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A naturalistic longitudinal evaluation of counselling in primary care
Abstract
This study evaluated the effectiveness of generic counselling in a primary healthcare setting during three months of counselling and followed up the patients' progress after counselling had finished for the next twenty-one months. Questionnaires were completed by patients within the Dorset Primary Care counselling service on referral to counselling and at set points afterwards. A naturally occurring waiting-list group was compared with patients receiving counselling at baseline and three months. Measurements were taken of patients' psychiatric symptomatology, quality of life (QOL) and self-esteem. Patients who received counselling made highly significant improvements compared with those on the waiting list. These improvements were maintained throughout the long-term follow-up. This would indicate that generic counselling has positive effects that can be maintained for a long period of time after counselling has been completed.
... These are most frequently tested against routine primary care and cover a wide range of target problems, including anxiety and depression, generic psychological problems, postnatal depression, psychosomatic disorders and chronic fatigue. There were nine studies which measured outcomes before and after the intervention (pre and post counselling studies) (Baker et al., 2002;Booth, Cushway, & Newnes, 1997;Evans, Connell, Barkham, Mashral, & Mellor-Clark, 2003;Gordon & Graham, 1996;Kates, Crustolo, Farrar, & Nikolaou, 2002;Mellor-Clark, Connell, Barkham, & Cummins, 2001;Murray, Sharp, Quigley, & McKenzie, 2000;Nettleton et al., 2000;Newton, 2002). All studies were conducted in the UK, apart from that of Kates et al. (2002), which is Canadian. ...
... Survey ' User perspectives USA Non-specific generic counselling Depression Evans et al. (2003) To evaluate a service with reference to the ethnicity of service users using CORE data Pre post '' Effectiveness UK Non-specific generic counselling Non-specific, generic psychological problems Gordon & Graham (1996) To evaluate outcomes of short-term and long-term effects of a brief counselling intervention in primary care Counselling in primary care 211 strate that as a brief, 6-to 10-session intervention, between 60% and 80% of patients achieve reliable and clinically significant improvements (Evans et al., 2003;Gordon & Graham, 1996;Kates et al., 2002;Mellor-Clarke et al., 2001). The long-term effects of counselling are more equivocal, with evidence from a systematic review (Bower & Rowland, 2006) and an RCT (Murray et al., 2003) finding a lack of effect in the long term (up to two years), but two pre and post studies finding a positive effect over the long term (Baker et al., 2002;Gordon & Graham, 1996). When compared against CBT, counselling was shown to be as effective with typical heterogeneous primary care populations, in one systematic review and two clinical trials. ...
... One systematic review (Bower & Rowland, 2006) also suggested that counselling may be as effective as medication. A pre and post counselling study demonstrated that counselling and medication in combination is more effective than either intervention offered as a single treatment (Baker et al., 2002). In terms of individual versus group counselling, there was a lack of studies, but one clinical trial suggested that individual counselling may be more effective than counselling delivered in groups in the treatment of postnatal depression (Milgrom et al., 2005). ...
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.
... The WHO (1978) asserts that, as the foundation to the health and social well-being of people in every country, governments have a responsibility to provide equitable access to PHC that is available to people in their own communities and is based on principles of public participation, health promotion, accessible skills and technology, as well as intersectoral cooperation between health and social service disciplines. There is good evidence that access to PHC services positively impacts the mental and physical health of individuals and populations (Agency for Healthcare Research and Quality, 2004;Baker, Allen, Gibson, Newth, & Barker., 2002;Shi et al., 2004;Starfield, Shi, & Macinko, 2005). In U.S. studies, researchers have found that communities in which there is access to PHC centers have higher documented rates of preventative health services, such as Pap smears, immunizations, and prenatal care, and report better population health outcomes than communities without such access (Agency for Healthcare Research and Quality, 2004;O'Malley, Forrest, Politzer, Wulu, & Shi, 2005;Regan, Schempf, & Politzer, 2003). ...
