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.     

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.     

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.     

Avatar‐based counselling for young people within school counselling. Qualitative analysis of client experience

Background

This study is a qualitative analysis of clients’ experiences of a new avatar based counselling intervention, based on the ‘ProReal’ software ( www.proreal.world ). The intervention was piloted in eight secondary schools in the UK in 2016.

Aims

Twenty‐nine participants (53% of the full sample) were interviewed about their use of the software, experience of the intervention, process of change and views about its helpfulness.

Materials and Methods

Interviews were semi‐structured and were analysed using thematic analysis.

Results

The analysis shows that the intervention was potentially attractive to these clients, particularly those enthusiastic about digital software and clients who found visual communication helpful. The software provided additional opportunities for clients to communicate their inner worlds to the counsellor and supported the development of insight. Male clients, in particular, commented on its helpfulness.

Discussion

There is an indication that digital imagery supported the process of change in counselling and the development of meaning bridges: both internally and with the counsellor (Stiles, 2011; Stiles et al., 1990). However, the software could be experienced as an obstacle when clients wanted to talk about specific problems or ‘vent’ their feelings. All clients who reported that they did not find the software helpful were female. There were a number of suggestions about developing the software to increase opportunities for expression as well as appropriateness for clients from different minority ethnic backgrounds.

Conclusion

Use of digital software in counselling has a potential to enhance communication and support a process of change, particularly with male clients, those who find visual communication helpful, and clients enthusiastic about digital technology. Further research is needed to develop the intervention and compare it to the use of other creative media in counselling.     

Pilot randomised controlled trial of counselling in a community mental health setting: Pitfalls and learnings

The establishment of counselling and psychotherapy as “evidence‐based” interventions is contingent on the effective implementation of randomised controlled trials (RCTs) in real‐world clinical settings. This paper identifies some of the pitfalls that led to the termination of a practical RCT in a community mental health setting. It reflects upon the significance of the lessons learned by drawing on similar challenges that are documented in the wider literature. Issues surrounding staff turnover, counsellor engagement and procedural clarity are discussed, as is the conflict between the time required for research procedures and counsellors’ clinical time constraints. In our recommendations, we recognise the decisive role of collaboration and counsellor motivation in research partnerships, and the significance of clinical relevance, communication, training and research co‐production in achieving them. Time commitment is identified as the pivotal challenge in the formation and maintenance of collaborative research, but one that also must be overcome for the advancement of the counselling and psychotherapy field.     

Reflecting on Maltese school‐based counselling practices: An autoethnographic collaborative writing project

Maltese counsellors working in schools are, at times, just making ends meet due to lack of human resources and work schedules. ‘Why do our students/children have to repeat the same story to so many professionals?’ teachers/parents angrily query. This autoethnographic study voices our professional experiences as authors and participants. This empowers us to be advocates for our young clients. Collaborative autoethnography (CAE) methodology best fits our research question as we ‘seek to discover and systemically analyze (graphy) personal experience (auto)…understand cultural experience (ethno)’ (Ellis, Adams, & Brochner, 2011, p. 273). Our writing and reflections conclude that best practices include counsellors who work, at least, in pairs within transdisciplinary teams at one school for cycles of five years, with clarity of roles across professionals.     

The role of randomised controlled trials in developing an evidence‐base for counselling and psychotherapy

Background: Representatives of counselling and person‐centred organisations indicate many of their members feel their profession and orientation is under threat, with counselling services being decommissioned in NHS settings. Aims: To understand the views of key figures in the psychological therapies field (policy makers, researchers and representatives of the counselling community) towards randomised controlled trials (RCTs), and their present and future role in developing the evidence‐base for counselling and psychotherapy. Method: Interviews (phone, Skype or face‐to‐face) were conducted with 24 authorities in the field. Relevant practitioner and academic networks were also contacted and key documents in the field were reviewed. Results: Key figures believe that RCTs will continue to play a decisive role in determining which psychological interventions are recommended and commissioned within the NHS for the foreseeable future. Other methods are seen as having some validity, but are generally considered supplementary to RCTs and not a replacement for them. Discussion: Although many members of the counselling community are critical of RCTs, they are likely to remain the mainstay of commissioning policy for some years to come. This means, in the coming years, members of the counselling community may face difficult choices in how to promote their work, while maintaining their core principles and values.     

“She was on my side,and grounded me when I needed it:” Research supervision in the field of therapy,based on counsellors’ and psychotherapists’ views on their engagement with research

