Partnerships in preventing adolescent stress: increasing self-esteem, coping, and support through effective counseling.

Primary prevention initiatives are important not only for mental health professionals but for school personnel as well. We offer mental health counselors two prevention models: Bloom's Configural Equation and Albee's Incidence Formula as excellent tools to plan and implement prevention programs in schools and in community-wide efforts to improve adolescent well-being. We acknowledge that diverse environmental variables impact mental health. We offer guidelines for building community-based partnerships to increase adolescent coping skills and to provide them with adequate support systems. We critically assess both primary prevention models and outcome research and offer ideas in how to utilize them in the practice of mental health counseling.

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We need prevention programs and community-based partnerships if we are to impact adolescent mental health concerns. Most professionals know that youth are vulnerable to environmental risk factors. Some, however, do not fully understand the current mental health status of youth and the risk and protective factors associated with various mental health disorders. We intend to provide this information to mental health counselors so that we can take a proactive stance in support of health in our teen population.

CONTEXTUAL OVERVIEW OF ADOLESCENT MENTAL HEALTH CONCERNS

Four major health problems account for 72% of the mortalities in youth between the ages of 5 and 24. They are: motor vehicle crashes, unintentional injuries (i.e., falls, fires, poisonings), homicides, and suicides, according to the Centers for Disease Control and Prevention (CDC, 1993). In addition, sexually transmitted diseases as well as unwanted pregnancies affect millions of youngsters every year.

Failed efforts to cope with the anxieties and difficulties in life can lead to mental health problems. Prevalence rates of 12% for mental health disorders and 15% for maladjustment disorders for the nation's youth are common (Institute of Medicine, IOM, 1994; McCabe as cited in Walker & Townsend, 1998). Preventing psychological problems has become as important as intervening when they arise. Mental health counselors need to acquaint the profession with prevention models that can work for at-risk children and youth.

Promoting mental health can prevent further behavioral problems and improve the quality of life for youth (Walker & Townsend, 1998). New initiatives in mental health counseling need to include primary, secondary, and tertiary prevention efforts designed to detect, treat, and forestall mental health problems before they take hold.

Premise and Purpose

Schools and mental health agencies have known the importance of prevention since 1994 because of Acts such as School Reform and Mental Health Reform. These reforms cite schools as a focal point of public health and primary care initiatives (Short & Talley, 1997). The elevation of schools as a place to intervene and prevent problems is logical because health problems interfere with learning. Promoting a holistic view of the learner, we see that children do not live in a vacuum and that many factors can impede their academic performance. For this reason schools and primary care facilities can serve as a hub where a wide variety of services can address the needs of all youth. Building partnerships between mental health counselors and schools is now a critical aspect of prevention in today's environment.

Multiple challenges face adolescents who experience numerous risk factors. Mental health and school counselors can team up to reduce adolescent stress and increase their coping strategies. The rationale for building partnerships is that environments can produce or reduce stress; therefore, services need to be available in the environmental settings where adolescents live and work.

We hope to provide mental health counselors with three pieces of information: first, we offer a critical overview of the empirical literature on primary prevention programs that target adolescent mental health concerns. Second, we promote partnerships between mental health and school counselors that can best utilize community resources within a given geographic region. Adolescent coping and self-esteem can be increased when services are coordinated and when they target specific risk factors. Third and finally, we want to convince mental health practitioners that prevention models can guide clinical research and practice.

PRIMARY PREVENTION

Definition

Primary prevention in mental health counseling is basically creating a program to help youth before something debilitating happens Prevention goes beyond restoration and focuses on strengthening existing skills (D'Andrea, 1984; p.554).

Three critical elements are prerequisites to any effective prevention program: a group orientation, a sound theoretical foundation, and a proactive stance (Cowen, 1982). Of course, prevention programs target at-risk groups who have the potential to develop problems.

