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.     

Counselling — Why not? A qualitative study of people's accounts of not taking up counselling appointments

The aim of this research was to explore the reasons behind people's decision not to take up a counselling referral. A qualitative study was carried out, using semi‐structured interviews and written responses. The investigation was based in NHS primary care counselling services in a GP practice in the North of England. People who had been referred for counselling by their GP, but did not attend any counselling appointments, were interviewed or invited to submit written comments. Many people talked about the courage it took to ask for help. The referral itself was sometimes therapeutic as it legitimised their distress. The GP's response affected people's decisions. Waiting time and what happened during waiting was important. Some people had their own resources, which they used actively, seeking other sources of help; others were more passive, their lives changed around them. Other factors that contributed to non‐engagement were being referred in a crisis; lack of knowledge about counselling and mental distress; and concern about stigma and its impact on work. Perceived waiting time was the most significant factor for participants in this study, but most people had a combination of reasons for not engaging. Support from the GP, information about the service and being given a realistic expectation of waiting times, may help people feel better able to access counselling services.     

Self-administered behavioural family intervention for parents of toddlers: effectiveness and dissemination

This study examined the effectiveness of a self-administered behavioural family intervention (BFI) for parents of toddlers, within the context of a regular telephone counselling service provider. Telephone counsellors were trained in the delivery of BFI, and 110 mothers of toddlers completed the intervention. There were significant short-term effects of intervention in terms of child behaviour problems and parenting style, parenting confidence and anger. In addition, there were improvements in mother's personal adjustment, and lower levels of parenting conflict. The intervention effects were maintained at 3-month follow-up. The results provide support for the effectiveness of self-administered BFI, and have implications for the population level delivery of behavioural family interventions.     

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.     

Can CORE assessment data identify those clients less likely to benefit from brief counselling in primary care?

Studies show that counsellors in primary care see many clients with difficulties of a severity similar to those found in secondary care services. Evidence from both RCTs and studies of routinely collected data indicates that many of these ‘clinical’ clients benefit from brief counselling intervention. However, little is known about why some benefit while others fail to do so despite completing their counselling contract. This paper considers client characteristics recorded at assessment and aims, using logistic regression analysis, to identify those characteristics predictive of a poor outcome. Results indicate that a number of characteristics are associated with poor outcome; the most important predictors are economic inactivity and aspects of the patient's condition, particularly continuous/recurrent depression, with some differences between genders. However, the models produced were not acceptable in their predictive power. This may be partly due to data quality issues or important characteristics not being available in the data. The paper concludes that being unemployed or on state benefits may be a proxy measure of severity that has an important impact on outcome for all patients, and particularly for males. Some reasons are suggested and areas of future research are identified.     

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.     

Both group peer counselling and individual counselling reduce anxiety and depression,and increase self-esteem and overall life satisfaction in palliative cancer care

This study compared group peer counselling and individual counselling in relation to quality of life, well-being and perceived control in individuals receiving palliative cancer care. The study utilized a quasi-experimental pretest-posttest design to assess the effectiveness of counselling type, in a sample of individuals diagnosed with breast, bowel or lung cancer. Nine females underwent group peer counselling and nine underwent individual counselling. Individuals were administered self-report questionnaires which included standardized subscales that measure quality of life in terms of psychological well-being and perceived locus of control before and after counselling. Both group peer counselling and individual counselling significantly increased self-esteem, self-reported levels of overall life satisfaction, and reduced anxiety and depression. Self-esteem, overall life satisfaction, and anxiety and depression were comparable in the two counselling types, both at outset and after counselling, however, individuals with internal locii of control scored higher for self-esteem on post-test, and lower for depression and anxiety, irrespective of type of counselling.     