... Furthermore, both unmet need for and fit of primary medical services in a PHC system, such as those provided by a family doctor, general practice physician, or nurse practitioner, have been associated with early detection of illness and disease, resulting in better mental and physical health outcomes (Bindman, Grumbach, Osmond, Vranzian, & Stewart, 1996;Shi, 1994;Shi et al., 2004;Vogel & Ackerman, 1998). Moreover, patients who access mental health services in PHC settings, such as those provided by counselors, social workers, psychologists, and psychiatric nurses, without the requirement of a referral, report significant improvements in depressive symptoms, anxiety, self-esteem, and quality of life over time (Baker et al., 2002;Greasley & Small, 2005;Nettleton et al., 2000). Few Canadian researchers, however, have examined the impact of either unmet need or fit of PHC services on the mental and physical health of Canadians, including women who have experienced IPV. ...
Primary health care (PHC) can improve the health of women who have experienced intimate partner violence (IPV), yet, access to, and fit of PHC services may be shaped by income and racialization. We examined whether income and racialization were associated with differences in PHC service use, unmet need, fit with needs, and mental and physical health in a sample of 286 women who had separated from an abusive partner. Mothers, unemployed women and those with lower incomes used more PHC services and reported poorer fit of services. Poorer fit of services was related to poorer mental and physical health.
... Data were collected by questionnaire designed by researcher and by unstructured interview was taken by researcher. Qualitative method was used for data analysis [6]. ...
... he longer term impact of counselling, investigating two linked questions: Are there any enduring benefits of counselling from a user perspective? What mechanisms bring about those benefits and maintain them? Several studies have examined long-term impact of counselling using different criteria and measures of outcome, but findings are inconsistent. Baker et al. (2002), using standardised patient outcome tools (Bedford and Foulds Delusion-Symptom-States Inventory (DSSI); Rosenberg-Self Esteem Scale; Watson and Marks Life Impairment Scale), found sustained improvement at two years. Gordon and Wedge (1998) , employing the Hospital Anxiety and Depression Scale (HADS) and a questionnaire on client percept ...
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.
... Psychologists were asked to define the problem type of participating patients by completing a diagnostic information sheet based on DSM III-R (Baker et al., 2002). This procedure has been used in previous research and was embedded in the clinical service (Baker, Allen, Gibson Newth and Baker, 1998). ...
Cognitive Behavioural Therapy (CBT) is not primarily conceptualized as operating via affective processes. However, there is growing recognition that emotional processing plays an important role during the course of therapy.
The Emotional Processing Scale was developed as a clinical and research tool to measure emotional processing deficits and the process of emotional change during therapy.
Fifty-five patients receiving CBT were given measures of emotional functioning (Toronto Alexithymia Scale [TAS-20]; Emotional Processing Scale [EPS-38]) and psychological symptoms (Brief Symptom Inventory [BSI]) pre- and post-therapy. In addition, the EPS-38 was administered to a sample of 173 healthy individuals.
Initially, the patient group exhibited elevated emotional processing scores compared to the healthy group, but after therapy, these scores decreased and approached those of the healthy group.
This suggests that therapy ostensibly designed to reduce psychiatric symptoms via cognitive processes may also facilitate emotional processing. The Emotional Processing Scale demonstrated sensitivity to changes in alexithymia and psychiatric symptom severity, and may provide a valid and reliable means of assessing change during therapy.
... Sometimes a questionnaire was described in part but not published and further enquires drew a blank, such as the modified Rosenberg Self Esteem Scale [16], and the Personal Concerns and Goals Assessment [17,18]. Questionnaires could be broadly categorised as follows, although there was some overlap between categories: satisfaction with/orientation of life [19-22]; coping with/adjustment to illness [23-27]; quality of life [28-34], Self-efficacy [21,35-39]; self-concept [15,22]; spiritual wellbeing [18,40,41]. ...