Advance Premises

Analyzing primary prevention practices and high-risk populations, D'Andrea (1984) noted that traditional mental health services lack primary intervention initiatives because they focus on remediation rather than on strengthening current skills. If primary prevention programs are to work, they must use strengths that exist to build in additional protective factors.

Three areas of prevention can be initiated, according to the Institute of Medicine. Prevention initiatives can be selective, universal, or indicated. First, selective prevention targets specific at-risk populations. Second, universal prevention targets the general population. Third, indicated prevention targets individuals who do not meet the criteria for a mental disorder but who nevertheless present symptoms associated with a certain mental disorder (IOM, 1994).

Prevention is useful when any one of four distinct prevention approaches is evoked. First, programs can focus exclusively on improving skills (cognitive, behavioral, affective) without directly addressing environmental variables. Second, programs can target both skills and the environment. Third, programs can have multiple components that target the relationships of youth with significant adults. Finally, programs can have multiple components that target the group level rather than the individual level (Weissberg & Bell, 1997).

Prevention program models address the complexity and nature of adolescents' mental health concerns when they identify risk factors (potential causes) of mental problems and when programs are designed to minimize the impact of these risk factors (Dulmus & Wodarski, 1997).

Bloom's Model

Primary prevention is defined as "coordinated actions seeking to prevent predictable problems, to protect existing states of healthy functioning, and to promote desired potentialities in individuals and groups" (Bloom, 1996; p. 2). Prevention plays a critical role in diagnosing and treating children and adolescent disorders; we offer you Bloom's configural equation and Albee's incidence formula as excellent tools to use when you plan or implement school-wide or community-wide partnerships. Both models are also excellent guides to conceptualizing psychological problems within the prevention context.

Bloom (1996) suggests using his configural equation in several ways. This model is a conceptual tool as well as a "best practices" treatment guide. In this article we show mental health counselors how to intervene in three key dimensions of adolescent life.

Bloom's first dimension requires us to increase individual strengths and decrease individual limitations. In this dimension, mental health counselors determine the cognitive, affective, behavioral, and biological factors that could explain the origin of adolescent mental health problems. We advocate a holistic perspective because we want to emphasize the impact that environmental variables have in shaping psychological disturbance in teens.

Bloom's second dimension requires us to increase social support and to decrease social stress. In this dimension, mental health counselors look for ways to assess contribution of diverse groups (i.e., primary, secondary, and sociocultural), of the physical environment (both natural & built), and of life course events to psychological disorders. We already know that parents and peers clearly contribute to the mental health and, conversely, to the mental deterioration of youth (Dryfoos, 1996; Dulmus & Wodarski, 1997; Garmezy, 1983; Gillham, Shatte, & Freres, 2000), but we do not know how to specifically intervene in these relationships in order to prevent environmental contributions to mental health disturbances. Nevertheless, we know that prevention programs will be effective to the extent that they assess the relative contribution of individuals important to adolescents as they influence their mental health outcomes.

Blooms third dimension requires us to look at environmental variables as we develop our prevention programs. One environmental factor is poverty for its consequences clearly affect adolescent mental health (Dryfoos, 1996; Garmezy, 1983; Patros, 1989). A second environmental variable is natural disaster, for its consequences immediately challenge adolescent security. Mental health professionals can educate the community regarding the impact of environmental factors such as poverty and natural disasters and can make available to the community supportive resources (Bloom, 1996). A third environmental variable is the availability of community programs for youth, for their presence in a community can buffer the stresses inherent in adolescent life. Regardless of whether the target is poverty, natural disasters, or lack of community programs for youth, when mental health counselors enlist adolescents to create and protect environmental resources, youth can experience their sense of agency and competency.

In addition to Bloom's configural model of prevention, there is another effective prevention model: Albee's incidence formula (Albee & Gullotta, 1977). To prevent psychological maladjustment we must decrease the negative effect of biology and stress, and we must increase the positive effect of strengthening coping skills, improving self-esteem, and bolstering supportive systems. Overall, Albee's model helps mental health counselors improve adolescent motivation to responsibly improve their mental health outcomes.

