The importance of research in counselling and psychotherapy
Questions regarding the effects of counselling and psychotherapy (therapy) are important and such questions range from the general to the particular. For example, to know how the effects of therapy generally compare with those of medication can guide national policy-makers as to whether to invest in medication or psychological therapies for people with psychological problems. The emergence of the Improving Access to Psychological Therapies programme would not have occurred without sound research as to the effectiveness of therapy as compared to medication. Similarly, on a more specific level research can tell us which types of therapy are most effective for particular types of client (e.g. children/ older people) or types of problem (e.g. anxiety/depression). This helps therapeutic services adapt themselves to meet the needs of local populations. The types of research investigating the effects of therapy are often divided into 2 categories: efficacy research which studies therapy under strictly controlled experimental conditions, comparing the difference between control and intervention groups, and effectiveness research which investigates therapy in routine settings using pre- and post- measures, but without a control group. Efficacy research is often referred to as Evidence-based Practice (EBP) and effectiveness research as Practice-based Evidence (PBE), the similarity of the two phrases denoting a complementary relationship. EBP tends to ask does it work? Whereas PBE asks does it work in routine practice? Both of these are important and related questions. The importance of research can be seen from a number of viewpoints. Firstly, as professionals we have a responsibility to expand the frontiers of knowledge in our field. Secondly, it is arguably unethical to offer therapy to clients where no evidence of effectiveness exists; to do so would be to waste their time or even put them at risk. Thirdly, we live in an era where the commissioning of therapy, particularly in the NHS, is guided by clinical guidelines which are derived from research evidence and so if we want our therapeutic interventions to be commissioned we must provide evidence of their effectiveness. Cognitive Behavioural Therapy (CBT) currently has the largest body of research evidence as to its effectiveness and in many ways other approaches such as Humanistic and Psychodynamic are playing "catch up". In this sense research is not only a scientific and an ethical endeavour, it is a political one which has at its root the desire to promote therapeutic plurality and choice of interventions for clients.
Types of Study
Randomised controlled trials (RCTs): A study in which people are allocated at random to either an intervention or control/comparison group. The effects of the intervention are determined by comparing the outcomes of both groups.
Systematic Reviews: Systematic reviews aggregate the findings of similar types of study addressing the same type of question, thus providing robust findings based on large amounts of data. Systematic reviews of RCTs, often known as meta-analyses are viewed as the most reliable type of evidence on which to base clinical and policy decisions.
Practice-based research: Studies which use pre- and post- measures (such as CORE) to study the effects of an intervention in a particular cohort of clients, without the use of a control group. Some types of case study and qualitative research can also fit within this category.
There is recent evidence to suggest counselling to be equally as effective as Cognitive Behavioural Therapy (CBT) with approximately 40% of people in Increasing Access to Psychological Therapies (IAPT) services moving to recovery for both interventions (Glover, Webb & Evison, 2010). A number of review papers have been conducted providing support for counselling to have significantly greater clinical effectiveness compared with usual care and it has been reported than person-centred counselling is effective for clients with common mental health problems such as anxiety and depression (e.g., Bower et al., 2000; Cape et al., 2010; King et al., 2000). Research comparing counselling to CBT and usual care indicates a comparable reduction in depressive symptoms for both counselling and CBT compared to usual care (e.g., Rowland et al., 2001); suggesting these interventions to be equally effective. In addition, there have been found to be no significant differences in direct costs between the three interventions, with some research indicating counselling to be less costly than CBT. Furthermore patients receiving counselling tend to be more satisfied with their treatment, than patients receiving CBT or usual care (Roijen et al., 2006).
Studies using routine outcome measures, such as Clinical Outcomes for Routine Evaluation (CORE) have reported reliable improvement pre- and post intervention for counselling for three quarters of clients (Mellor-Clark et al., 2001). Counsellors have also perceived their clients as having changed in their experience of themselves or of their relationships and to have benefitted from counselling (Howey & Ormond, 2002).
When provided with the choice 51% of clients chose counselling over antidepressant medications; effectiveness and cost of these interventions were found to be equivalent, although patients choosing counselling did better than those randomised to it (Unutzer et al., 2003). It has been suggested that perhaps the combination of counselling and anti-depressant medication may produce the most significant positive outcomes for clients (Baker et al., 2002).
NICE guidelines for depression
Summary of the types of studies included in NICE guidelines: what's not included and why.
