School-based humanistic counselling: Does it help reduce distress, and if so, how? EBPU 2012, London Mick Cooper, Jo Pybis, Katherine McArthur, Karen Cromarty, Andy Hill, Nancy Rowland, Jamie Murdoch, Nick Turner, Ruth Levesley Contact: mick.cooper@strath.ac.uk
BACKGROUND
Schools are an accessible and popular site of mental health service delivery
The emergence of schoolbased counselling for young people in the UK 1960 1970 1980 1990 2000 2010
Dissemination of school-based counselling in UK secondary schools Scotland: 64-80% (approx.) NI: All schools since 2007 Wales: All schools since 2008 England: 61-85% (approx.) Source: BACP 2012; estimated data for England and Scotland
Cases in England (per year) School-based counselling (approx. 60,000) Other CAMHS (79,966, 10-18 year olds, 2008-9) Source: CHIMAT, Cooper, 2004, 2006; BACP, 2012; Other CAMHS = multi/single disciplinary generic, targeted, dedicated worker in non-camhs team, & Tier 4
Outcome measure score (higher scores mean more distress) Change from pre- to postcounselling Counselling consistently associated with significant reductions in psychological distress from beginning to end Welsh Strategy evaluation Meta-analyses, ES= 0.81 1.09 from pre- to post- 25 20 15 10 5 Pre-counselling Post-counselling Source: Hill, 2011; Cooper, 2009; data from 5,575 cases
Predictors of effect Measure: YP-CORE gives approx. double effect size to SDQ Completeness of data: lower response rates give larger effects
Effect size Welsh evaluation: Effect size by response rate 2 1.5 1 0.5 0 0 20 40 60 80 100 Response rate (%)
But large pre- to post change with 97.3% response rate (n = 256) Effect size (d) = 1.26 (95% CI = 1.06 -- 1.46) (Cooper et al., in preparation)
Less distress Comparison against CAMHS, as recorded in the CORC dataset for clients receiving a psychological intervention 20 15 School-based counselling (UKwide). ES = 0.56 10 T1 (baseline) T2 School-based counselling (Wales). ES = 0.68
Less distress Comparison against CAMHS, as recorded in the CORC dataset for clients receiving a psychological intervention 20 School-based counselling (UKwide). ES = 0.56 15 10 T1 (baseline) T2 School-based counselling (Wales). ES = 0.68 CAMHS psychological interventions. ES = 0.52
But Not clear what intervention is being evaluated Lack of control means that change may be due to other factors
School-based humanistic counselling (SBHC) Distillation of UK school counselling practices Relatively non-directive: offers young person an empathic, nonjudgmental and trustworthy relationship to help make sense of their own difficulties Core practices include reflections, summaries, inviting client to explore and make sense of lived-experiences
STUDY I: SCOPED (2009)
1 st pilot RCT: SCOPED, 2009 Aim: To test the feasibility of a procedure for undertaking a randomised controlled trial assessing the clinical effectiveness of school-based counselling 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 at reducing psychological distress than waiting list conditions after 6 weeks
SCOPED design Assessment/ Pre-test Counselling Post-test Screening Check pastoral care/ parents Random allocation Not counselling (e.g., wait-list)
Counselling Standard SBHC Up to six weeks Experienced and qualified practitioner Delivered according to Skills for Health humanistic competences Sessions recorded, audited using the person-centred and experiential psychotherapies scale (PCEPS)
Waiting list No formal intervention (but young people could contact established school counselling service/pastoral care at any time)
Principal measures Strengths and Difficulties Questionnaire (SDQ) Emotional Symptoms subscale YP-CORE emotional distress 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 6 weeks Photos courtesy of and copyright Free Range Stock, www.freerangestock.com and Chance Agrella
Recruitment Screened n = 379 Not interested in participating n = 288 Assessed for eligibility n = 58 (15.3%) Do not meet inclusion criteria n = 26 Randomised n = 32 (8.4%) Counselling n = 16 Waiting list n = 16 Withdrew n = 3 Analysed n = 13 Withdrew n = 1 Wrongly allocated n = 1 Analysed n = 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