ADOLESCENT MENTAL HEALTH

Literature on prevention and adolescent mental health reveals that prevention programs exist within a storm of controversy over whether or not prevention itself is effective or even possible. In the 1970s to 1980, prevention programs for adolescents flourished as an antidote to increasing adolescent juvenile delinquency and substance abuse (Center for Substance Abuse Prevention, 1993). Today, several examples of effective prevention programs exist and are seen as instrumental in decreasing the potentially severe consequences of adolescent psychological disturbance.

One example of effective prevention for adolescents is the Multidimensional Family Prevention model (Liddle & Hogue, 2000). This model decreases anti-social behavior among adolescents through two methods: traditional (curriculum-based, protective orientation) and psychosocial (assess and solve problems within the context of key relationships). This model emphasizes an individualized plan to satisfy a family's unique needs. The robust element in this model is its success in creating a resilient family environment that allows at-risk adolescents to protect themselves against traumatic environmental influences.

A second example of effective prevention for adolescents is Ellis's multi-factor, multi-system, multi-level comprehensive prevention program (Ellis, 1998). Ellis accepts the reality that adolescent mental health problems are caused by multiple factors and systems and insists that effective prevention requires us to address all relevant risk, need, and protective factors facing the adolescent across multiple systems and environments. Mental health counselors who are serious about preventing adolescent mental disturbances will look at three types of intervention: multi-factor, -system, and -level.

Multi-factor interventions are those that address all risk, need, and protective factors existing within the adolescent environment. Multi-factor prevention plans contain both an individual and a collective component. Individually, the plan is specific to the needs of each adolescent; collectively, the plan provides sufficient resources to meet the needs of all individuals in the target population (Ellis, 1998; p. 62).

Multi-system interventions are those that address the factors that exist in every social context in which the individual interacts. Furthermore, the author stresses that because the risk factors are interactive and the systems interact with one another it is critical to understand the role of each system in the life of each individual.

Multi-level interventions are those that address the need to provide resources at both the micro (individual) and macro (collective) level. Ellis believes that sufficient intervention and prevention resources must be in place and accessible at both levels. At the macro level of prevention planning, there are three critical questions to ask about service availability: Do people know that these services exist? Do people have ready access to these services? and, Do people know that they need the services that are offered?

OUTCOME RESEARCH

Prevention works. For decades, prevention literature suggested that using initiatives is an effective way to reduce health problems among youth, yet, not until the 1970s were there any empirical studies to evaluate program effectiveness. Happily, prevention outcome research has flourished in the past 25 years so that today we see more than 1,200 prevention outcome studies focus on children, adolescents, and their families. Now we know, not just believe, that prevention works not only for reducing depression and other intrapsychic disturbances, but also for reducing by half the rate of bullying, school dropouts, violence, and child abuse and neglect (Durlak, 1998). Longitudinal, meta-analyses, and family-based prevention programs work in helping adolescents navigate the emotional and behavioral aspects of their lives, as we see in the following paragraphs.

One recent longitudinal study on preventing substance abuse for high-risk second and third grade students found that prevention is effective. Positive program effects for children were found in the increased use of personal competency skills which include: refusing wrongdoing, solving peer and school problems, showing courteousness to teachers and other school personnel, and behaving ethically. Positive program effects were also found in children's report of good feelings toward school and grades. From this study, we see that mental health counselors can work with schools to provide a buffer from the multiple risks in children's lives (St. Pierre & Kaltreider, 2001).

One meta-analysis on primary prevention mental health programs for children and adolescents found that outcome evaluations of 177 primary prevention programs were effective. Problems were significantly reduced, competencies were significantly increased, and children were better able to adjust in several aspects of their lives (Durlak & Wells, 1997; p. 137). Importantly, this meta analysis also revealed that primary prevention programs are designed to improve practical areas of life and functioning in youth. A second meta-analysis of 156 educational, behavioral, and psychological interventions indicated that participants were functioning within the normal range and within the range achieved by other interventions in the behavioral and social sciences (Lipsey & Wilson, 1993). In sum, meta-analyses reveal that mental health preventions are effective as tools for change in both normal and disturbed adolescent populations.

