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.     

A five‐year evaluation of the effectiveness of person‐centred counselling in routine clinical practice in primary care

Counselling is the recommended treatment for individuals with mild to moderate mental health problems of recent onset. In this evaluation of a primary care counselling service offering person‐centred counselling, the Core Outcome Measure (CORE‐OM) was administered at referral and at the beginning and end of therapy. A pre‐post therapy effect size for 697 individuals over a 5 year period was 1.2. This compares with a waitlist (between referral and pre therapy) effect size of 0.24 for 382 individuals over a three year period. The results indicate that person‐centred counselling is effective for clients with common mental health problems, such as anxiety and depression. Effectiveness is not limited to individuals with mild to moderate symptoms of recent onset, but extends to people with moderate to severe symptoms of longer duration.     

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.     

Counselling in primary care: a systematic review of the evidence

Primary objective: To undertake a systematic review which aimed to locate, appraise and synthesise evidence to obtain a reliable overview of the clinical effectiveness, cost‐effectiveness and user perspectives regarding counselling in primary care. Main results: Evidence from 26 studies was presented as a narrative synthesis and demonstrated that counselling is effective in the short term, is as effective as CBT with typical heterogeneous primary care populations and more effective than routine primary care for the treatment of non‐specific generic psychological problems, anxiety and depression. Counselling may reduce levels of referrals to psychiatric services, but does not appear to reduce medication, the number of GP consultations or overall costs. Patients are highly satisfied with the counselling they have received in primary care and prefer counselling to medication for depression. Conclusions and implications for future research: This review demonstrates the value of counselling as a valid choice for primary care patients and as a broadly effective therapeutic intervention for a wide range of generic psychological conditions presenting in the primary care setting. More rigorous clinical and cost‐effectiveness trials are needed together with surveys of more typical users of primary care services.     

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.     

Establishing psychological services in a community-based,health care setting: A 3-year case study

Health care practitioners are being challenged to reorganize service delivery and psychology providers are emerging as important participants in shaping the development of primary health care practices. The article outlines the 3-year process of a community/academic/health care center partnership to develop a new model for providing interdisciplinary health care services. The authors describe the process of integrating psychological services into an interdisciplinary, primary care community-based health care center, outline specific planning strategies, and identify the roadblocks and barriers encountered.     

Pilot study evaluation of suicide prevention gatekeeper training utilising STORM in a British university setting

Recent years have seen increasing awareness of the wide range of mental health problems faced by students. Gatekeeper training has been shown to have a positive impact on knowledge and attitudes about suicide prevention, although the evidence for skills acquisition is limited. We utilised the STORM® training package in an exploratory study to determine explore whether skills training could be successfully implemented in an educational establishment in the United Kingdom. In a pilot study assessing competence before and after the intervention there was evidence of acquisition of skills, improved attitudes and increased confidence. Further research should include a randomised controlled trial of such training.     

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.     

Counselling in primary care: A study of the psychological impact and cost benefits for four chronic conditions

Primary care counselling services have expanded rapidly over the last twenty years. Their principal focus has been to manage the demands placed on general practitioners by high service users, such as frequent attenders and patients with mental health problems. To date, very little research has been conducted to ascertain the impact of counselling for other patient groups in terms either of psychological outcomes or of cost-benefits. This study looked at the effect of short-term counselling on both the uptake of health services and the psychological states of four patient groups – frequent attenders and patients with diabetes, hypertension and asthma. All patients on the chronic disease register for these conditions and all patients who had made at least eight GP appointments over the previous twelve months were invited to take part in the study. The participants received eight 90-minute small-group counselling sessions, conducted by trained counsellors. The counselling followed a cognitive behavioural therapy (CBT) approach, with an emphasis on developing personal responsibility. Psychological outcomes were assessed using three proprietary measures (SF 36, HADS and CORE) immediately following counselling and at six months post-intervention. Health service uptake was assessed for each group over the twelve months post-intervention, using number of GP consultations, home visits, hospital referrals and test/investigations requested as outcome indicators. These data were compared with those for comparable control groups for each condition. The results suggested that, overall, all patient groups showed a significant improvement in psychological well-being, and that these gains were maintained for the six-month study period. The intervention groups also significantly reduced their uptake of primary and secondary care services, by comparison with their comparable control groups. The results suggest that the psychological and fiscal benefits of counselling provision within a primary care setting can extend to other patient categories.     

Evaluating the effectiveness of counselling in primary care: Taking a fresh look

One criticism voiced by counsellors and psychotherapists is that research does not reflect either the culture or values of therapy. Researchers, on the other hand, accuse practitioners of not attending to their findings, and the implication is made that the latter engage in treatment processes that are ill‐informed. These polarised understandings give rise to the situation where the client — and his or her development — fall into the practice‐research gap. In more recent studies of counselling in primary care, an attempt has been made to offer new perspectives for interpreting and understanding findings, and the relative value — and limitations — of different research questions and methods. They provide just a few examples of how practitioner‐researchers in the future may ask more precise questions, yet reflect on their findings from a broader set of viewpoints.     

