Weighing up the evidence: A qualitative analysis of how person‐centred counsellors evaluate the effectiveness of their practice

Research into the effectiveness of counselling and psychotherapy has great practical significance, as a means of collecting evidence that may potentially enhance the quality of services delivered to users. In recent years, the evidence base for counselling and psychotherapy has increasingly relied on data derived from self‐report questionnaires completed by clients, with relatively little attention being paid to therapists’ evaluations of outcomes. To make full use of therapist estimates of outcome, it is important to develop an understanding of the processes and criteria that therapists employ when making such judgements. However, little is known about the evaluation strategies used by therapists in their everyday practice. The aim of the present study was to explore the implicit and informal construction of outcome evaluation by experienced practitioners. Person‐centred therapists were interviewed about their approach to evaluation. The interview data were analysed using a grounded theory approach. These practitioners reported that they engaged in a process of evaluation based on a range of different sources of evidence, which was then “weighed up”. Evaluation was a continuous activity that was embedded in the counselling process itself rather than arising from discrete measurements carried out at particular times. The findings of this study suggest that practitioners may possess a sensitivity to the complexity of outcome that is missing in much current research. Implications for training, research and practice are discussed.     

The experiences of counselling for persons with ME

A number of studies have evaluated counselling interventions for people with myalgic encephalitis, but few report client perceptions in any detail. This study seeks to explore client perceptions using a qualitative methodology. A sample of 25 individuals with myalgic encephalitis were interviewed about their experiences in counselling. The interviews were transcribed and subjected to thematic analysis using grounded theory principles. The analysis showed that people with myalgic encephalitis endure significant changes to their lives, often involving great loss and trauma. After seeking help through counselling, participants had experienced a wide variety of approaches and there were positive and negative perceptions of each. Other perceptions related to therapist characteristics and the way in which interventions were carried out. Recommendations for practitioners are given.     

A feasibility study of the systematic evaluation of client outcomes in a voluntary sector counselling agency

There is an increasing demand on voluntary sector counselling agencies to evaluate the effectiveness of their work with clients. A pilot study was carried out in a voluntary sector counselling agency to assess the feasibility of adopting a well‐established evaluation system (CORE) designed to measure client outcomes. The paper describes the issues and complexities involved in introducing such a system, and explores the impact of the evaluation on counsellors, staff and users of the service. It is suggested that evaluation can play an important role within voluntary organisations in enabling counsellors and staff to reflect on their work.     

How effective is workplace counselling? A review of the research literature

The provision of counselling for work‐related problems has expanded in recent years, as organisations have recognised the value of this approach to staff support. However, there has been relatively little research into the outcomes of workplace counselling, and no systematic reviews have been conducted into the effectiveness of counselling in this setting. This paper presents the results of a preliminary review of evidence in this area. 34 studies of the effectiveness of workplace counselling were identified, of which 16 were sufficiently well designed to be considered as comprising reliable findings. The results of these studies suggest that, in general, workplace counselling is effective for clients for a wide variety of type and severity of presenting problems, employed across a range of different organisational contexts. The paper includes discussion of methodological issues associated with this research, recommendations for further research, and implications for practice.     

Motivation as a predictor of outcomes in school‐based humanistic counselling

Background: Recent years have seen a growth in the provision of counselling within UK secondary schools, and research indicates that it is associated with significant reductions in psychological distress. However, little is known about the moderators and mediators of positive therapeutic benefit. In the field of adult mental health, motivation has been found to be one of the strongest predictors of therapeutic outcomes, and it was hypothesised that this may also be a predictor of outcomes for young people in school‐based counselling services. Aims: To assess the relationship between young people's motivation for counselling and its effectiveness within a secondary school setting. Sample: Eighty‐one young people (12–17 years old) who attended school‐based humanistic counselling services in Scotland. Method: Clients completed a measure of motivation for counselling at the commencement of their therapeutic work and a measure of psychological wellbeing at the commencement and termination of counselling. Results: Motivation for counselling was not found to be significantly related to outcomes. Discussion: The results indicate that the association between motivation and outcomes may be weaker in young people as compared with adults. However, a number of design factors may also account for the non‐significant findings: insufficient participants, marginal reliability of the motivation measure and social desirability effects.     

