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.     

The implementation of routine outcome measures in a Tier 3 Psychological Therapies Service: The process of enhancing data quality and reflections of implementation challenges

Background: The Newham Psychological Therapies Service (PTS) has been using the CORE System of evaluation to demonstrate effectiveness since 2004. More recently there has been the national and local drive to improve outcomes as outlined by a number of Department of Health policies and the Improving Access to Psychological Therapies (IAPT) initiative. Aims: This paper describes how, as a secondary care complex mental health service, we have engaged with the process of outcome measurement through complementing the usage of the CORE System with additional measures forming the service pilot minimum dataset. The process of implementation is outlined along with reflections on the challenges which the service faced in introducing outcome measurement. Findings: Engagement with outcome measurement by a service requires attention to be paid to the organisational and professional aspects and personal resonances for clinicians if it is to become established as a meaningful enterprise within secondary care services. Despite success at this task, challenges remain to the further development of this area of work.     

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.     

Exploration of the attitudes of employees towards the provision of counselling within a profit‐making organisation

The provision of workplace counselling has risen significantly over the last 20 years in response to the increase in stress‐related illness amongst employees in UK profit‐making organisations. Despite this expansion there is very little exploration of employee attitudes towards this provision. This paper describes a case study of employee attitudes towards counselling in a UK profit‐making organisation utilising an Employee Assistant Programme (EAP) for staff counselling. The method used for the research was a quantitative approach administered using a short questionnaire distributed to employees by e‐mail. The responses to the questionnaire illustrated that most employees were highly aware of the service and believed stress to be the highest presenting issue to the EAP counsellors. However, stress was actually the lowest presenting issue. The results from this study also suggested that managers had a more negative attitude towards counselling than non‐managers. Men and women were found to have the same highly positive attitude towards counselling. Respondents felt that wider, constant and regular positive promotion of counselling, by the employer as well as the EAP, was needed to increase utilisation of the EAP counselling service. Concerns over confidentiality for those using, or contemplating using, the service were also found — as in other studies — but this study found concerns particularly in relation to managers finding out that an employee had attended counselling. The implications of these findings are discussed.     

An investigation into the psychometric properties of the CORE‐OM in patients with eating disorders

Aim: The current study aimed to explore the psychometric properties of the CORE‐OM (Clinical Outcomes in Routine Evaluation – Outcome Measure) when used in an eating disorder sample. Method: The CORE‐OM was administered at assessment to 360 individuals referred to an eating disorders service. Principal component analysis was conducted to look at the psychometric structure of the CORE‐OM, and psychometric properties were investigated using analyses of reliability and validity. Results: Analyses of the psychometric structure suggested a three‐component solution reflecting negatively worded, positively worded and risk items. The CORE‐OM showed good acceptability, acceptable internal and test‐retest reliabilities, as well as good convergent and known groups validity. Conclusions: The results of the current study support the CORE‐OM as a reliable and valid measure for assessing psychological distress in eating disorders.     

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.     

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.     

Provider Perspectives on Outcome Goals for Children's Day Treatment

I describe service provider perspectives regarding outcome goals of children's day treatment and their ideas for how to make day treatment programs successful in achieving stated outcomes. Respondents were direct service staff from ten day treatment programs in one county in Washington state. Data were obtained through nominal group process methods. The primary outcome goals of day treatment reported were: community re-integration, improved adaptive functioning skills, psychological growth, and improved family functioning. Aspects of day treatment that may help achieve outcome targets included: team quality; comprehensive programming; a consistent, safe, accepting program environment; an individualized, developmental approach; linkages with other services; family involvement, and a low staff-to-client ratio. Outcome goals are discussed relative to those described within the research literature on children's mental health services. Implications for the use of outcome goals for quality improvement are described.     