Changes in self-concept are an important potential outcome for many interventions for people with long-term conditions. This study sought to identify and evaluate outcome questionnaires suitable for quantifying changes in self-concept in people with long-term conditions, in the context of treatment with acupuncture and Chinese medicine.
A literature search was followed by an evaluation of three questionnaires: The Wellbeing Questionnaire W-BQ12, the Patient Enablement Instrument (PEI), and the Arizona Integrative Outcome Scale (AIOS). A convenience sample of 23 people completed the questionnaires on two occasions and were interviewed about their experience and their questionnaire responses. All acupuncturists were interviewed.
Changes in self-concept were common and emerged over time. The three questionnaires had different strengths and weaknesses in relation to measuring changes in self-concept. The generic AIOS had face validity and was sensitive to changes in self-concept over time, but it lacked specificity. The PEI was sensitive and specific in measuring these changes but had lower acceptability. The sensitivity of the W-BQ12 was affected by initial high scores (ceiling effect) and a shorter timescale but was acceptable and is suitable for repeated administration. The PEI and W-BQ12 questionnaires worked well in combination.
Changes in self-concept are important outcomes of complex interventions for people with long-term illness and their measurement requires carefully evaluated tools and long-term follow-up. The literature review and the analysis of the strengths and weaknesses of the questionnaires is a resource for other researchers. The W-BQ12 and the PEI both proved useful for this population and a larger quantitative study is planned.
This paper reports an evaluation of a counselling service that was introduced into 20 general practices within Bradford City Primary Care Trust. Clinical Outcomes in Routine Evaluation (CORE) Assessment and End of Therapy forms were used to record referral and attendance information along with problems identified and demographic information about clients. There was a large disparity in the number of referrals across practices illustrating a range of influences on take-up of the service. Levels of attrition from referral for counselling to commencing were relatively high (188 invitations: 89 took up counselling). A longitudinal evaluation of outcomes was conducted using the CORE outcome measure and the SF-36 Health Survey Questionnaire. Data was collected at the beginning of counselling, at six months and at 12 months follow-up. We found some indication of positive change relating to severity of problems and ability to engage in social activities. However, evaluators should be aware that high attrition rates can create problems in achieving statistical reliability in contexts where overall population numbers are relatively small and/or the time for data collection is relatively short. In light of the recent growth of counselling within primary care, and the need to evaluate these services, the issues encountered in setting up this counselling service, and in seeking to evaluate it, may be instructive to others. Focus groups with counsellors and practice staff explored the benefits and problems in providing the service within practices.
To review the published material on practice-based research and to compare results with benchmarks derived from efficacy studies.
Electronic and manual searches were carried out up to and including 2008. Studies were screened for content relevance and selected according to specified inclusion criteria. Data were extracted from all studies that met criteria and were quality assessed using an adapted version of a checklist designed for the appraisal of both randomized and non-randomized studies of health care interventions. Studies were synthesized according to (1) the type of problem being treated and (2) study design using descriptive and meta-analytic methods where appropriate.
Psychological treatment conducted in routine clinic settings is effective for a range of client problems, particularly common mental health problems (uncontrolled effect size = 1.29; 95% CI = 1.26-1.33, N = 10,842). When benchmarked against data from efficacy studies, practice-based studies yielded effect sizes that fell short of the selected benchmark. In contrast, the practice-based studies achieved the benchmark for percentage of clients meeting a stringent criterion for recovery.
Clients receiving treatment as normally delivered within routine practice report significant relief of symptoms. However, the result of comparisons with efficacy benchmarks is dependent on the outcome index used. Notwithstanding this, substantive factors are also likely to contribute. Therefore, in addition to attending to methodological issues, further work is required to understand the relative contribution of these factors.
The government white paper Health of the nation has highlighted mental health as a key issue for the next decade. Primary care is being encouraged to take a leading role in developing effective services for people with mental health problems. This paper reviews current research on key aspects of mental health in adults: the prevalence of mental health problems, improving detection and management of mental health problems, the role of counselling, and communication between primary and secondary care. Recommendations are made for initiatives in both research and service development.