Finally, D'Andrea's (1984) Family Development Project is an example of a successful systemic prevention program. Designed to help young women in their transition to parenthood, this program includes four components: educational consultation, individual counseling, psychosocial system consultation, and research and evaluation services. Overall, data on effectiveness showed that participants perceived that their psychosocial networks were stronger, more elaborate, and more responsive as a result of their participation in the program.

So, primary prevention programs are effective. Knowing this, we hope that mental health counselors are encouraged to begin the prevention process at the population level.

LEVELS OF PREVENTION AND INTERVENTION

Definition

Primary prevention involves helping people before they are actually suffering. Secondary prevention involves helping people when they are in crisis and suffering. Tertiary prevention involves helping people during the process of treatment or rehabilitation (Durlak, 1998).

Best Practices

To prevent compromised cognitive capacity in adolescents related to adolescent depression, we need to look at their problem situation, including their irrational ideas and distorted perceptions. To prevent depression, we need to teach adolescents to solve their problems, restructure their cognitive processes, systematically desensitize themselves to noxious stimuli, self-instruct, and increase their competence and coping skills (Bernard & Joyce; Cardlige & Millburn; Clarke et al.; Hains & Ellman; as cited in Gillham et al., 2000).

To prevent negative feelings associated with adolescent depression, we need to teach them self-care related to their affective functioning. We need to show adolescents how to decrease their feelings of alienation, increase their self-esteem, and build a robust sense of hope (Patros, 1989). According to the author, effective strategies to reduce these limitations are relaxation training, stress management, self-esteem techniques, and use of religious and spiritual beliefs as a source of support for the client. Additionally, we should increase hope and optimism via individual and group therapy (Thompson & Rudolph as cited in Patros, 1989).

To prevent unhelpful behaviors associated with adolescent depression, we need to improve their social skills, model appropriate nondepressive behaviors, rehearse nondepressive behaviors, prevent suicide risks, and use booster sessions to prevent relapse. To this end, we can recommend the cognitive-behavioral model to treat depression in adolescents (Gillham et al., 2000).

In preventing adolescent depression, we need to have a healthy respect for biological aspects associated with depressed functioning. We need to analyze potentially causal factors such as nutrition, eating patterns, possible chemical imbalances (thyroids), frequency of headaches or stomachaches, genetic predisposition, and general physical condition (Beadslee et al. as cited in Gillham et al., 2000). We must look first to biology to consider whether a medical condition might warrant medication.

We advocate treating adolescents holistically, and so we look to all areas of functioning, including biological, cognitive, affective, behavioral, or spiritual contributions to the disorder. We therefore design intervention and prevention efforts that will encourage adolescents to increase their self-efficacy, assertiveness, social competence, and resilience (Bloom, 1996). We also recommend the use of stress-management techniques, depression prevention programs, and parent training. Finally, we recommend proven prevention strategies in treating adolescent depression, including group counseling, self-help groups, peer aids, parent effectiveness training, and community programs (Patros, 1989). The following paragraphs explain in more detail some effective depression prevention programs that can be adapted by working mental health counselors.

Gillham et al. (2000) reviewed several depression prevention programs and found mixed results on effectiveness. One particularly effective program is a cognitive-behavioral approach known as the Adolescent Coping with Depression Course (Clarke et al. as cited in Gillham et al., 2000). In addition, a review of the effectiveness of family interventions (i.e. family therapy, parent training) found greater promise when combined with cognitive-behavioral therapy. More research is needed to prove the effectiveness of early interventions and best practices in preventing problems similar to adolescent depression.

