outcomes of school-based person-centred counselling for psychological distress in young people mick...
TRANSCRIPT
Outcomes of school-based person-centred counselling for psychological distress in
young people
Mick CooperKatie McArthur
Rosemary Lynass
WAPCEPC 2012
Thanks to Karen Cromarty, Nancy Rowland, Jo Pybis, Susan McGinnis, Jamie Murdoch, Nick Turner, Ruth Levensley, and all colleagues who have helped with the collection and analysis of data
RATIONALE
Mental distress
• Levels of mental health
problems in children and
young people are increasing
• One in ten children in
the UK now experiencin
g a diagnosable
mental disorder
Person-centred counselling in UK schools
• Approximately 33% of counselling provided in UK schools is person-centred
• Remaining 66% is based around a person-centred/humanistic core, with elements integrated from other therapies
• Generally one-to-one, open-ended• Delivered by trained counsellors• Evidence for effectiveness very
limited
School-based humanistic counselling (SBHC)
• Formalisation of person-centred/humanistic counselling in schools
• Aim is to help young people find more satisfying ways of being by becoming aware of, and acting on the basis of, their genuine feelings, needs and experiences
• Provides an empathic, non-judgmental and trustworthy relationship
• Core practices include reflections, summaries, inviting client to explore – and make sense of – lived-experiences
• ‘Manualised’ through core competences for humanistic psychological therapies
• Audited using the Person-centred & Experiential Psychotherapy Scale
Effectiveness of SBHC
• Cohort studies indicate school-based counselling in the UK is associated with significant improvements in psychological health from pre- to post-counselling
5
10
15
20
25
Pre-counselling Post-counselling
Out
com
e m
easu
re s
core
(hi
gher
sco
res
mea
n m
ore
dist
ress
)Changes in levels of mental distress from pre- to post-
counselling across 16 counselling in UK secondary schools evaluations (Cooper, 2009)
Overall effect size (d) = 0.81
But…
• Need controlled evidence to evaluate whether SBHC is bringing about improvements
Objectives of initial pilot
• ‘To test the feasibility of a procedure for undertaking a randomised controlled trial assessing the clinical effectiveness of SBHC for emotionally distressed young people in schools’
• An opportunity to: – Identify any ethical issues and other
problems– Evaluate the suitability of measures– Identify likely recruitment rates– Obtain preliminary indication of efficacy
Principal experimental hypothesis
• For children and young people (13 – 16 years old) experiencing emotional distress, weekly counselling will be more effective than waiting list conditions after six weeks
DESIGN
Pilot RCT
Counselling
Not counselling
(e.g., wait-list)
Assessment/‘Pre-test’ ‘Post-test’
Randomallocation
ScreeningCheck pastora
lcare/
parents
Counselling
• Standard SBHC• Up to six weeks• Experienced and qualified
practitioner• Delivered according to Skills for
Health humanistic competences• Sessions recorded and audited
using PCEPS
Waiting list
• No formal intervention(but young people can contact established school counselling service/pastoral care at any time)
Principal pre- and post-test measures
• Strengths and Difficulties Questionnaire (SDQ) Emotional Symptoms subscale
– emotional distress• YP-CORE
– general difficulties (also every session)
• Moods and Feelings Questionnaire (MFQ)– depression
• Adapted Change Interview – qualitative measure of
process/outcomes
Recruitment
• Project based in five secondary schools: two in North East England, three in Scotland
• All schools currently have school-based counselling service : RCT service runs alongside
• Aim to recruit 32 participants: 16 counselling, 16 wait-list
• Key inclusion criteria: SDQ-ES > 4
Randomisation
• Undertaken as participants accepted into trial
• Allocation by independent computer software, accessed by internet
• Student told either:– ‘counselling straight away’ – ‘counselling in six weeks’
Results
Recruitment Screenedn = 379
Assessed for eligibilityn = 58 (15.3%)
Randomisedn = 32 (8.4%)
Not interestedin participating
n = 288
Counsellingn = 16
Do not meet inclusion criteria
n = 26
Waiting listn = 16
Analysedn = 13
Withdrewn = 3
Withdrewn = 1
Wrongly allocatedn = 1
Analysedn = 14
27 participants completed (7.1%)
Feasibility of protocols
• Recruitment rate feasible: approx. 3 participants/school/term (based on screening of approx 2 classes/school)
• Attrition rate acceptable: 12.9%• No major ethical obstacles• Participation in trial generally
described as positive and worthwhile by clients and professionals