Research‐supported practice is increasingly emphasised within counselling and psychotherapy at all stages of training. Guided by an interest in how to support therapists in their efforts to develop research knowledge during doctoral training, this paper focuses on research supervision. Research supervision is a surprisingly under‐researched area. Little is known to date about how supervisors “go about their supervision” (Bruce & Stoodley, 2013, p. 5), despite the fact that “high failure rates for research dissertations in the social sciences have been partly attributed to student dissatisfaction with supervision and poor student–supervisor relationships” (Armstrong, 2004, p. 134). Between 2016 and 2019, we explored accredited counsellors' and 'psychotherapists engagement with research during or after their doctoral training. This paper explores research supervision with these two previous studies serving as the backdrop (Bager‐Charleson et al., 2018; Bager‐Charleson et al., 2018b), together with a literature review into research supervision within social sciences and psychotherapy. Supervision is discussed as a crucial coping/support strategy to (a) link research with practice in therapy work, practically and epistemologically; (b) contain and make sense of the use of transformative learning; (c) balance “enculturation” with critical thinking and emancipation; and (d) support reflective and reflexive development. This paper discusses an adaptive research supervision model, akin to a “holding bond” (Stevens, 2016) which supports the student to reflexively position her/himself personally, intersubjectively, theoretically and socio‐culturally, whilst “negotiating the tension” (Lee, 2008) during a process of enculturation into the discipline, and also fostering critical thinking and emancipation to contribute to new knowledge.     

Qualitatively driven mixed‐methods approaches to counselling and psychotherapy research

Many researchers and clinicians take an ‘either, or’ position regarding factors responsible for change when conducting research. Qualitatively driven mixed methods privilege the qualitative approach and offer the opportunity to generate multi‐dimensional material, permitting a more holistic insight into experiences that can be understood from a combination of epistemological and ontological stances. A qualitatively driven mixed‐methods approach apply a ‘both, and’ position when exploring the elements that produce change or that are under investigation, which can be of particular value to counselling and psychotherapy research. There are various ways of engaging with qualitatively driven mixed methods. Some designs include both qualitative and quantitative components, where the former is the core element. The secondary component may also be qualitative, known as a multimethod design. Yet, other designs mix different qualitative approaches, through the application of different qualitative analyses to the same data (pluralistic qualitative research). This paper discusses the application and value of qualitatively driven mixed methods in counselling and psychotherapy research through the presentation of two research case studies; one which mixes both qualitative and quantitative components to investigate the experiences of pain alleviation following a CBT pain management programme; and one which applies a pluralistic approach to a counselling psychology doctorate exploring the experiences and meanings attached to self‐harming. Through illustration and discussion of the case studies’ mixed‐methods approaches, this paper demonstrates that qualitatively driven mixed methods produce a more enhanced and holistic understanding into phenomena, and therefore a more balanced perspective to counselling and psychotherapy research.     

Using time‐lagged panel data analysis to study mechanisms of change in psychotherapy research: Methodological recommendations

The introduction of novel methodologies in the past decade has advanced research on mechanisms of change in observational studies. Time‐lagged panel models allow us to track session‐by‐session changes and focus on within‐patient associations between predictors and outcomes. This shift is crucial as change in mechanisms inherently takes place at a within‐patient level. These models also enable preliminary casual inferences, which can guide the development of effective personalised interventions that target mechanisms of change, used at specific treatment phases for optimal effect. Given their complexity, panel models need to be implemented with caution, as different modelling choices can significantly affect results and reduce replicability. We outline three central methodological recommendations for use of time‐lagged panel analysis to study mechanisms of change: (a) taking patient‐specific effects into account, separating out stable between‐person differences from within‐person fluctuations over time; (b) properly controlling for autoregressive effects; and (c) considering long‐term time trends. We demonstrate these recommendations in an applied example examining the session‐by‐session alliance–outcome association in a naturalistic psychotherapy study. We present limitations of time‐lagged panel analysis and future directions.     

Users of secondary school‐based counselling services and specialist CAMHS in Wales: A comparison study

Background: The increasing prevalence of mental health issues in young people has contributed to a rise in the provision of school‐based counselling services in the UK. Between 2008/09 and 2010/11, data were collected from users of secondary school‐based counselling services in Wales. Aims: To identify the characteristics of users of school‐based counselling services in Wales – including demographics, referral pathways, presenting issues, and predominant issues – and how they compare to users of specialist CAMHS in Wales and Welsh secondary school pupils in general. Method: Data were collected on 10,687 episodes of counselling. School counsellors completed a client record sheet after each counselling episode and submitted these to their Local Authority. Collated results were then compared to matched data from Welsh specialist CAMHS and Welsh secondary schools data. Results/findings: A typical user of a secondary school‐based counselling service in Wales was female, of white ethnicity, and from the ‘middle’ school years. There was a marked under‐representation of users from BME backgrounds. Users were most often referred by school staff, and the most common presenting issues were family‐related, anger, and behaviour‐related. Conclusions: There was a higher proportion of females accessing school‐based counselling services than males. This was in direct contrast to data from specialist CAMHS and possible explanations for this are discussed. The under‐representation of BME populations suggested that there were some equality issues associated with accessing these services. Implications for practice: Future research should explore equality issues associated with young people from BME backgrounds accessing intervention services.     

