Outcomes of school-based person-centred counselling for psychological distress in young people Mick Cooper Katie 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 experiencing 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

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’ Random allocation Screening Check pastoral care/ 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 Screened n = 379 Assessed for eligibility n = 58 (15.3%) Randomised n = 32 (8.4%) Not interested in participating n = 288 Counselling n = 16 Do not meet inclusion criteria n = 26 Waiting list n = 16 Analysed n = 13 Withdrew n = 3 Withdrew n = 1 Wrongly allocated n = 1 Analysed n = 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)

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 Less psychological distress

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 & Expectations Desire 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