alike can master solution-focused counseling and experience great success with students because of it. Fundamentally, solution-focused counseling recognizes that student problems related to behavior or performance in school are generally “imbedded in a social system rather than residing strictly within the student,” says Murphy, a member of ACA. He recommends school counselors search for new approaches in working with students rather than relying on other, more “traditional” approaches such as lecturing, threatening and pleading for rational thinking. Utilizing the student’s ideas in a collaborative relationship and stressing the student’s strengths and past successes is key, he says.

Putting the filling in the pie

According to Murphy, research shows change comes proportionally from the following sources: the client and what he/she brings to the session (40 percent); the client’s relationship with the counselor (30 percent); hope factors (15 percent); and models or techniques used (15 percent).

If counselors look at this breakdown in terms of “change pie,” Murphy says, then “ignoring the resources of the client is like baking a pie without filling.” He says using a solution-focused approach with students addresses at least 85 percent of the change factors by focusing on the needs and strengths of students, offering them a collaborative relationship and giving them hope through a new way of approaching their problems.

Cooley says school counselors dedicated to using the approach must first make certain assumptions: Students possess resources that, though not always visible, can help them solve their problems, and students are the experts about their issues. Solution-focused counseling suggests that if one method isn’t working, the student should try another approach, she says, adding that the solution may not be very complex or even directly connected to the problem. Change of some sort is inevitable, she says, and will affect other parts of the client’s life.

Murphy spells out certain “tasks for school-based solution-focused counseling,” including:

• Establish cooperative, change-focused relationships by being curious and respectful, listening carefully, validating and complimenting the students and getting their feedback.
• Clarify the problem and related details by defining and describing the problem and describing how change can occur. Find out what the student has tried to do previously, how the student thinks and how counseling might help.
• Develop clear and meaningful goals. Allow the student to focus on a better future and goals that are “personally meaningful, specific and positive.”
• Build on “exceptions” — behavior that is different than the unacceptable or unsuccessful norm — and other resources the student possesses by identifying circumstances when the problem wasn’t occurring or was less intense.
• Change the “doing” or viewing of the problem by suggesting behavioral experiments or encouraging other changes in performance and the way the problems is viewed. Suggest the “do something different” experiment.
• Evaluate and empower progress by looking at improvements in the student’s referrals, class work, grades and so forth. Give students ample credit for success.

Cooley tells counselors in training at California State University-Sacramento where she is a professor that they should approach students with questions that focus on the students and their goals. For example:

• Scaling questions that highlight differences or exceptions to a problem, such as when things were going better for the student
• Questions that can yield compliments for the student
• Accomplishment questions that focus on positive events
• Goal questions that establish positive, achievable end results
• Questions that ask the student to describe the problem in observable terms
• Questions that highlight changes the student has noticed or changes in how other people view the student
• Motivation questions to determine whether the counselor “really has a customer for change”

A good fit

An approach that ideally requires less time exploring the client’s past and problems, solution-focused counseling is attractive to time-strapped school counselors in large part because the therapy has proved effective for typical school counseling sessions, which are often brief and sometimes occur without follow-up. “Being effective is the top priority, but it is a simple numbers game,” Akos says. “If you are serving 450 students, efficiency is part of that equation. That is where solution-focused counseling comes in.”

Julia Taylor, an eighth-grade counselor at Apex Middle School in North Carolina, agrees that efficiency is always an issue. “Solution-focused counseling works in a school setting because the school counseling we do is always brief,” she says, noting that the approach is useful even in short sessions with students or in brief discussions to remind students of the approach.

Solution-focused counseling works in schools for a variety of reasons, Murphy says, but primarily because it creates an atmosphere in which a student is willing and open to try to do things a different way. “School counselors want to promote change, period. That’s it,” he says. “A solution-focused approach responds to the simple reality that change is the name of the game.”

Cooley says although solution-focused counseling is potentially very effective in schools, proper training and careful attention to the process are essential to earning the hoped-for results. She suggests school counselors work collaboratively with other counselors to adopt and correctly use the technique or view tapes of counselors successfully utilizing the approach. Cooley has also observed that it is often harder for counselors with prior training in other approaches to adapt to solution-focused counseling.

Others suggest that the effective use of solution-focused counseling in schools may also require prior experience with young people, a clear and objective understanding of their motivations and a knowledge of how they can use their strengths more productively. “I like to think (expertise in solution-focused counseling) is possible to cultivate by making counselors aware of how to capitalize on the client’s assets in different ways,” Akos says, “but that sensitivity to the client is hard to develop.”

Doing something different

In addition to perhaps battling their own tendencies to slip back into problem-focused approaches, Cooley says counselors may encounter pressure from other school personnel to use more traditional techniques. “People stick with what is comfortable because they don’t know what else to do,” she says. “Traditional punishment works for the kids in the mainstream, but those aren’t the ones who are always sitting in the vice principal’s or the counselor’s office and really need to change.”

“Some teachers will think that (solution-focused counseling) is anti-discipline,” says Linda Metcalf, a former teacher and current school counselor, speaker and author of several books, including Counseling Toward Solutions . She is also president-elect of the American Association for Marriage and Family Therapy and a member of ACA.

In her presentations, Metcalf points out that using solution-focused counseling stands to help not only the student, but the student’s teacher. This can be a big selling point when counselors explain solution-focused counseling to their school colleagues. “A counselor may intend to help kids,” Metcalf says, “but unless they approach teachers who have some resistance with a technique that is also going to help them, it is hard to get buy-in. These are stressed and busy people.”

Yet, Metcalf notes that when she surveys her audiences, she is typically told that only 20 to 30 percent of students actually change their behavior based on traditional modification techniques rooted in disciplinary actions. “To that I say, let’s do something different,” she exclaims.

Murphy says school counselors can easily find themselves repeating unsuccessful techniques with students without giving it much thought. He asks school counselors to consider how often they have found themselves trying to convince students that they have a problem without the students buying in; felt a student becoming less and less engaged; realized they were working a lot harder than the student to change a problem; or felt responsible for providing a solution to a student’s school problem.

Murphy notes that school counselors often try one of two common tactics with students — the “rational persuasion approach” of trying to talk students out of their opinion or the “fatalistic future approach” in which the counselor lets students know how miserable their life will be unless they change. “Even when these resistance-countering responses are applied with the best of intentions, they usually backfire and make matters worse,” he says.

Like other proponents of solution-focused counseling, Murphy recommends that school counselors try something different. This starts with recognizing that “every client is unique, resourceful and capable of change,” he says. Students are such a critical part of the process, he emphasizes, that counselors must involve them, making use of their ideas, experiences, strengths and values.

“You really have to do something interesting enough to make them want to work on the problem,” Murphy says. “That means they have to be involved. If you don’t develop an alliance with the person in front of you, it’s like trying to climb a mountain on a bike with one wheel.”