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.     

Evidence based practice: A guide for counsellors and psychotherapists

There has been an increasing tendency for healthcare policy makers and managers to require that all forms of therapy are supported by rigorous research evidence. This paper, which has also been distributed as an Information Sheet to all members of the British Association for Counselling and Psychotherapy (BACP), provides a practitioner‐oriented introduction to evidence‐based practice, with suggestions for further reading on this topic.     

Action: a bridge between vocational and mental health counselling*

A theory of goal-directed action is proposed as a conceptual link between vocational and mental health counselling. Originally emerging from the vocational counselling field, contextual action theory is presented as a critical conceptual link not only between mental health and occupational life but also between counselling practices in these domains. This specific application of goal-directed action to vocational and mental health counselling is addressed by describing counselling as goal-directed action, the five tasks of counselling it invites, and tools for supporting client goals, such as the self-confrontation interview.     

Outcomes of training in supervision: Randomised controlled trial

There is little controlled research on the impact of supervisor training on supervision. The current study examined the effects of supervision training in a sample of 46 supervisor–supervisee pairs of mental health practitioners. It compared Immediate 2‐day workshop training of the pair, a wait‐list control in which workshop training was delayed 3 months, and a condition in which supervisors were trained 3 months before their partners (Split). Benefits of Immediate training were restricted to supervisors reporting fully specified agreements, and to reduction of some perceived problems. Self‐efficacy in providing effective supervision fell in the Split condition, relative to the other conditions. Across conditions in general there was a fall from baseline to post‐test assessment in the proportion of sessions where recommended supervision strategies were used, perhaps partly because the controlled trial extended across the summer vacation period. Results are consistent with other observations of the limited impact of workshop training on practice.     

Adventure based counselling,individual counselling and object relations: a critical evaluation of a qualitative study

Adventure based counselling is a short-term experiential psychotherapeutic approach, which utilises adventurous activities and being in natural environmental in order to facilitate therapeutic change in clients. The present paper critically appraises the results of a qualitative study that investigated how clients with self-reported anxiety and depression experienced participating in an innovative counselling intervention with combined individual counselling with such an adventurous outdoor transaction. Interpretative Phenomenological Analysis, as described by Smith and Osborn (2008), was used in order record and analyse the experiences of four male and six female students who were treated at the Teesside's University Counselling Service. Interviewees perceived the counselling sessions as offering a safe therapeutic space within which they could unveil their anxieties and achieve inner healing, whereas the outdoor transaction as providing an experiential venue for achieving personal change. Interviewees felt that without the outdoor transaction the therapeutic significance of the counselling process would not have reached its full potential. Likewise, without the individual counselling, the outdoor transaction would just have an entertaining event and not a venue for personal change. These findings are discussed in relation to object relations theory.     

School-based,randomised controlled trial of an evidence-based condom promotion leaflet

A condom use promotion leaflet was designed for use with older teenagers in schools. The text targeted a series of cognitive and behavioural antecedents of condom use identified in the literature. Given previous evidence that motivational incentives can enhance the effectiveness of health promotion leaflets, the leaflet was presented in conjunction with a quiz and prize draw. Students were randomly assigned to either the intervention condition or a (no leaflet or incentive) control condition. Measures were taken immediately, pre-intervention and 4 weeks later from 404 students. The 20-min intervention successfully promoted six of the eight measured cognitions, namely (1) attitude towards using condoms with a new partner (2) attitude towards using condoms with a steady partner (3) normative beliefs in relation to preparatory actions (4) self-efficacy in relation to both preparatory actions and (5) condom use (6) intention to use condoms, as well as three measured preparatory actions, that is, purchasing condoms, carrying condoms and discussing condom use. The intervention did not increase condom use with steady or new partners but power to test intervention impact on condom use was curtailed.     

Time for change: using implementation intentions to promote physical activity in a randomised pilot trial

Objective: A common barrier to exercise is a perceived lack of time. The current pilot study examined the effects of an implementation intention intervention to enhance exercise self-efficacy, increase confidence to exercise when facing time constraints, and increase physical activity in middle-aged adults (n?=?63, aged 35–69). Design: Participants received a pedometer (Fitbit) to objectively measure activity and were randomly assigned to either a control or intervention condition. After a 1-week baseline, the intervention condition received instructions to plan how, where, and when they would add steps to their daily routine to meet their step goal, using personalised schedules and maps. Both groups were contacted nightly via email. Main Outcome Measures: Physical activity (steps and time spent in moderate-to-vigorous activity), goal achievement, exercise self-efficacy, time-relevant exercise self-efficacy and affect. Results: Compared to the control, the intervention condition significantly increased in steps, time spent in moderate-to-vigorous activity, and time-relevant exercise self-efficacy. Goal achievement was related to greater time-relevant exercise self-efficacy and more positive affect at the daily level. Conclusion: Findings suggest that the personalised planning intervention increased physical activity and confidence in achieving physical activity goals under time constraints. Avenues for future directions, especially for producing more sustained effects, are discussed.     

Cognitive-behaviour therapy for chronic fatigue syndrome: comparison of outcomes within and outside the confines of a randomised controlled trial

Outcomes for cognitive-behaviour therapy (CBT) in randomised controlled trials (RCTs) have rarely been compared to those in routine clinical practice. Taking the case of CBT for chronic fatigue syndrome (CFS), we evaluated the results of a successful RCT against those of the same treatment given in the same setting as part of routine practice. Fatigue and social adjustment scores were compared for patients who received CBT for CFS as part of a RCT (N=30) and patients who received CBT as part of everyday clinical practice (N=384). The results in the RCT were superior to those in routine clinical practice. Between pre-treatment and 6-month follow-up, the RCT showed a larger reduction in fatigue and greater improvement in social adjustment than those in routine treatment. The changes in fatigue scores were similar for both groups during treatment but were greater in the RCT between post-treatment and follow-up. Potential reasons for the superior results of the RCT include patient selection, therapist factors and the use of a manualised treatment protocol. Practitioners need to pay particular attention to relapse prevention and ensuring adequate follow-up in addition to encouraging patients to continue with cognitive-behavioural strategies once treatment has ended.     