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.     

Time‐limited therapy in a Community Mental Health Team setting

This study examines time‐limited therapy in a Community Mental Health Team (CMHT) setting. This work is a key tension for CMHTs who are under pressure to focus on clients with a serious mental illness as a priority as opposed to clients who might be deemed the ‘psychologically distressed’. The development of CMHTs in the UK is described. Limited research on time‐limited therapy in a CMHT setting is identified. Results suggest that time‐limited therapy has a positive impact on the mental health needs of clients referred to a CMHT by GPs. It is concluded that it is appropriate to justify the use of time‐limited therapy in a CMHT‐based setting. Suggestions for further research are made.     

Who drops-out? Do measures of risk to self and to others predict unplanned endings in primary care counselling?

Aims: Unplanned endings, where clients unilaterally end therapy, are of concern for psychological therapy services generally as they raise questions about the appropriateness of the treatment and it's delivery for some clients. Limited available data indicates that those who drop-out often have more severe symptoms at entry, and have poorer clinical outcomes. This raises further questions about risk to self and others for those clients who leave therapy prematurely and how these clients might be identified and kept engaged. Method: This paper uses a large dataset of CORE data collected routinely in a primary care counselling service between 2000 and 2003. Logistic regression was utilised to consider different measures of risk and other client characteristics recorded at assessment to predict drop-out from the service. Results: These indicate that younger age, greater psychological distress at assessment, an addiction problem and greater risk to others, are associated with an unplanned ending. However, no reliable logistic regression model could be produced. This may be partly due to data quality issues or important characteristics not being available in the data. Implications for practice: The paper concludes that counsellors should actively seek to minimise unplanned endings, as amongst them may be represented the more distressed and risky clients referred to primary care counselling.     

A group‐randomized evaluation of a theatre‐based sexual abuse prevention programme for primary school children in Germany

The study reports a group‐randomized trial of a theatre‐based intervention to prevent sexual abuse targeting first and second grade primary school children in Germany. A sample of 148 first and second graders saw a live performance of a play designed to promote skills in dealing with abuse‐prone interactions with adults, watched a recording of the play on DVD or were assigned to a no intervention control group. Both the live performance and the DVD groups showed significant increases in the target variables (distinguishing good/bad touch and secrets, getting help, rejecting unwanted touch) from baseline to post‐intervention and a follow‐up after 2 weeks, while the control group did not show changes. The live performance and DVD groups participated in a further follow‐up 30 weeks post‐intervention, which showed sustained effects of the intervention. The findings indicate that with appropriately culture‐sensitive measures, sexual abuse prevention programmes can have sustainable effects with young primary school children. Copyright © 2009 John Wiley & Sons, Ltd.     

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.     

Therapists’ and clients’ perceptions of routine outcome measurement in the NHS: A qualitative study

Primary objective: This is the first qualitative study that elicited the perceptions of both psychological therapists and their clients in the use of Clinical Outcomes in Routine Evaluation with computer software (CORE‐Net), where instant visual feedback for session tracking was given on a computer screen in the therapy room at each therapy session. The study also examined how therapists viewed its potential value in supervision and provides suggestions for improving training. Research design: The study adopted a convenience sample of four therapists in a primary care counselling setting (PCC – General Practitioner referrals) who were experienced in using CORE‐Net, and five therapists in an NHS employee/occupational support counselling service (OH) who had just begun to use CORE‐Net for session tracking with 10 of their clients. Method: A qualitative methodology was used and interview data were collected from the therapists via focus groups; the clients were interviewed individually face to face. All data was analysed inductively. Findings: The study identified six overarching themes: (i) therapists were initially anxious and resistant; (ii) therapists adapt ‘creatively’; (iii) outcome measures help the client/therapist relationship; (iv) clients perceive visual measures as helpful; (v) CORE scores inform supervision; and (vi) proper and ongoing training/support of therapists is necessary. The main limitations are comparability of data and the generalisabilty of results. Conclusions: The implementation of routine outcome measurement (ROM) is a challenge but can be made easier with proper training and supervision. Clients appear happier than their therapists when routine outcome measurement is used.     

Professional education of psychologists using online problem‐based learning methods: Experience at Charles Sturt University

Abstract: Problem‐based learning (PBL) is a pedagogical approach to professional training that emphasises the development of clinical reasoning skills and self‐directed learning. In contrast to more traditional lecture‐based approaches that focus upon the linear acquisition of course content, PBL is undertaken in the context of actual case presentations. Although PBL has been adopted widely in the professional training of medical practitioners and nurses, it is only just beginning to be used in the professional education of psychologists. This paper examines the nature and benefits of PBL for education in clinical and forensic psychology by outlining its implementation and development at Charles Sturt University, located in a rural area of Australia. Although a full and independent evaluation of PBL for education in clinical or forensic psychology is yet to be undertaken, this paper argues that PBL can make a significant contribution to professional training in psychology.