Practice‐based evidence in school‐based counselling

Aims: Counsellors are becoming commonplace within the support structures of secondary schools. To date, research findings from practice‐based outcome studies suggest this is a positive move. There are, however, numerous limitations to this work, and this project aims to develop this existing body of literature. Method: Nine 13–15 year olds attending counselling in six school‐based services participated in the project – one individual withdrew. A standardised self‐report questionnaire (YP‐CORE) was collected at four intervals: (1) the point of referral; (2) the onset of counselling; (3) the completion of counselling; and, (4) a two‐month follow‐up. The change indicated in each of these phases is examined and reported here. Additionally, YP‐CORE was completed during each session. Findings: The YP‐CORE indicates an improvement in the well‐being of this small sample, while waiting for and attending therapy. Further examination of session‐by‐session data also highlights how pre‐ and post‐outcome data should not necessarily be viewed as linear in nature. Discussion: This is a small‐scale investigation and further work is needed in this area. It does, however, raise a number of issues regarding the complexity inherent in conducting outcome research that warrant further investigation.     

School‐based humanistic counselling for psychological distress in young people: A practice research network to address the attrition problem

Aims: School‐based humanistic counselling (SBHC) is a common psychological intervention for young people, particularly in the UK. However, studies have tended to suffer from high attrition rates, such that effects may have been over‐estimated. This paper describes a low budget ‘star topology’ practice research network (PRN) outcome evaluation of SBHC in a sample where attrition rates were minimised. Design: A practice‐based longitudinal study in a small PRN compared levels of psychological distress at first and last session from session‐by‐session data. Multilevel regression modelling was used to identify predictors of outcomes. Methods: Eight counsellors working across 11 schools agreed to use session‐by‐session self‐rating on the Young Person's CORE (YP‐CORE) yielding data from 256 young people aged 11 to 17. Predictors of outcomes were analysed using multilevel regression analysis. Results: Mean levels of distress on the YP‐CORE reduced from 18.29 (SD = 7.32) at baseline to 9.10 (SD = 6.19) at endpoint, giving a baseline to endpoint effect size of 1.26 (95% CI = 1.06–1.46). Lower levels of psychological distress at endpoint were associated with male clients, younger age groups, greater rates of attendance at counselling, and bereavement as a presenting problem. Conclusions: This ‘star topology’ PRN focused on a single study and demonstrated that such a system can provide relatively low cost, high quality data. The data showed that SBHC is associated with large reductions in psychological distress, and that this cannot be attributed to the high attrition rates of previous datasets.     

Therapist orientation,supervisor match,and therapeutic interventions: Implications for session quality in a psychotherapy training PRN

Background: Theoretical orientation is a multifaceted construct that is integral to the process of psychotherapy and psychotherapy training. While some research has been conducted on personal identification with particular schools of psychotherapy, techniques used in psychotherapy sessions, and match between trainees and supervisors in training, there is insufficient information regarding how these may interact with one another. Aim: This study, conducted in a practice research network of trainee therapists, was designed to test whether these variables may be related to one another in predicting session quality. Method: The sample comprised 328 sessions from 26 clients and 11 therapists, with the clients completing session quality measures and therapists completing measures of technique immediately post‐session. Results: Using multilevel linear modelling, the data showed varied results. For behavioural therapy and person‐centred therapy, techniques and orientation were unrelated to session quality in the sample. However, process‐experiential, psychodynamic, and cognitive therapy techniques were all involved in interactions with therapist and/or supervisor orientations. Conclusions: These results suggest that the impact of specific psychotherapy techniques sometimes depends on the orientation of the therapist and/or supervisor. For instance, sessions high in cognitive therapy techniques were only associated with positive outcome when both the therapist and supervisor were highly cognitively oriented. Though preliminary, these results suggest that orientation may be an important variable to consider in training and supervision, especially in the context of other variables.     