• Mean sessions attended: 4.54
No significant differences on principal outcome measure (SDQ emotional
symptoms)
2
3
4
5
6
7
8
Baseline Endpoint
SD
Q E
motional Sym
pto
ms
Counselling
No significant differences on principal outcome measure (SDQ emotional
symptoms)
2
3
4
5
6
7
8
Baseline Endpoint
SD
Q E
motional Sym
pto
ms
CounsellingWaiting list
-1.50
-1.00
-0.50
0.00
0.50
1.00
1.50
2.00
Effect sizes and 95% confidence intervals on primary and secondary outcome measures
large effect
med effect
small effect
‘Depressed’ young people (MFQ ≥ 29) did significantly better in counselling (vs. waiting list)
than non-depressed
Non-depressed participants (n = 15)
0
2
4
6
8
Baseline Endpoint
Waitlist
Counselling
Less
psy
cholo
gic
al
dis
tress
Depressed participants (n = 10)
0
2
4
6
8
Baseline Endpoint
Waitlist
Counselling
Qualitative data
(from Lynass, Pykhtina and Cooper, 2012)
Results – Helpful Aspects
Helpful aspects of counselling
• talking or getting things out• counsellor qualities• being able to talk about things that
they felt unable to talk to family/friends about
• having other help alongside counselling
• feeling listened to/understood• confidentiality/privacy
Helpful Aspects
Talking or Getting Things Out
• “You pile them up and pile them up.
That’s what it’s like with
all my problems…but like talking to the counsellor I was able to
take one off at a time”
Counsellor Qualities
• “It’s not like she made me
feel uncomfortable or as though I didn’t want to
be there...I liked how she spoke to me
and stuff, and how she acted”
Helpful Aspects Talking About
Things They Didn’t Want to Talk to
Family and Friends About
• “ ’Cause like the counsellor was nothing
to do with me or anything it was easier to talk to her ”
Having Other Help Alongside
Counselling
• “ Some of my friends knew
that I was going...they were kind of more like ‘oh we’re here for
you’ ”
Helpful Aspects
Feeling Listened To & Understood
• “It was like they spoke to me as if they knew what
was going on inside my head. So I felt more
happy about that because then I felt
that someone understood what was happening and what was
wrong with me”
Confidentiality
• “Cause in here like I know it would just be
between me and the person”
Results
Problematic Aspects
• overall positive view of the counselling • few clients had any criticisms about the
counselling itself • not enough advice or questions • things that they would like to have
changed in counselling that didn’t • two clients who felt that little had
changed for them since counselling but did talk about some changes
More Direction? Differing Client Needs &
ExpectationsDesire for More Direction in Counselling
• “I didn’t really know what to expect but I
expected it to be a wee bit more
like…for them to like help a wee bit
more” • “A bit more
support…cause they were just like agreeing and that and not really telling me that much”
Value of Non-Directive Nature of
Counselling• “I think it was ‘cause, like, they
gave you the responsibility of
you, and they like helped to, they
made it look as if it’s your person. Then nobody else can tell you what
to do”
Pilot II: SUPPORT
SUPPORT trial
• McArthur, Cooper and Berdondini, 2011
• Revisions from initial pilot: – No screening. Intake through standard
pastoral care– Longer intervention: 12 weeks– Higher cutpoint for distress– YP-CORE as primary outcome– Use of goal-based outcome measure
Pilot III: RELY
RELY trial
• Replication of SUPPORT trial, except added 6 months follow-up
• Conducted with large provider of school-based counselling: Relate
What did we learn?
Ethics
• It is possible to conduct RCTs of person-centred interventions – no major ethical or philosophical issues emerged
• Most participants seemed to benefit, and no evidence that any suffered from the experience (see McArthur, 2011)
• Data emerging from even a small scale RCT can have a significant political impact
A programme of research
• Developing RCT evidence needs to be part of a programme of study: we learnt from the first study to develop a more effective second and third study; now onto fourth trial and building to large-scale funding bid
• RCT provides an opportunity to conduct associated, qualitative research: case studies, qualitative interview studies
• Potential to combine data, with bigger n…
Design issues
• Importance of trained counsellors and researchers
• Essential to have an effective and skilled coordinator
Improving the intervention
• Qualitative evidence indicates that non-directivity was unhelpful for some clients: suggests more active intervention may be of benefit
• Weekly monitoring of outcomes seems part of effective therapy