Emotional support and counselling for people with visual impairment: Quantitative findings from a mixed methods pilot study

Aims: This paper reports on mainly quantitative findings from a mixed methods evaluation of a new model of emotional support and counselling for people with moderate visual impairment. Method: The CORE Outcome Measure was completed with service users at baseline and post‐intervention to assess the impact of the new service on psychological wellbeing and social functioning. Their perceived needs and expectations of the service were also explored. Results: Of the 35 individuals providing data at each assessment time, mean item scores on the CORE fell significantly (p<.001), taking the sample from within a clinical population before therapy, to a mean score below this following therapy. A more positive outlook accompanied this improvement in functioning. Discussion: Findings from the study augment the growing evidence that emotional support and counselling services can play an important role alongside and within related vision services. Implications for practice: The study indicates that therapeutic input for the visually impaired client group may need to target both wellbeing (feelings about oneself and the future) and problems (depression, anxiety, physical health, and trauma). Conclusions: Our findings suggest that a dual model of emotional support and counselling offers considerable benefit for people with visual impairment.     

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.     

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.     

Counselling provision for staff in the National Health Service in England: A survey of patterns of provision

This paper reports the findings of a research project carried out in 2001, mapping the provision of counselling services for staff in the National Health Service in England. A postal survey was used to gather both quantitative and qualitative data in order to produce a picture of service provision in NHS Trusts throughout England. Analysis of information concerning the qualifications, experience and pay structure of counsellors, and patterns of service delivery, revealed significant variations across Health Trusts. Findings are discussed in relation to implications for policy, practice and future research.     

The CORE‐10: A short measure of psychological distress for routine use in the psychological therapies

Background: There is a need for a generic, short, and easy‐to‐use assessment measure for common presentations of psychological distress in UK primary care mental health settings. This paper sets out the development of the CORE‐10 in response to this need. Method: Items were drawn from the CORE‐OM and 10 items were selected according to a combination of usefulness, coverage of item clusters, and statistical procedures. Three CORE‐OM datasets were employed in the development phase: (1) a primary care sample, (2) a sample from an MRC platform trial of enhanced collaborative care of depression in primary care, and (3) a general population sample derived from the Office of National Statistics Psychiatric Morbidity Follow‐up survey. A fourth dataset comprising a sample from an occupational health setting was used to evaluate the CORE‐10 in its standalone format. Results: The internal reliability (alpha) of the CORE‐10 was .90 and the score for the CORE‐10 correlated with the CORE‐OM at .94 in a clinical sample and .92 in a non‐clinical sample. The clinical cut‐off score for general psychological distress was 11.0 with a reliable change index (90% CI) of 6. For depression, the cut‐off score for the CORE‐10 was 13 and yielded sensitivity and specificity values of .92 (CI=.83–1.0) and 0.72 (CI=.60–.83) respectively. Conclusion: The CORE‐10 is an acceptable and feasible instrument that has good psychometric properties and is practical to use with people presenting with common mental health problems in primary care settings.     

Helpful processes in psychological therapy for patients with primary cancers: A qualitative interview study

Aims: The purpose of this study was to identify what patients with primary cancers found helpful in therapy. Method: In‐depth qualitative interviews were conducted with eight patients who had completed a course of psychological therapy within an NHS psychology service for cancer patients. Data were analysed using thematic analysis. Results: The participants identified a range of helpful processes in therapy: talking and expressing their feelings to someone outside of the family; forming a relationship with their therapist; normalisation through the therapists' expert knowledge; problem‐solving and CBT. Limitations: As with all qualitative studies, the small sample and size and dependence on participant recall limits generalisability of the findings. Implications: The findings of this study are consistent with a pluralistic perspective: that multiple therapeutic processes ‐ aligned to a range of different orientations ‐ can be of value to patients with primary cancers. This supports the provision of a range of therapeutic interventions and strategies for this patient group.     