Oppression within the counselling room

This paper suggests that the oppression experienced by disabled people in society is sometimes replayed in the counselling room by counsellors who are unaware of their own disablist attitudes and prejudices. Whilst the provision of Disability Equality Training (DET) within counselling courses would ameliorate the problem, I believe that disabled people would be most empowered by a counselling approach which recognises the potential for oppression within the counsellor‐client relationship. One solution may be the creation of a new counselling approach (disability counselling) which includes the social model of disability as one of the foundations. An alternative solution may be found within the emerging counselling approaches that treat counselling as a social and political process and place emphasis on developing comprehensive anti‐discriminatory practice.     

Observing a client's grieving process: bringing logical positivism into qualitative grief counselling research

This positional paper originates from our need as researcher/practitioners to establish a meaningful epistemological framework for research into bereaved people's journey through loss and grief over time. We describe how the field of grief research has a long and established biological basis, in keeping with a positivist epistemology. However, there has been a diminution of the influence of logical positivism in twenty-first-century counselling research. We argue that in grief counselling research, naturalistic observation of the grieving process within a logical positivist paradigm, remains a valid and valuable construct. We posit an observational protocol for the grief counselling process which minimises the intrusion of research method into the therapeutic process. We offer this as a means of conducting qualitative research within a bereavement counselling service. Further, we suggest that the development of an observational protocol for a client's grieving process has potential implications for developing good practice in grief work.     

Explorations of the effectiveness of a voluntary sector psychodynamic counselling service

This paper reports two studies of individual psychodynamic counselling provided by a voluntary sector service. The first study examines evidence of the effectiveness of counselling, as evaluated by the General Health Questionnaire and Personal Opinion Survey. Measures of the process of counselling indicated the improvements that clients attributed to counselling, the changes that occurred during it, and the factors that were most beneficial, as well as the approaches used by counsellors. The second study, using the CORE Outcome Measure and ratings of problem severity, found counselling to be equally effective with disadvantaged and non‐disadvantaged clients, as defined by British Department of Health criteria, but these clients differed somewhat in their perceptions of helpful aspects of counselling. Both studies also indicated predictors of positive outcome of counselling. The studies are used to illustrate some of the methodological issues around research in this area.     

The effectiveness of workplace counselling: A systematic review

Background: In response to the stresses of the contemporary workplace, the challenges of maintaining satisfactory work-life balance, and the costs to business of employee mental health problems, many organisations have contracted to make counselling services available to their staff. It is essential to evaluate the effectiveness of workplace counselling, in order to maintain standards, and to identify examples of good practice. Objectives: This paper presents a comprehensive, systematic review of the effectiveness of workplace counselling. Findings are analysed in terms of client satisfaction, psychological functioning, the meaning of work, work behaviour, and negative outcomes. Findings: Taken as a whole, the results of research suggest that counselling is generally effective in alleviating psychological problems, has a significant impact on sickness absence, and has a moderate effect on attitudes to work. Discussion: Methodological issues are discussed, and it is recommended that more high-quality research is required in order to reinforce the evidence base for workplace counselling in relation to a number of key questions.     

