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

(hig

her s

core

s m

ean

mor

e di

stre

ss)

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’

RandomallocationScreening

Check 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

SDQ

Emot

ional

Symp

toms

Counselling

No significant differences on principal outcome measure (SDQ emotional

symptoms)

2

3

4

5

6

7

8

Baseline Endpoint

SDQ

Emot

ional

Symp

toms

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 effectmed 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

chol

ogica

l di

stre

ss

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

mick.cooper@strath.ac.uk