CORE-OM mental health norms of students attending university counselling services benchmarked against an age-matched primary care sample

Whilst concern has been expressed at the increasing severity of the mental health of students, there has been very little research on this growing population outside of small, single institution studies. The aims of this paper are to provide CORE Outcome Measure (CORE-OM) norms for the psychological health of students across multiple sites receiving university counselling, and benchmark these against an age-matched sample of people receiving treatment in NHS primary care settings. Results indicate that students using university counselling services show severity levels only marginally lower than young people presenting in primary care, with the differences being at a functional/relationship rather than a symptomatic level and with levels of risk to self being similar. This suggests that university counselling services deliver a service to people who closely resemble NHS primary care clients in terms of severity and risk to self.     

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.     

Employee Assistance Programs: A Systemic Investigation of Their Use

Braun, A.L., & Novak, D.E. (1986, November/December). A study of EAP non-utilization. EAP Digest, pp. 52–55. O'Connell, V. (1987, March/April). A strategy for overcoming supervisors' resistance. EAP Digest, pp. 63–66. Penzer, W.N. (1987, March/April). Toward sustaining quality mental health services. EAP Digest, pp. 35–40.     

Dynamic interpersonal therapy in an NHS tertiary level specialist psychotherapy service

We describe the introduction of dynamic interpersonal psychotherapy (DIT) into an National Health Service (NHS) tertiary psychoanalytic specialist psychotherapy service. Training in DIT began as our contribution to Improving Access to Psychological Therapies and primary care services, supporting the training and supervision of their DIT practitioners. We then discovered DIT could be a valuable treatment within our own tertiary NHS service for patients with complex presentations. Currently fighting for survival, like many NHS psychoanalytic psychotherapy services nationally, we have adopted a manual-guided, psychoanalytically based therapy to broaden our tertiary clinical psychoanalytic service and accommodate trends in mental health service provision, whilst protecting the quality and integrity of our psychotherapy. DIT helped us continue providing relevant and beneficial psychoanalytic and psychodynamic services to individual patients despite limitations of the financially challenged NHS, NICE guidelines and Payment by Results. We outline the progress and outcomes for patients with complex mental health presentations, include individual case discussion and our experience of using the DIT approach within a traditionally longer term psychoanalytic psychotherapy service.     

Arts for the blues – a new creative psychological therapy for depression

ABSTRACT

Routinely prescribed psychological therapies for depression are not always effective. Arts therapies, particularly Dance Movement Psychotherapy, may offer additional therapeutic mechanisms for depression. Therefore, client-reported helpful factors from various therapy types, along with client preferences, are key in devising new therapeutic interventions. We present a framework for a new pluralistic “meta-approach” of therapy for depression, based on an interdisciplinary thematic synthesis (Thomas, J., & Harden, A. (2008). Methods for the thematic synthesis of qualitative research in systematic reviews. BMC Medical Research Methodology, 8[1], 45) of active ingredients from both talking therapies and creative approaches. Lastly, we offer an illustrative group therapy workshop based on this approach, to be piloted with clients and practitioners within an NHS mental health service. Further research is required to evaluate this pilot and to devise a full treatment for trialling within the service.     

Inside the experience of anorexia nervosa: A narrative thematic analysis

Aim: This study considers the question of whether inpatient admission for anorexia nervosa was a therapeutic experience for two women with chronic anorexia nervosa. The question of whether inpatient admission for anorexia nervosa can be therapeutic is not answerable through existing research evidence. Method: The women were interviewed about their experience of having anorexia, its impact on their lives and the treatment they received. The interviews involved learning about the women's experiences by listening to their stories rather than asking them direct questions about what has been therapeutic about their treatment. Analysis: Their narratives were used to develop understanding grounded in experience and were analysed using a narrative thematic analysis. Ideas, themes and connections were noted but not coded as found in some forms of thematic analysis. Discussion: Consideration is given to the therapeutic qualities of the treatments the women received and the place of therapeutic inpatient admission. The central theme of this research was ‘relationships’ which indicates the use of therapeutic approaches that emphasise the importance of the therapeutic relationship in the treatment of chronic anorexia nervosa. It is suggested that psychodynamic and attachment theories should be used to inform overall treatment models. Some important issues for service provision and areas for further research are identified.