Research into the effectiveness of counselling in primary care is rare. This study attempts to provide a thorough evaluation of the effects of a new counselling service introduced throughout Dorset.
To evaluate the impact of counselling on client symptomatology, self-esteem, and quality of life. The effect of counselling on drug prescribing, referrals to other mental health professionals, and client and general practitioner (GP) satisfaction were also assessed.
All new clients referred for counselling were asked to complete and return questionnaires before and after counselling. A total of 385 clients took part in the study. The first and second assessments were compared statistically. Clients were ascribed a psychiatric diagnosis using a simplified version of DSM-IIIR (Diagnostic and Statistical Manual of the American Psychiatric Association). GPs' views of the service were determined using a specially designed questionnaire. Drug data were obtained from the Prescription Pricing Authority and referral statistics from Dorset HealthCare National Health Service (NHS) Trust.
The number of psychiatric symptoms and their severity were significantly reduced by counselling. There were no significant differences in the prescription of anxiolytic/hypnotic and anti-depressant medication between matched practices with and without counsellors. The presence of a counsellor did not affect the rate of referral to other mental health professionals. Clients and GPs valued the service highly.
The Psychology Managed Counselling Service is an effective method of running a counselling service and is well received by both clients and GPs. Counselled clients improved significantly on several measures.
Counselling in general practice has become very popular with patients and GPs over the past 20 years. Counselling as a profession has expanded greatly since the 1970s with a parallel increase in counselling training. Counselling in general practice courses have become available and the British Association of Counselling has set up a Counselling in Medical Settings division, which produced guidelines for counselling in general practice. We review the extent of mental illness in the community and the need for counselling, explore what counselling is and who the counsellors are, and critically examine the evidence for whether counselling works in a general practice setting.
Counselling in primary care in the UK is expanding rapidly, and its evidence base needs to be established. We present the rationale for conducting controlled trials of counselling in primary care, and suggest that a systematic review of controlled trials of counselling in primary care is timely. We describe the process of conducting the review in accordance with Cochrane Collaboration guidelines. The review aimed to assess the effectiveness and cost-effectiveness of counselling in primary care, by systematically reviewing cost and outcome data from randomised controlled trials and controlled patient preference trials of counselling interventions, for patients with psychological and psychosocial problems considered suitable for counselling. The search strategy, inclusion and exclusion criteria, data collection and data analysis are described. The results of the review are presented. The review included only controlled trials of counselling in which counsellors accredited by the British Association for Counselling (or equivalent) provided non-directive counselling in primary care. Four trials met the inclusion criteria. Results indicated that patients who receive counselling show a modest but significant improvement in symptom levels compared with those who receive GP care. Levels of satisfaction with counselling are high. There is very tentative evidence to suggest that counselled patients are more likely to be considered recovered than usual GP care patients. There is limited information about the cost-effectiveness of counselling. We conclude by reflecting upon the results of the review and their implications for counselling research.
This paper describes the level of mental health problems that are encountered in primary health care. The limitations of using randomised control trials (RCTs) in evaluating effectiveness of psychological therapies in primary health care are described. Although the RCT may be useful in evaluating interventions in highly controlled situations, its use in evaluating clinically representative service delivery research is limited. A three-stage model of psychological therapies research is described to show that distinct stages require different methodologies in order to evaluate them, and this model is used to structure the review. The literature on research carried out in more naturalistic circumstances is then reviewed. Evaluating psychological interventions in this way shows there is considerable evidence that psychological therapies are effective in a number of ways in a primary care setting. The naturalistic studies that are more typical of clinical practice support the use of psychological interventions. The theme of the grey literature is almost entirely positive from the point-of-view of patients and GPs alike. However, there is considerable diversity in the sophistication of the methodology of the latter studies. Some were comprehensive evaluations, while others were more akin to audit. A major shortcoming is that few described their qualitative methodology. This said, the themes arising from the reports are very consistent and, had they been supported by a more robust qualitative methodology, would have added even more support, financially and clinically, for the arguments for counselling provision in primary health care. The level of referred clients' distress, measured by a variety of measures, was shown to be moderate to severe and similar to the level of patients referred to Community Mental Health Teams (CMHTs). When they were measured, there was a considerable reduction in subsequent psychiatric symptoms.