Managing boundaries under pressure: A qualitative study of therapists’ experiences of sexual attraction in therapy

Aim: To identify therapists’ views on sexual boundaries and the strategies they employ to manage them in therapeutic practice. Method: In‐depth qualitative interviews were conducted with a sample of 13 accredited, experienced practitioners of psychotherapy or counselling. A grounded theory approach, informed by principles from Free Association Narrative methodology, was employed, in which team members used debriefing sessions for extending depth of understanding of the interviews. Findings: There is consensus about boundaries at the extremes, but variability about fantasy, flirtation and touch. A core process was generated from accounts of successful management of sexual attraction. We identified four problematic ways of reacting to boundary pressure, each with potential to harm clients and therapy. Discussion: A participant‐observer stance was conceptualised as essential for managing threats to boundaries, consistent with the empathic stance. Minor boundary crossings were viewed by interviewees as both potential precursors of more serious transgressions, and as opportunities for understanding the client's difficulties. Implications for practice: These span training, accrediting organisations, supervision and therapy practice.     

‘The third person in the room’: Recording the counselling interview for the purpose of counsellor training – barrier to relationship building or effective tool for professional development?

Objective: Audio and videotape interview recording for training and supervision in counsellor education is commonplace within New Zealand, yet researchers have paid little attention to its value perceived by students. This study explores counselling students’ perceptions of the effects of recording counselling interviews on themselves, their clients and on the counselling process. Design: Counselling students from five tertiary educational settings in New Zealand participated in individual or focus group interviews to discuss their experiences of recording counselling interviews. Findings: All interviewees indicated that recording initially curtailed their ability to be completely present in the counselling interview. Some thought this may have negatively influenced their clients’ ability to use the counselling session effectively. Most noted their own increased confidence over time. Almost all considered recording to be extremely beneficial to the development of effective counselling skills. Conclusion: Most students considered the benefits of recording to outweigh the drawbacks. Implications for continuing the practice of recording and playing back interviews in counsellor‐education programmes are considered.     

The experiences of therapists using a new client‐centred psychometric instrument,PSYCHLOPS (Psychological Outcome Profiles)

PSYCHLOPS (‘Psychological Outcome Profiles’) is a newly developed client‐generated psychometric instrument which can be used as an outcome measure. Uniquely, it asks clients to state their own problems, in their own words. As part of its validation, we used it alongside an existing measure, CORE‐OM (‘Clinical Outcomes Routine Evaluation – Outcome Measure’). Based on a qualitative methodology, we report here on the first‐hand experiences of four therapists using both instruments. The key themes that emerged from therapists’ responses were feasibility, validity and usefulness. Both questionnaires were perceived as complementing each other, the qualitative information from PSYCHLOPS balancing the quantitative information from CORE‐OM and that both could contribute to the therapist‐client interaction. The key features of PSYCHLOPS are likely to prove attractive to therapists and should increase acceptance and uptake of outcome measures.     

Person‐Centred and Experiential Psychotherapy Scale: Development and reliability of an adherence/competence measure for person‐centred and experiential psychotherapies

Aims: This study aimed to assess the reliability of the Person‐Centred and Experiential Psychotherapy Scale (PCEPS), a new adherence/competence measure of person‐centred and experiential psychotherapies. The PCEPS consists of 15 items with two subscales: Person-Centred Process and Experiential Process. Method: One‐hundred twenty audio‐recorded segments of therapy sessions were rated independently by two teams of three raters using the PCEPS. Half of the segments were 10 minutes long and the other half were 15 minutes long. Six therapists were experienced therapists and four were counsellors in training. Seven of the therapists identified their work as ‘person‐centred’, and three identified their work as ‘process‐experiential’. Three raters were qualified and experienced person‐centred therapists and three raters were person‐centred counselling trainees in their first year of training. Results: Interrater reliabilities were good (alpha: .68–.86), especially when ratings were averaged across items (alpha: .87); interitem reliabilities were quite high (alpha: .98). Exploratory factor analyses revealed a 12‐item facilitative relationship factor that cuts across Person‐Centred and Experiential subscales (alpha: .98), and a nonfacilitative directiveness factor (3 items, alpha: .89). Conclusions/Implications: The PCEPS has potential for use in RCT research as well as in counselling training and supervision, but will require further testing and validation.     