A mixed methods research study on the video‐based counselling method Marte Meo

Marte Meo is a video‐based counselling method founded by Maria Aarts in the Netherlands and now in worldwide use (Aarts, Aarts Production, 2008). Marte Meo has been adopted and put into practice by a large and diverse network of trained and certified counsellors across the world. It was invented, developed and spread by a vanguard of practising counsellors who have adapted it to a variety of contexts. This is a classic example of research and theory emerging from and following practice; we first need to synthesise the lessons the practitioners and families have learned. We need to better understand how it is implemented; how it is viewed by its practitioners and recipients; and the extent to which variability in implementation may be an asset or a drawback in the continuing evolution of the programme, and in any eventual attempt to document its effects. Therefore, the present article aimed to address this important and hitherto unexplored research topic of the Marte Meo method in counselling and to describe the current state of use of Marte Meo. How is Marte Meo used and applied in a counselling and therapeutic context? Who uses Marte Meo in professional practice? Which function and which meaning does Marte Meo have in general practice and especially in counselling and therapy? What are typical concerns, goals or areas of application? We report on an ongoing mixed methods research project which began in 2015. This paper focuses on the research methods. We will explain why an integrated exploratory sequential design (Cresswell, 2017) is best suited to our purposes. The exploratory sequential design of the Marte Meo project has five phases: as the first phase, we conducted a systematic literature review, analysing the status of existing research. The staged qualitative research consisted of designing, conducting and analysing semi‐structured interviews with parents and Marte Meo counsellors (phase 2), and then using that analysis to inform the design, the conduct and the analysis of videotaped observations of everyday situations in day‐care centres to examine the process and effects of Marte Meo interaction elements on children (phase 3). Combining these qualitative analyses then became the basis for the development of an online questionnaire that could enable us to collect quantitative data on the current use of Marte Meo in practice by experts (phase 4). This builds into the fifth phase in the final interpretation. One of the key findings of the qualitative parts is that Marte Meo is perceived as advantageous. The experts reported more joy and success in their work. In particular, in the pedagogical context, the daily, resource‐oriented ‘Marte Meo view’, which was sharpened by the training, seems to be essential, as it enables an awareness of the needs of the interaction partners and the beneficial interaction elements. Moreover, for some interviewees the use of Marte Meo does not seem to be limited to professional practice, but is expressed in a general humanistic attitude towards interpersonal relationships of all kinds. The quantitative survey has confirmed and supplemented these results. On the other hand, we found that Marte Meo is most often used in addition to the systemic approach. A later article will focus more on the findings. This article will conclude with a discussion of the advantages and disadvantages of the research design—concerning this special research project and concerning counselling research in general.     

Using a cross‐contextual qualitative diary design to explore client experiences of psychotherapy

Qualitative research in counselling and psychotherapy has largely been based on interviews carried out with clients and therapists. However, other approaches to qualitative data collection are possible. The present paper uses a diary design to explore the connection between what goes on in therapy sessions, and client activities and experiences in other contexts. Clients and counsellors kept diaries about significant aspects of therapy sessions, while clients also kept diaries about new and different experiences in other contexts in their lives. Ethical and practical issues involved in the use of diaries are discussed, and the methods that were employed to analyse diary‐based data are described. The types of findings that the study generated are presented, along with discussion of their implications for research into client experiences of therapy.     

Trauma‐focused CBT with maltreated children: A clinic‐based evaluation of a new treatment manual

The effectiveness of a locally developed trauma‐focused cognitive behavioural therapy (TF‐CBT) program for maltreated children with post‐traumatic stress disorder (PTSD) was examined across different therapists in a child protection clinic setting. An earlier phase of the research piloting the program had provided promising results. This second phase involved two studies evaluating the completed TF‐CBT manual delivered by (a) the developer and (b) other therapists. A single‐case multiple‐baseline design was used to demonstrate the controlling effects of the treatment on PTSD symptoms and child coping. Eight 9–13‐year‐old abused children with PTSD were treated. Positive outcomes support the effectiveness of the TF‐CBT program delivered by both the developer and other therapists. The study design and methodology were robust enough to confirm empirically the clinically beneficial effects and potential for this new program. It was also apparent, however, from study limitations, including missing data for some patients, that there are a number of challenges in carrying out such research in a busy child protection service setting with multiply‐abused patients. This paper considers implications and ways forward for engaging in empirically supported practice as well as future development and research.     

The long‐term effects of counselling: The process and mechanisms that contribute to ongoing change from a user perspective

Aims: This qualitative study aimed to expand the limited evidence base about the long‐term effects of psychological therapies.Method: We conducted in‐depth interviews with 15 people, 1–3 years after primary care counselling, to investigate whether they could identify enduring benefits and the mechanisms that brought about and maintained them. From their narratives, we developed a model of the change process of counselling and mechanisms that were perceived as essential to produce lasting benefit. The model conceptualised movement through distinct phases: engagement; exploration of internal and external worlds; consolidation and negotiated ending. Results: Mechanisms integral to sustained impact were: the active engagement of people during and between sessions to work toward their own solutions; and acquisition through the change process of skills which could be further built on after the counselling ended. These enabled ongoing, dynamic change in the way people conducted their lives and relationships. Conclusion: A key concept in securing long‐term benefit was co‐production, both during counselling and in taking ownership of and using the ‘box of skills’ acquired. Support of the model was reinforced through comparison with the experience of three interviewees who reported no long‐term benefit.