Murphy, John J. & Duncan, Barry, L. (2007). Brief Intervention for School Problems: Outcome-Informed Strategies (Second edition). Reviewed by Arthur S. Ellen, New York City, Department of Education

Murphy, John J. & Duncan, Barry, L. (2007). Brief Intervention for School Problems: Outcome-Informed Strategies (Second edition). NY: Guilford Press Pp. xiv + 210         ISBN 978-1-59385-492-8

Reviewed by Arthur S. Ellen
New York City, Department of Education

October 2, 2008

Ask school psychologists why they got into the field and they frequently tell you, “I wanted to work with children, but the workload makes this difficult or impossible.” They imply doing therapy and they show palpable disappointment in not doing what first got them interested in their career. I suspect the same from other school mental health professionals. According to the authors, “This book hopes to convince you that every contact, no matter how brief, is an opportunity for change” (p. 4). Indeed, this assures interest and provides reason for optimism.

Brief intervention is not about a particular theoretical orientation because psychotherapy outcome research has shown that no one theoretical approach has trumped any other. Intervention depends more on the quality of the therapeutic alliance, that is, mutual client and practitioner empathy and agreed upon goals. It suggests that when interventions are ineffective, it is time to change either the intervention or the practitioner. The point of intervention is to create change because hopefully even very small changes may enable future possibilities for change. Based upon examples from the book, school interventions encompass four or five irregularly spaced intervention sessions lasting about 30 minutes or more with the referred student and meetings with all those involved with the referral. This approach to intervention derives from solution‑focused brief therapy (SFBT) and, importantly, the authors’ clinical experience.

SFBT, associated with the “miracle question,” includes (a) focused, goal‑directed therapy that involves guiding a client to define a problem as understood and valued by the client; (b) identifying and amplifying the client’s skills to address the problem; and (c) assessing the effectiveness of the intervention. Murphy and Duncan ask the miracle question, “If you went to sleep tonight and a miracle occurred and ended the problem, what would be the first thing you would notice at home and school that would be different?” (p. 21). This kind of question creates expectancy for change and leads to problem/solution definition. A tenet of SFBT is that “clients possess talents and resources for resolving their difficulties and that it is the task of therapy to help them to build on existing partially successful attempts to reach a solution” (Lethem, 2002, p. 189).

Chapters 3-6 contain the meat of the book, where brief intervention principles, guidelines, and practice are explained and then illustrated with the authors’ case materials. Chapter 3 focuses on how to interview in order to recruit the client (child, teacher, or parent) as an agent of change. The client, not the practitioner, defines the problem as a young girl poignantly tells us “All my other counselors haven’t asked what I wanted to work on” (p. 24). It is the client who like a hero brings unique skills, skills which may not yet be known, to move towards a solution. In one example, a practitioner helps a boy with bed wetting by drawing an analogy to his favorite video game. The boy starts to get the parallel and says, “Well, the water is a trap. It’s like a big giant blob that when you drink it, it gets all over your body and you get stuck in it, and then the pee monster makes you pee” (p. 37). The approach is about engaging the client in change and relying upon the client’s skills to initiate change.

Chapter 4 takes us step-by-step through the authors’ approach to outcome‑informed strategies. Their approach relies heavily upon integrating two kinds of client-completed rating scales into intervention: the Outcome Rating Scale (ORS) and Session Rating Scale (SRS), which are available from www.talking.com in three age‑differentiated versions. The ORS, used to evaluate the effectiveness of intervention, consists of 4 items (individual, interpersonal, social, and overall) each marked on a 10-cm line. A client rates how well she/he has been doing on each item at the start of every meeting. After the client marks the line, the practitioner measures the distance from the start of the line to the client’s mark with a millimeter ruler. Marks farther to the right indicate higher functioning. The overall score is the sum of the 4 ratings, and interpretive cut scores for the overall score are given. The effectiveness of what transpired between sessions is immediately evaluated, and then the practitioner discusses this with the client. This way an unsuccessful approach will rapidly be changed. The ORS is also used to track progress.