A systematic review of the literature on counselling and psychotherapy for the prevention of suicide: 2. Qualitative studies

Scope of review: The paper reports a meta‐synthesis of 13 qualitative studies of counselling and psychotherapy with people at risk of suicide. Publication time span: The studies considered were reported between 1997 and 2006. Publication origin: Seven studies were conducted in the UK, four in the USA, one in Canada, and one in Sweden. Findings: Themes in clients' and therapists' accounts of the process of counselling or psychotherapy were therapist qualities; therapy components; theoretical framework; and therapy techniques. Themes in their accounts of the effectiveness of counselling and psychotherapy were decrease in self‐destructive behaviour, and quality of life. Themes in clients' views of barriers to effective counselling or psychotherapy were therapist characteristics; therapy components; secrecy; and transferring to the real‐life situation. Secrecy was also identified as a barrier by therapists, as were responsibilities of the profession; training; and the nature of suicide and self‐harm. Facilitators of successful counselling and psychotherapy as identified by clients were responsibility; support; and teaching therapy skills to family members, the latter also being identified by therapists.     

Intimate boundaries: Therapists’ perception and experience of erotic transference within the therapeutic relationship

Aim: This study explored therapists’ understanding and experiences of erotic transference within therapeutic relationships. Method: A small‐scale qualitative research project was undertaken with six therapists working within different counselling contexts. Data was collected through semi‐structured face‐to‐face interviews, and an Interpretative Phenomenological Analysis used for analysis of individual perception and experience. Findings: All participants had experienced what they understood to be erotic transference and/or sexual and loving feelings within therapy. There was little differentiation between the two phenomena, and both were often referred to interchangeably. There were contradictory views as to whether using the phenomena would be beneficial to client work, but there was a strong motivation to learn more about it. Therapists who encountered sexual attraction within therapy experienced feelings including shame and embarrassment. Supervisory support was seen to be beneficial. Implications/conclusion: The importance for therapists to acknowledge a lack of clarity that exists around the understanding of erotic transference and its relationship to sexual attraction within therapy is noted. Also, a recognition that better access to training regarding erotic transference and sexual responsibility within client relationships might be helpful to therapists in their work.     

Practice‐based supervision research: A network of researchers using a common toolkit

Aim: Given that various systematic reviews of supervision literature have revealed how little is known about supervision, that studies are not usually routed in practice, and that a multitude of diverse measures are used, the primary aim of this project was to support and encourage practitioner research related to supervision using a prescribed common set of instruments. Method: Funded by the British Association for Counselling and Psychotherapy (BACP), a Supervision Research Practice Network (SuPReNet) was established. A toolkit (a series of measures) that could be used routinely by practitioners was selected following the assembly of available measures of supervision and an assessment of them. Findings: The appraisal, conducted by the three authors, yielded five core measures, free for anyone to use, and accessible through the SuPReNet website. The measures are being piloted through a practice research network at a university counselling and psychotherapy research clinic where supervision data are being collected through a special module of CORE Net. Discussion: The potential yield from this initiative for practitioners, researchers, and the developing evidence‐base is discussed and a model proposed for the next generation of research on supervision.     

Quantitative and qualitative analysis of a set of goal attainment forms in primary care mental health services

Aims: The aim of this paper is to present an attempt to collate the results of the client‐completed Goal Attainment Form (GAF) and to explore the usefulness of analysing the data in this way. The GAF is used primarily to add qualitative idiosyncratic data to the quantitative data collected by the CORE‐OM (Clinical Outcomes for Routine Evaluation Outcome Measure) questionnaire. Method: A sample of 477 completed GAF were used during short‐term therapy through primary care mental health services to investigate potential correlations in various different aspects between the GAF and the CORE outcome measure (CORE‐OM). The themes from these forms were qualitatively analysed to compare how clients describe their experience of therapy with clinical perspectives. Results: The results reveal several significant correlations. Themes used by clients to describe their problems and benefits of therapy were different from clinicians' perspectives. Discussion and recommendations: Several suggestions and recommendations are offered regarding evaluation, therapy and primary care short‐term therapy services.     