Creativity as Identity Skill? Late Adolescents' Management of Identity,Complexity and Risk‐Taking

The link between identity and creativity has received surprisingly little attention from developmental psychology researchers, although flexibility and the ability to generate multiple solutions to problems are key competences for contemporary society based on continuous innovation and de‐standardization of development trajectories. These competences are critical for identity formation processes, mainly during late adolescence when young people have to explore and commit to defining themselves. This study was concerned with exploring the relationships between creative and identity processes to identify typologies of ‘creativity‐identity interplay’ in late adolescence. The participants comprised 315 late adolescents attending the last 2 years of Italian high schools. Two self‐report measures were used: Utrecht‐Management of Identity Commitments Scale and Test of Divergent Feeling. Participation was voluntary and anonymity was guaranteed. Our findings confirm the relationship between identity and creativity, identify six identity statuses (moratorium, critical exploration, achievement, early closure, diffusion, and searching moratorium), and they describe differences in terms of creativity processes involved in identity formation. Suggestions for future research and limitations are discussed.     

How are counselling and therapeutic services experienced by orthodox Jewish primary schools in North-West London? What are the cultural sensitivities,attitudes and beliefs of senior staff members in these schools?

This study investigates how Jewish senior staff at orthodox Jewish primary schools in North-West London experience therapeutic services such as counselling for their students and community. A qualitative approach using semi-structured interviews with seven female orthodox Jewish participants was employed. Thematic analysis was used to analyse data. Results highlighted six broad themes covering the school’s view of counselling and other therapeutic services. Uptake of counselling was often low. Negative parental attitudes, stigma, fear of local authorities and lack of culturally appropriate signposting were some of the factors determining whether counselling services were accessed or not, and why. The importance of the therapist’s own religion and the language used to describe therapy was also significant. Further research into increasing awareness of mental health needs for orthodox Jewish schools and to increase uptake of therapeutic services should be undertaken and has implications cross culturally.     

不同语境下的初级卫生保健

初级卫生保健一词在国内文献中涵义不同,研究发现《阿拉木图宣言》中的初级卫生保健更多的具有卫生体系变革的涵义,强调公平性、多部门合作、社区参与、适宜技术和适宜人力的原则;选择性初级卫生保健则以推广具有成本效益的卫生干预措施为重点;国内政策语境下的初级卫生保健则更多的是具体的卫生服务内容。     

A Prospective Comparison Study of Different Methods of Gathering Self-Reported Family History Information for Breast Cancer Risk Assessment

Currently there is much debate regarding the ability of mathematical models incorporating epidemiological information or mutation-based risk algorithms to accurately predict a woman's risk of developing breast cancer. Without access to accurate family history information these models have limited use. This study compares different methods of gathering family history information and the impact on subsequent risk assessment. These methods were compared to the gold standard interview with a trained genetics' professional. The amount and accuracy of information provided by primary care doctors' letters was found to be poor and better information was obtained by sending a postal questionnaire directly to the patient. Because of the high number of low-risk women referred to clinic a questionnaire (the FCAT) was designed to provide reassurance and piloted as part of this study. This paper highlights the importance of using appropriate methods to gather the family history information. It presents evidence for the importance of a skilled assessor and the need to allow time for women to discuss the importance of this information with their family.     

Containment in theory and practice

Abstract

This article selects the term ‘containment’ as a vehicle for an exploration of multi-professional work and communication in the general practice setting. The term was selected because of its widespread use by and relevance to the different professionals who work in general practice. It is sufficiently elastic to be applied to one-to-one work between patients and GPs, counsellors, nurses or complementary therapists, and to a multi-professional teamwork process.

The exploration of the concept in use at Marylebone Health Centre is complicated by the multi-professional nature of the team and then-wide range of belief systems and language groups. In the process of exploring the term, members of the team had to cope with their discovery that it was being used in contradictory ways. They decided that a new and more grounded definition in shared and ordinary (nonprofessional) language was needed, if the term were to become a vehicle for inter-professional collaboration and if unhelpful, anti-task social defences were to be minimised.