The SRS employs the same 10-cm scale, is completed at the end of each meeting, and includes 4 items pertinent to the therapeutic alliance (relationship, goals and topics, approach and method, and overall). The SRS is used to closely monitor the quality of the alliance. The authors suggest a range of strategies to improve upon the quality of the alliance. Still, if there is not a good match between practitioner and client, then it may be time to refer to another practitioner. Indeed, research about the therapeutic alliance points to possible client attrition based upon the quality of the relationship as soon as the first session (Creed & Kendall, 2005). One must keep in mind that the quality of the therapeutic alliance is integral to change. As the authors indicate, the practitioner must come to rely upon the alliance. Therefore, letting another practitioner work with a student is not viewed as prematurely terminating a client, but as necessary to rapidly move towards change. Although the authors argue for the pragmatic and clinical utility of these scales, these visual analogue scales are problematic because the 10-cm scales are subdivided into millimeters creating the impression of more precision than actually exists (Linacre, 1998).

Chapters 5 and 6 each contain a case study along with helpful author commentary. The cases show the sequence of intervention and the application of the authors’ guidelines. They illustrate how to use the ORS and the SRS so that they are closely integrated with intervention. We see that intervention is not “paint‑by‑the‑numbers” therapy, but requires one to draw upon skills of spontaneous creativity to develop, with clients, unique, individual solutions. Moreover, the two cases reveal the details of how collaborative efforts in a school setting work, which can be so unlike cases in a clinic. After all it was Murphy (1999) who had previously said, “Psychotherapy typically occurs in a one-to-one context involving a therapist and client, whereas requests for school-related change come in various shapes and sizes and encompass a wide range of services, service providers and contexts” (p. 364).

Chapter 7, written by Jacqueline Sparks, PhD, and new for the book’s 2^nd edition, critiques the extensive use of psychotropic medication with children. In the pursuit of decreasing possible naive confidence in the facile use of medication, the critique discusses four of the many possible threats to the internal and external validity of drug efficacy studies: adequacy of the control group, reliance on clinician‑rated outcome measures, the short course of medication trials, and bias from investigators financial conflicts. The author then recommends that even with medication, solution‑focused alternatives as illustrated in the chapter and book should be considered. This chapter stretches one’s thinking about the role of medication and how we as practitioners can intervene with children who are taking or will be prescribed psychotropic medication.

There is much substance to this book. All case material is realistic and accurately reflects the kinds of challenges faced with school referrals. The extended cases in chapters 5 and 6 are rich in the careful use of language necessary to set the tone for productive change. They compel re‑reading in order to appreciate the nuances of the practitioner‑client interaction in particular how questions are posed in order to develop change. Notably, through explanation and example the authors instruct practitioners how to elicit and benefit from negative client feedback. Perhaps in order to convince us of the merits of brief interventions, the authors describe mostly successful interventions. I wanted to read about a practitioner who has stumbled through an intervention to see what could go wrong and learn from that. However, I believe the authors have met their aim that the book will have “…immediate and practical assistance to you and your clients (p. xi).” Even though in schools we must often focus on student deficits, Murphy and Duncan show us how powerful change comes from identifying and expanding student assets.

References

Lethem, J. (2002). Brief solution focused therapy. Child and Adolescent Mental Health, 7, 189-192.

Linacre, J.M. (1998). Visual Analog Scales. Rasch Measurement Transactions, 12 (2), 639. Retrieved July 25, 2008, from http://www.rasch.org/rmt/rmt122s.htm.

Murphy, J. J. (1999). Common Factors of School-Based Change. In M. A. Hubble, B. L. Duncan, & S. D. Miller (Eds.), The heart and soul of change: What works in therapy. (pp. 361-386). Washington, DC: American Psychological Association Press.

Torrey, C. A. & Kendall, P. C (2005). Therapist alliance-building behavior within a cognitive-behavioral treatment for anxiety in youth. Journal of Consulting and Clinical Psychology, 73, 498-505.

About the Reviewer

Arthur S. Ellen, PhD, a school psychologist with the New York City Department of Education, has provided counseling as a related special education service. He has worked on integrating change into school settings. This always embraces the puzzle of simultaneously working with students, parents, teachers, and administrators.