Therapeutic outcomes in the Welsh Government's school‐based counselling strategy: An evaluation

Aims: The purpose of this study was to evaluate the outcomes of school‐based counselling, as delivered in the Welsh Government's School‐based Counselling Strategy, for reducing psychological distress in young people aged 11–18. Method: The study used a quantitative cohort design, comparing levels of distress on either the Young Person's CORE (YP‐CORE) or the Strengths and Difficulties Questionnaire (SDQ) from baseline to endpoint. Data were available on 3613 episodes of counselling, across 42 datasets. Meta‐analytical procedures were used to identify the mean effect size and predictors of outcomes. Results: Within each dataset, counselling was associated with significant reductions in psychological distress, with a mean effect size (d) of 0.93(95% CI = 0.89–0.97) using a fixed effects model and 1.09 (95% CI = 0.97–1.22) using a random effects model. Datasets using the YP‐CORE had larger effect sizes than those using the SDQ, and datasets with more complete response rates had lower outcomes than those with poorer response rates. Conclusion: The results confirm that school‐based counselling, as delivered in the UK, is associated with significant reductions in psychological distress, comparable to adult counselling and psychotherapy services.     

‘A baptism of fire’: A qualitative investigation of a trainee counsellor's experience at the start of training

Background: Belief in the effectiveness of professional counselling and psychotherapy training is widespread and generally unquestioned. Few studies have attempted to understand the changes experienced by trainees, or identified which aspects of professional training programmes assist them in the process of becoming therapists. Aims: to investigate how a trainee counsellor changes at the start of training, and to identify which aspects of a professional counsellor training programme were helpful in instigating and supporting change. Method: the experience of one trainee counsellor, Margaret, was captured through three semi-structured interviews conducted at the beginning, middle and end of her first term. The data were subjected to systematic qualitative analysis. Findings: Margaret experienced significant change during her first term. Each interview revealed a different phase of her development. The core categories were: becoming something new (week 3); growth in therapeutic confidence (week 6); surviving ‘stressful involvement’ through supervision (week 11). Experiential learning, in particular group supervision, was helpful throughout. The presence of real clients was identified as the main driver for change. Conclusion: The findings were found to be consistent with a number of other studies, which suggest that training is potentially painful because of the emotional demands it places on trainees, particularly at the start of practice. Consequently trainees require opportunities for experiential learning, peer support and supportive supervision to assist them in their development, but most importantly, given that supportive supervision can only minimise the harm of stressful involvement (Orlinsky & Ronnestad, 2005), they need early positive experiences with clients.     

Client perspectives: The therapeutic challenge of domestic violence counselling – a pilot study

Aims: This qualitative pilot study explored the perceptions of four female domestic violence clients regarding counselling they had concluded in order to identify a preliminary client‐preferred domestic violence counselling approach. Method: Semi‐structured interviews asking about significant events during counselling were held. An adapted grounded theory and narrative methodology was used. Results from the analysis were reviewed with two of the participants. Participants were offered additional counselling support if required after the research interview. Results/Findings: Domestic violence clients found starting counselling particularly difficult after years of keeping the abuse to themselves. Participants actively withheld and managed information for several sessions and needed to know they had time to explore their experiences. The counsellor being consistent and non‐judgemental, and understanding domestic violence and its effects was helpful. Having a clear ending was appreciated by the participants. Discussion: The initial development of the therapeutic relationship benefited from active discussion of how domestic violence could affect behaviour and emotions. Good early therapeutic relationships showed elements of the three main psychological schools. Participants benefited from a pro‐active discussion of endings. A key limitation of this research is the small sample size. Implications for practice: The research suggests that counsellors would benefit from knowledge and skills from different psychological schools and specific training in domestic violence. Allowing flexibility on the number of sessions available to clients may be helpful. Conclusions: Further work is required to explore these preliminary findings. However, early indications suggest that domestic abuse clients may benefit from non‐time‐limited specialist counselling services.     