Between the idea and the reality: A study of the counselling experiences of bereaved people who sense the presence of the deceased

There have been many theories of the process of loss and bereavement, from Freud, to the present day. Early theories of bereavement described a process which, following various stages and associated tasks, ended at the relinquishment of the bond to the deceased. In more recent years theories have taken different directions, identifying how bereaved people re‐learn life, recreate biographies, and continue relationships to the deceased. Some research studies of bereavement have investigated the counsellors’ perspective, but there are very few studies of the client's experience and most studies have focussed on outcomes of counselling. This qualitative study, using semi‐structured interviews, provides an insight into the bereaved client's perspective on the content and process of their counselling experiences. Taking as its focus the client's sense of the presence of the deceased, this study aimed to identify whether or how counsellors facilitate exploration of this experience and which theories they use in client work. The main finding is that 80% of the counsellors were not perceived by participants to have worked with them satisfactorily in relation to their sense of presence of the deceased or in relation to the story of the death itself.     

A follow‐up study of the long‐term effects of counselling in a primary care counselling psychology service

Despite much recent work examining the short‐term effect of counselling in primary healthcare settings, to date relatively little research has examined the effectiveness of such treatment programmes over the longer term. In this study, 58 participants underwent brief, time‐limited integrative counselling sessions, with symptoms being measured using the CORE‐OM immediately before, immediately after, and 30 months after counselling. It was found that in addition to participants reporting significantly lower levels of psychological distress immediately post‐counselling, a further significant improvement at 30‐month follow‐up was also apparent, indicating that the benefit from counselling was maintained. In addition to this reduction in symptoms post‐counselling, a significant reduction in GP visits was also detected in the 12 months following counselling when compared with the 12 months prior to counselling, indicating a lower reliance on the primary healthcare team after counselling.     

The effectiveness of counselling with older people: Results of a systematic review

In 2003 the British Association for Counselling and Psychotherapy (BACP) commissioned a systematic review of the research evidence relating to counselling older people. This paper reports on some of the findings of this review, particularly those which address the effectiveness of counselling with this population. Electronic searches of the research literature spanned six databases and were supplemented by hand‐searches of reference lists and key journals, along with an extensive search of the “grey” literature. The location of papers testing interventions which fall within a definition of counselling set out by the BACP, with samples aged 50 years of age or above resulted in the inclusion of 47 relevant studies. Studies investigated a variety of mental health problems in older people, particularly depression, anxiety, dementia and the psychological impact of physical conditions such as chronic obstructive pulmonary disease. Of the 47 studies, eight tested counselling as a generic treatment, 15 tested cognitive behavioural therapy, 13 tested reminiscence therapy, and 11 tested various other specific approaches. The review concluded that counselling is efficacious with older people, particularly in the treatment of anxiety and depression and outcomes are consistent with those found in younger populations. Evidence as to the efficacy of counselling interventions in the treatment of dementia is weak.     

Considering methodological integrity in counselling and psychotherapy research

Within the field of counselling and psychotherapy research, qualitative methods have been a longstanding tradition of inquiry due to the mutual interest of therapists and researchers in both internal experiences and intersubjective processes. Methodological integrity is a conceptual framework that has been advanced to increase the rigor of these methods. In this paper, we consider the value of this concept for counselling and psychotherapy researchers and reviewers. This framework guides investigators and reviewers to consider how procedures can be adapted to meet the goals of specific studies, given their characteristics and approach to inquiry. In this brief article, we exemplify the relevance and application of this concept to this field by describing the decision‐making process within the designing of a qualitative research project to investigate clients' needs within rape crisis counselling. Through this exemplar, we also provide guidance to counselling and psychotherapy researchers on considerations during the process of research review and reporting.     

Voluntary sector counselling: Has inadequate research resulted in a misunderstood and underutilised resource?

Although much counselling already takes place in the voluntary sector, little is known about the nature of the work being done or about its effectiveness or the training and experience of its practitioners. Given the gap between the demand for and supply of psychological therapies in Britain today, lack of research into the effectiveness of this work could mean that a valuable resource is being under‐utilised. This paper describes a study of a large, generic counselling centre and, using the CORE monitoring and evaluation system, makes comparisons between its work and that of a number of NHS psychological therapy services. It shows; that it is of at least as complex or severe a nature; and that it is as effective. It also shows that the therapy carried out in this agency is done by appropriately qualified and experienced practitioners.     