Research Outcomes for Adolescent's Mental Health Concerns

One outcome study supports early intervention and preventive efforts in children and adolescents at-risk of developing major mood disorders (Duffy, 2000).

Another study, a meta-analysis of 42 outcome studies on helping children and adolescents manage chronic illness, found an effect size of 1.12 and maintenance of treatment gains for more than 12 months after the treatment began (Kibby, Tyc, & Mulhern, 1998). Most of these studies used behavioral and cognitive-behavioral techniques. Behavioral techniques were as effective as cognitive-behavioral methods for managing disease, distress, and adjustment. Cognitive-behavioral packaged interventions, behavior modification, and relaxation approaches were all effective in treating disease-related and emotional and behavioral problems.

A final outcome study conducted by Durlak and Wells (1998) evaluated the outcomes of 130 secondary prevention mental health programs for children and adolescents. Their intent was to identify early signs of psychological maladjustment and to intervene before full-blown disorders develop. Indeed, their preventive interventions produced positive effects that are statistically and practically significant. Furthermore, the mean effects achieved by behavioral and cognitive behavioral programs are moderately high in magnitude and are similar to other established social and psychological interventions.

In conclusion, preventive interventions focusing on CBT or behavioral techniques appear as effective as psychotherapy (Durlak & Wells, 1998). These results are impressive and provide empirical support for implementing secondary prevention programs.

BUILDING PARTNERSHIPS: MENTAL HEALTH AND SCHOOL COUNSELORS

When mental health counselors consider teaming up with school counselors, it is important that they share a common set of assumptions, including the fact that if adolescents are to develop properly, they must enjoy positive interactions at home, at school, and within their socio-cultural environments. People who work with adolescents know that they, like adults, will behave differently in different environmental contexts, so we must keep in mind the multiple contexts of the adolescent world as we design prevention and intervention plans to improve their lives (Bronfenbrenner, 1979).

Mental health counselors and school counselors also share the premise that cognitive development cannot be separated from either socio-cultural or biological development (Bronfenbrenner, 1979; Lerner, 1986). Lerner also hints that not only adolescents, but also significant adults in their lives will benefit from school partnerships. Partnerships between mental health professionals and school personnel can improve the life of adults so that their environment changes in ways that can benefit adolescents. By developing partnerships, counselors can lobby for the use of community resources. When community resources are accessed and when they target healthy child development, they are effective in reducing school failure and increasing overall academic achievement (Masten, Best, & Garmezy; Werner as cited in Walsh, Howard, & Buckley, 1999).

Mental health counselors and school counselors can work together in primary care settings to develop prevention programs that will increase mental health. Major changes in medical care related to primary care and prevention challenge our ability to provide optimum care to adolescents (Beckman, 1996). When providing primary prevention services in medical settings, we need to coordinate our network of care, and we need to insist on equal access to medical services for all adolescents. Developing partnerships among the different health care services, social and human services, school services, and the community is critical to providing access to appropriate prevention and intervention efforts for adolescents.

In addition to agreement regarding a set of developmental constructs between and among partners who wish to help adolescents, partnerships must comply with established standards if we are to provide access to underserved populations such as adolescents. These standards are provided by the Human Resources and Services Administration's Bureau of Primary Health Care in the U.S. Department of Health and Services and include six important partnership guidelines. First, partnerships must involve community members in the design and delivery of services. Second, partnerships must identify people at risk for health problems during crisis events. Third, partnerships must reach out to adolescents by providing coordinated health services in accessible community sites or in homes of families. Fourth, partnerships must emphasize community ownership of health problems and solutions. Fifth, the partnership must develop training mechanisms that cut across traditional professional boundaries to help health professionals and community members provide holistic and coordinated care. Sixth and finally, the partnerships must create new structures in order to integrate the traditionally fragmented systems of care (HRSA, 1996).