A discourse analysis of power in relation to PSYCHLOPS (Psychological outcome profiles) in the context of CBT for psychosis

Aims: Outcome measures (OMs) and routine change measurement have developed dramatically in psychological therapies over the last two decades and some therapists have expressed concerns that this, depending on how it is handled by the parties involved, can markedly affect the therapy. However, little research has investigated this. It therefore seemed timely to explore discourses of OMs drawn upon by both parties in the therapy room. Method: PSYCHLOPS (Psychological Outcome Profiles) is a client‐centred measure which offered an opportunity to explore how therapists and clients receiving CBT for psychosis talked about OMs. A useful contrast was provided by the CORE‐OM (Clinical Outcomes in Routine Evaluation‐Outcome Measure). The discourses drawn upon by clients (n=4) and therapists (n=4) were analysed, informed by a Foucaultian framework. Results: OMs were constructed as empowering or disempowering of clients, as being able to do therapeutic work of engagement and containment, and as part of the apparatus of service power, positioning therapists as relatively powerless to question their use. Discussion: It is suggested that client‐centred measures like PSYCHLOPS, although partly aligned with a recovery framework, may become part of top‐down state and service power, and there is a need for more research into the different ways in which OMs are used in therapy and the impacts on therapists, clients and their relationships.     

An outcome evaluation study of a psycho‐educational course in a primary care setting

Rationale: To date relatively little research has examined the effectiveness of psycho‐educational courses provided in a primary care setting to adults with mild‐to‐moderate mental health concerns. Aims: To determine whether group psycho‐education could be a viable alternative to individual counselling by (1) assessing the clinical effectiveness of an 8‐week psycho‐educational course, and (2) examining the group outcomes in comparison with individual treatment outcomes from a previous study in the same counselling service. Method: A total of 57 participants attending a psycho‐educational course provided data over a 36‐month period, using the Clinical Outcomes in Routine Evaluation – Outcome Measure (CORE‐OM) pre‐ and post‐intervention. A comparison was then made with the data of 58 previous participants of individual counselling evaluation, using the same CORE‐OM system. Results: Participants reported significantly lower levels of psychological distress after attending the course and these results are comparable to outcomes measured in the same service for individual counselling, indicating that group interventions could be considered a legitimate alternative to individual counselling, thus increasing cost effectiveness and reducing waiting times. Limitations of the study and implications for practice and further investigation are considered.     

Repurposing process measures to train psychotherapists: Training outcomes using a new approach

Aims: First, this paper presents the rationale for a novel approach to training counsellors in which measures for psychotherapy process research are taught to students before moving on to teaching basic empathic reflections and interventions. The rationale for this is that client process measures can be re‐purposed to help orient and sensitise trainees to key in‐session moments. Second, we present a training outcome study that assesses the effectiveness of this approach. Method: Using an experiential‐integrative therapy approach, a 13‐week training program was used to teach psychotherapy skills and process research measures to22 clinical graduate students taken from two cohorts. As part of the course, trainees conducted several single sessions with volunteer clients on four separate occasions. Training outcomes were measured using both trainee and client reports. Results: Compared to baseline, therapists reported significant and steady gains (all p's<.05) in session management, reducing their anxious self‐awareness, and in improved sense of self‐efficacy, with the latter having the largest effect (partial Eta Sq.=.381). Discussion: While the findings provide some support for a new training strategy, a dismantling design is needed next to more closely examine the process‐measure approach to training.     

An initial study of transgender people's experiences of seeking and receiving counselling or psychotherapy in the UK

Background: There are no published empirical research studies exploring transgender people's experiences of seeking and receiving counselling or psychotherapy outside of gender identity clinics within the UK. As a result, counsellors know little about why transgender people seek counselling, who they seek counselling from, and what their experiences are of receiving counselling. Aim: To address this gap in the literature, this study investigated transgender people's experiences of seeking and receiving counselling or psychotherapy outside of gender identity clinics within the UK. Funding for this study was provided by a BACP Seedcorn grant. Method: A mixed method small‐scale qualitative research design was employed, comprising an online survey and five semi‐structured interviews. Findings: Participants tended to seek counselling on two or more occasions and received between 2 and 12 sessions. Participants sought counselling for common psychological concerns as well as gender identity and coming out issues. A fear of being discriminated against and exploring gender for the first time were significant barriers in seeking help. Participants reported mixed experiences of counselling but valued a therapeutic relationship in which they felt affirmed, listened to and understood. Discussion: The findings from this study mirror aspects of previous research conducted in the USA concerning transgender clients' experiences of counselling. However, these findings point to the importance of recognising the potential vulnerability transgender clients experience when seeking counselling and the need for therapists to develop greater awareness, knowledge and competence regarding working with transgender clients.