Young clients' narratives of the purpose and outcome of counselling

This study explores how adolescent clients construct the purpose and outcome of counselling. A narrative analysis was performed on interviews with 22 clients (aged 16–18) who had used a school-based counselling service. The aim was to identify the purpose and outcomes that participants attributed to their counselling experience. The analysis identified four narrative forms that young clients used to describe counselling. These included ‘transformative’, ‘supportive’, ‘pragmatic’ and ‘disappointed’ narratives. Each narrative form constructed a different purpose and outcome for counselling. Engaging with clients' narratives about the purpose and intended outcome of counselling may allow counsellors to better match their expectations and approach to fit with their young client or to work with them to co-construct more flexible narratives that support helpful outcomes.     

Introduction to the Special Section ‘Innovative counselling and psychotherapy research methods’: Defining the future of counselling and psychotherapy research

In the call for papers for this Special Issue, we sought submissions that would introduce innovative methods with the potential to shape counselling and psychotherapy research into the future. We believe that we accomplished this goal and that this issue introduces a range of valuable examples of current innovations in counselling and psychotherapy research methods. Through the review process, we encouraged authors to offer practical guidelines on how to innovatively assess and analyse change and other relevant aspects of therapy. We also guided authors to not only provide the field with an update on cutting‐edge methodology, but also describe these methods in a practice‐friendly way. As such, the Special Issue aims at becoming a building block for future practice‐friendly research in counselling and psychotherapy.     

Genetic counselling: Predicting patient outcomes

Abstract

With the rapid development of genetic testing, the demand for genetic counselling is increasing. Yet there is little known about what makes for effective or efficient genetic counselling. The aim of the current study is to determine the main factors influencing outcomes of genetic consultations. One hundred and thirty one routine consultations conducted in a regional genetics centre were audiotaped, transcribed and coded. The main predictors of outcome tested were pre-interview patient and counsellor expectations; pre-interview patient concerns; length of consultations; counsellor directiveness; and the extent to which social and emotional issues are addressed in the consultation. The main outcomes were the patient's view of the extent to which their expectations were met, their satisfaction with information provided, and concern about the problem they were referred with.

Although there were six significant correlations between the process of consultation and outcome variables, multivariate analyses revealed no significant predictors of any of the outcomes. Using multiple regression analyses, small amounts of variance in patient outcomes were predicted by patient and counsellor variables assessed before the consultation, but none was predicted by any of the process measures made of the consultation. Various explanations are considered to explain the lack of influence of process variables upon outcomes. One possible explanation for these findings is that the consultation has a minimal effect upon patient outcomes. Alternatively, the study, in design or analysis, was not sufficiently sensitive to detect the influential aspects of the consultation.     

Action and language: Contextual action theory in counselling

Contextual action theory is presented as a conceptual framework useful for grounding the recent work in counselling and career development called Life Design. Based on the premise of the goal-directed nature of human action, this approach has links to language in theories of naive action and attribution, and theory of mind. Contextual action theory has an associated research method that has been used to generate a range of research studies that have described actions and projects in the career development and counselling domains. The link that contextual action theory provides between research and practice allows the identification of five tasks for the counselling practitioner informed by this approach.     

Introducing humanistic group counselling for somatisation in a primary care practice: Preliminary findings

Can group counselling help patients who present with symptoms that cannot be explained medically? Preliminary results of working with one such group are reported. Six patients in a primary care practice were offered weekly sessions for half a year. The findings suggest that the patients attended all group sessions. The patients reported experiences known to be related to group counselling, and when the group ended, patient reports show that the severity of their problems was reduced significantly (p<.001). Furthermore, during the six months after the group ended patients significantly (p<.025) reduced their visits to their general practitioners. These results seem to call for wider use of humanistic group counselling with somatising patients and further research into the impact of such form of counselling.