Given the nature and scope of our task in building mental health partnerships with school counselors and associated community helpers, it is evident that we need to continue to develop and expand our professional skill set. Building partnerships as a tool for primary care and prevention requires proficiency in these skills: (a) organizational; (b) creative resource packaging and budgeting; (c) training and consultation; (d) outcome evaluation and cost analysis; (e) marketing; and (f) building and sustaining new structures (Poole & Van Hook, 1997).

Community, School, and Home Linkages

According to Dryfoos (1996), there are several models of school-community partnerships, including the following three. The first and least intrusive model is the school-linked services approach, where schools coordinate for formal agreements for services with community agencies and resources. A second model is the school-based services in which the school serves as the host for a wide variety of services such as a school-based health clinic or a family resource center. A third and more inclusive model is the community school, where comprehensive services are provided within the school setting to address the diverse needs of the students such as full-service schools and extended-services schools (Dryfoos, 1996).

One example of effective community partnerships in preventing adolescent problems is Project SAFE. Project SAFE is an innovative school-based mental health program that focuses primarily on school-family partnerships. The main goal of this program is to prevent school failure. Data obtained from outcome research show that the reason this program is successful is because of the partnerships involving families, schools, communities, and public policy officials. Project SAFE differs from the traditional school-family partnership model in three ways. First, it provides comprehensive services ranging from early identification and assessment to monitoring adolescent progress. Second, this program emphasizes prevention and early intervention rather than secondary intervention. Third, project counselors coordinate resources in the community that families need to help their children succeed in school. Outcome research for this project indicates that people are highly satisfied with the program's services and outcomes (Poole, 1997).

Clearly, developing partnerships is a critical component of prevention. Mental health counselors need to know how to work with school counselors if we are to create initiatives that will counteract adolescent mental health problems. Walsh, Howard, and Buckley (1999) point out how school counselors could use their current skills to promote prevention programs as they partner with other helping professionals. Because adolescents spent a great amount of time in school, school counselors may be aware of the impact the environment has on academic achievement. Consequently, school-community partnerships can provide greater resources and services to at-risk children and youth than either mental health counselors or school counselors can when they work alone (Dryfoos, 1996; Wang, Haertel, & Walberg as cited in Walsh et al., 1999).

There are four key ways that mental health counselors can connect with school counselors to benefit adolescents. First, in partnership, mental health counselors can recognize that community services are an integral component of the services adolescents can access in a familiar environment: school. Second, as community liaisons, mental health counselors can work with school counselors to coordinate and integrate the diverse systems of care that our adolescents need. Third, mental health counselors can partner with school counselors to more effectively implement prevention and intervention programs. Finally, mental health counselors can join with school counselors to include programs for adults, which will indirectly benefit the lives of children as their family environment improves (Walsh et al., 1999).

CONCLUSION

Bloom and Albee have created primary prevention models that are excellent tools to guide our work with adolescents. Bloom (1996) provides five ways to use his model: as a planning guide for new projects; as a handbook for best practices; as a subject index to guide literature reviews on prevention programs; as an empirical perspective; and as a model to prevent similar problems in the future. Bloom's model is useful for a wide array of problems mental health counselors might encounter in their partnerships with parents, schools, and primary care settings. Albee (Albee & Gullotta, 1997) provides a useful model that addresses the complex origins of mental health disorders and a multi-modal method for intervening and preventing adolescent mental health disturbances. Finally, we urge mental health counselors to forge partnerships with school counselors, parents, and community leaders in order to provide comprehensive services to adolescents and their families. We hope that the empirical evidence from our literature review convinces mental health counselors that primary prevention strategies produce positive outcomes and that building partnerships may be a promising solution to securing the services adolescents need to cope with their mental health challenges.

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Alex S. Hall, Ph.D., is an assistant professor, Division of Counseling Rehabilitation and Student Development, The University of Iowa, Iowa City. Email [e-mail]. Ivelisse Torres, a doctoral student, is with the Sara A. Reed Children's Center, Erie, PA.