“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.     

Impact of play therapy on parent-child relationship stress at a mental health training setting

This study investigated the impact of Child-Centred Play Therapy (CCPT)/Non-Directive Play Therapy on parent-child relationship stress using archival data from 202 child clients divided into clinical behavioural groups over 3-74 sessions in a mental health training setting. Results demonstrated significant differences between pre and post testing on the Parenting Stress Index. CCPT appeared to be especially effective with children identified with clinical externalising behavioural problems, combined externalising and internalising behavioural problems, and children who were not categorised with clinical problem behaviours but whose parents sought counselling services for them. There were also significant differences determined by length of therapy. Results are discussed concerning implications for clinical practice and further research.     

Eye movement desensitization and reprocessing for mental health problems: a systematic review and meta-analysis

ABSTRACT

There is no comprehensive meta-analysis of randomised trials examining the effects of Eye Movement Desensitization and Reprocessing (EMDR) on post-traumatic stress disorder (PTSD) and no systematic review at all of the effects of EMDR on other mental health problems. We conducted a systematic review and meta-analysis of 76 trials. Most trials examined the effects on PTSD (62%). The effect size of EMDR compared to control conditions was g = 0.93 (95% CI: 0.67–.18), with high heterogeneity (I²= 72%). Only four of 27 studies had low risk of bias, and there were indications for publication bias. EMDR was more effective than other therapies (g = 0.36; 95% CI: 0.14–0.57), but not in studies with low risk of bias. Significant results were also found for EMDR in phobias and test anxiety, but the number of studies was small and risk of bias was high. EMDR was examined in several other mental health problems, but for none of these problems, sufficient studies were available to pool outcomes. EMDR may be effective in the treatment of PTSD in the short term, but the quality of studies is too low to draw definite conclusions. There is not enough evidence to advise it for the use in other mental health problems.     

Longer term outcome of cognitive-behavioural and psychodynamic psychotherapy in routine mental health care: randomised controlled trial

We investigated the comparative effectiveness of cognitive-behavioural (CBT) and psychodynamic therapy (PDT) under clinically representative conditions as a subtrial of a prior study (Watzke et al., 2010, BJP). A consecutive sample of 147 patients with common mental disorders was randomised to either CBT or PDT in routine mental health care. In a primary per-protocol analysis patients randomised to CBT had a significantly better longer term outcome in the primary outcome symptom severity (General Severity Index of the SCL-14; p=.001; partial η(2)=0.073) as well as in health related quality of life (Mental Component Summary of the SF-8; p=.013; partial η(2)=.041) and concerning interpersonal issues (Inventory of Interpersonal Problems, IIP-C; p=.001; partial η(2)=.070) 6 months after treatment than patients randomised to PDT. These results could be confirmed in intention-to-treat analyses (n=180) suggesting that there was no substantial attrition bias due to drop outs at the follow-up assessment. Thus, the so called equivalence outcome paradox was not replicated in this study.     

A randomised controlled trial of a brief online mindfulness-based intervention

ObjectivesThere is growing evidence that mindfulness has positive consequences for both psychological and physical health in both clinical and non-clinical populations. The potential benefits of mindfulness underpin a range of therapeutic intervention approaches designed to increase mindfulness in both clinical and community contexts. Self-guided mindfulness-based interventions may be a way to increase access to the benefits of mindfulness. This study explored whether a brief, online, mindfulness-based intervention can increase mindfulness and reduce perceived stress and anxiety/depression symptoms within a student population.MethodOne hundred and four students were randomly allocated to either immediately start a two-week, self-guided, online, mindfulness-based intervention or a wait-list control. Measures of mindfulness, perceived stress and anxiety/depression were administered before and after the intervention period.ResultsIntention to treat analysis identified significant group by time interactions for mindfulness skills, perceived stress and anxiety/depression symptoms. Participation in the intervention was associated with significant improvements in all measured domains, where no significant changes on these measures were found for the control group.ConclusionsThis provides evidence in support of the feasibility and effectiveness of shorter self-guided mindfulness-based interventions. The limitations and implications of this study for clinical practice are discussed.     

A randomised controlled trial of cognitive-behaviour therapy for clinical perfectionism: a preliminary study

Perfectionism can be a problem in its own right and it can impede the progress of treatment of Axis I disorders. This study reports on a preliminary randomised controlled trial of cognitive-behaviour therapy (CBT) for "clinical perfectionism". Twenty participants were randomly assigned to either immediate treatment (IT) (n=10) or a wait list (NL) (n=10). Treatment consisted of ten sessions of CBT over eight weeks. Two participants did not complete the follow-up assessments (10%). Fifteen of the original 20 participants (75%) were clinically significantly improved after treatment and the effect size was large (1.8). Treatment gains were maintained at 8-week and 16-week follow-up.     

Psychodynamic counselling in an educational setting: Containing,transference and clientele

Abstract

The concepts of containing and transference, as well as the specific nature of the clientele, may, on a first approach, be used to differentiate psychodynamic counselling in an educational setting (PES) from the ‘pure gold’ of psychoanalysis. Further, it is argued that a realistic understanding of PES, given the constraints in which it operates, demands that the psychodynamic practitioner be prepared to cut her procedural cloth in accordance with the demands her clients place upon her. This makes PES a pragmatical practice rather than some lesser cousin of ‘orthodox’ psychoanalysis.