SDQ Emotional Symptoms No significant differences on principal outcome measure (SDQ emotional symptoms) 8 7 6 5 Counselling 4 3 2 Baseline Endpoint
SDQ Emotional Symptoms No significant differences on principal outcome measure (SDQ emotional symptoms) 8 7 6 5 Counselling Waiting list 4 3 2 Baseline Endpoint
Effect sizes and 95% confidence intervals on primary and secondary outcome measures 2.00 1.50 large effect 1.00 med effect 0.50 small effect 0.00-0.50-1.00-1.50 Emotional symptoms (SDQ) Total Difficulties (SDQ) Prosocial (SDQ) Impact (SDQ) YP-CORE MFQ School absences (SIQ) School wellbeing (SIQ) Self-rated improvements (SDQ)
Less psychological distress Depressed young people (MFQ 29) did significantly better in counselling (vs. waiting list) than non-depressed Non-depressed Depressed participants (n (n = 10) = 15) 8 6 4 Waitlist Counselling 2 0 Baseline Endpoint
STUDY II: SUPPORT (2010 2011) STUDY III: RELY (with Relate) (2011-12)
Revisions from SCOPED study 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
Assessment/ baseline Midpoint 6 weeks Counselling endpoint 12 week Random allocation Not counselling (e.g., wait-list)
Combined data One counsellor in RELY trial was not compliant with SBHC auditing and data was removed Data available for up to 61 young people (33 SUPPORT, 28 RELY)
Participants 21 males (34.4%) and 40 females (65.6%) 13-18 years old, mean age = 14.38 Predominantly white ethnic origin Mean number of session attended = 6.60
Less distress Psychological distress (YP-CORE) 12 weeks (sig. diff.) N = 30 (SBHC), 31 (WL) p =.02 ES = 0.59 6 weeks (sig. diff.) N = 30 (SBHC), 29 (WL) p =.006 ES = 0.68
Less distress Psychological difficulties (SDQ) 12 weeks (sig. diff.) N = 30 (SBHC), 31 (WL) p =.002 ES = 0.72 6 weeks (NS) N = 29 (SBHC), 30 (WL) p =.06 ES = 0.39
Personal goals (GBOM) Less distress 12 weeks (sig. diff.) N = 18 (SBHC), 24 (WL) p =.003 ES = 0.97 6 weeks (sig. diff.) N = 18 (SBHC), 23 (WL) p =.049 ES = 0.62
Self-esteem (SEQ) Less distress 12 weeks (sig. diff.) N = 30 (SBHC), 31 (WL) p =.03 ES = 0.46 6 weeks (NS) N = 29 (SBHC), 30 (WL) p =.28 ES = 0.23
startpoint midpoint endpoint 6 months Follow-up data: YP-CORE 25 counselling 20 15 10 5 n = 17
startpoint midpoint endpoint 6 months Follow-up data: YP-CORE 25 counselling 20 15 10 5 n = 17
12 weeks pre 6 weeks pre startpoint midpoint endpoint 6 months Case controlled data: YP-CORE 25 counselling 20 15 10 5 n = 11 (n = 5 at 6 months)
How might school-based counselling help to bring about individual change?
Qualitative interviews Helpful Aspects Helpful aspects of counselling (6+) 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 From Rosie Lynass, Pykhtina and Cooper, 2011
Psychological distress worrying Time to talk isolation confusion ruminating Talking problems through confidentiality warmth advice shame challenge Life difficulties: e.g., family break-up, being bullied finding solutions understanding Source: Cooper, 2009; Hill, 2011; Lynass, 2012; McArthur, 2012
Psychological distress worrying Time to talk isolation confusion ruminating Talking problems through confidentiality warmth advice shame challenge Life difficulties: e.g., family break-up, being bullied finding solutions understanding Source: Cooper, 2009; Hill, 2011; Lynass, 2012; McArthur, 2012
SUMMARY School-based counselling is an increasingly prevalent intervention Evidence from preliminary RCTs suggests that it brings about significant improvements in psychological wellbeing Changes are consistent with qualitative and case study material
THANKS Summary McArthur, K., Cooper, M., & Berdondini, L. (2012). School-based humanistic counseling for psychological distress in young people: Pilot randomized controlled trial. Psychotherapy Research. doi: http://dx.doi.org/10.1080/10503307.2012.726750 School-based counselling is a widely disseminated intervention, but rigorous evidence of effectiveness is limited Emerging body of evidence suggests that it does bring about significant reductions in psychological distress Matches many clients experiences of counselling and cohort data