This is the third and last report in a series of three articles reviewing and reassessing the late Graham Foulds theoretical conceptions of personality disturbance and personal illness and the scales that were developed to assess them. We have already reported on the Personality Deviance Scales (PDS; Deary et al., 1995) and the Personal Disturbance Scale (DSSI/sAD; Bedford and Deary, 1997). The present report concerns the Delusions-Symptoms-States Inventory (DSSI). The literature on this instrument is reviewed under three broad headings: theoretical background and technical aspects, clinical reviews and other studies. Multivariate analyses of the DSSIs 12 subscales and total structure are reported. All 12 subscales have adequate psychometric characteristics. The higher order structure of the instrument reveals two clear but correlated factors of anxiety and depression-elation. Interpretation of a third higher order factor is less certain. A brief overall assessment of Foulds contribution to differential clinical psychology is made and it is concluded that his theories and clinical psychometric instruments have lasting value
Despite limited evidence of their effectiveness, counsellors are increasingly being employed as part of the primary health care team. Evaluation of counsellor services is therefore important.
In 1990 the Cambridgeshire Family Health Services Authority initiated a pilot scheme to evaluate the role of counsellors in general practice and to help the authority determine its policy towards claims by general practitioners for reimbursement through the ancillary staff scheme.
Two group practices were identified and an external evaluator appointed. The evaluator and the general practitioners developed their aims and objectives for counselling in the general practice context, the number of counsellor hours per week and the type and process of referral. An experienced counsellor was appointed to work in both practices. Information was gathered over two years about doctors' reasons for referral, counsellor's initial assessment, patient outcome at the end of treatment, the patients' and practice teams' opinions about the counselling service, and patient outcome a year after counselling.
A total of 293 patients were referred in the first two years of the scheme, of whom 75% were women. The main reasons for referral were that the general practitioners considered the patients to be suffering from anxiety/stress (33%), interpersonal difficulties (33%) and depression (20%). Almost all referrals (98%) were considered by the counsellor to be appropriate. The counsellor was able to provide an assessment for the 248 patients who attended and either take on the case for short-term counselling (69%) or suggest referral to a more appropriate service (25%) (6% withdrew). The expected maximum of six sessions of 45 minutes duration per referral was achieved in 87% of cases. The service was valued by patients and doctors. It coped effectively with a high proportion of patients with problems who did not reappear as demand elsewhere in the practice, and achieved a reduction in dose of psychotropic drugs among those seen.
This study has shown the value of clarifying referral criteria and the intended role of the counsellor prior to the counsellor's introduction. This ensures effective use of a scarce resource and a high level of satisfaction among doctors and patients.
A counsellor worked for 1 year in three practices in a rural area where there was previously no practice-based counselling. The service was evaluated, using a range of methods, in order to inform general practitioners and policy-makers about the demand for counselling, where it fits with other services, its potential value and how to organise and audit the service efficiently. Five kinds of information were collected: administrative data; patients' views; well-being scores; GPs' perceptions of individual patients; and interviews with the counsellor, GPs and other primary care staff by an independent researcher. All the GPs used the service, referring 131 people. The most common reason for referral was 'relationship difficulties'. There were improvements in patients' well-being, self-awareness and coping skills, and high satisfaction among GPs and patients. Communication with other services was seen to improve. The counselling service was found to fill a gap by addressing the needs of a substantial group of patients for whom psychiatric care was inappropriate.