The National Institute for Health and Clinical Excellence (NICE) was established as a Special Health Authority for England and Wales in 1999, with a remit to provide a single source of authoritative and reliable guidance for patients, professionals and the public. NICE guidance aims to improve standards of care, to diminish unacceptable variations in the provision and quality of care across the NHS and to ensure that the health service is patient-centred. All guidance is developed in a transparent and collaborative manner using the best available evidence and involving all relevant stakeholders. (Source: NICE Guidelines for Depression)
NICE guidelines do not incorporate all research conducted in an area of interest. There are very specific criteria that studies must adhere to in order to be included in the guideline. For example, with reference to research looking at the effectiveness of an intervention, only studies using a randomised controlled trial methodology (RCT) are considered. It is therefore important to remember, and NICE state this explicitly, that an absence of empirical evidence for the effectiveness of a particular intervention is not the same as evidence for its ineffectiveness. In addition NICE state:
Guidelines are not a substitute for professional knowledge and clinical judgement. They can be limited in their usefulness and applicability by a number of different factors: the availability of high-quality research evidence, the quality of the methodology used in the development of the guideline, the generalisability of research findings and the uniqueness of individuals with depression. (Source: NICE Guidelines for Depression)
Table 1. Counselling studies included in NICE guidelines for depression
Aims and method
Bedi et al., (2000)
Compared the effectiveness of counselling versus antidepressants
There were no significant differences and the evidence remains inconclusive (self-reported depression scores at endpoint: SMD 0.04; (95% CI -0.38, 0.47) and at 12-month follow-up: SMD: 0.17; (95% CI -0.32, 0.66); clinician-rated depression scores at endpoint: RR 1.20; (95% CI 0.80, 1.81) and does not support a conclusion that counselling and antidepressants are equivalent. This caution is supported by the 12-month follow-up, clinician-reported depression scores were significantly reduced in the antidepressant group when compared with counselling (RR 1.41; 95% 1.08, 1.83). The results of this study should be treated with some caution as the introduction of a patient preference element in the trial led to considerable differences in baseline severity measures between the two arms in the trial.
Greenberg, L.S. & Watson, J. (1998)
Examined the effectiveness of client-centered counselling versus process-experiential counselling.
The evidence indicates that there was no significant difference between treatments in reduction of self-reported depression scores (SMD 0.13; 95% CI, -0.57, 0.82).
Goldman, R.N., Greenberg, L.S. & Angus, L. (2006)
Compared client-centered counselling with emotion-focused counselling.
Clients' level of depressive symptoms, general symptom distress, interpersonal distress, and self-esteem improved in each condition, but improvement on symptomatology was superior in the emotion-focused therapy condition
Simpson, S., Corney, R., Fitzgerald, P., et al. (2003)
This study examined the effectiveness and cost-effectiveness of short-term counselling in general practice for patients with chronic depression either alone or combined with anxiety.
There was an overall significant improvement in the actual scores over time, but there were no significant differences between the two groups on any of the measures at either 6 or 12 months. However fewer experimental group patients were still ‘cases' on the BDI than controls at 12 months. There were no significant differences in the mean total costs, aggregate costs of services, or any service-group costs except for primary care, between the experimental and control groups over time.
Watson, J.C., Gordon, L.B., Stermac, L., et al. (2003)
Comparison of counselling versus CBT
There is insufficient evidence (only one small-sized study with wide CIs) to reach any certain conclusion about the relative effectiveness of these two treatments (for BDI scores post-treatment: SMD 0.04; 95% CI -0.38, 0.47).
Randomised controlled trials (RCTs) of counselling (not included in NICE guideline for depression)
Table 2. Summary of RCT studies of counselling
|Banerjee et al., (2011)||To assess efficacy and safety of two of the most commonly prescribed drugs, sertraline and mirtazapine, compared with placebo Randomised Controlled Trial||Older participants with probably or possible Alzheimers disease and depression were randomly allocated to receive sertraline (target dose 150 mg per day), mirtazapine (45 mg), or placebo (control group), all with standard care. The primary outcome was reduction in depression (CSDD score) at 13 weeks |
Results indicated no significant difference in depression scores at 13 weeks between groups. In addition, fewer controls had adverse reactions than did participants in the sertraline group or mirtazapine group, and fewer serious adverse events rated as severe.
Due to the absence of benefit compared with placebo and increased risk of adverse events, the present practice of use of these antidepressants, with usual care, for first-line treatment of depression in Alzheimer's disease should be reconsidered.
Bower et al., (2000)
Also reported in:
King, M., Sibbald, B., Ward, E., et al. (2000)
Ward, E., King, M., Lloyd, M., et al. (2000)
To determine the clinical and cost effectiveness of non-directive counselling, CBT and usual GP care in the management of depression and mixed anxiety and depression.
At four months depressive symptoms were significantly reduced for both non-directive counselling and CBT compared to usual GP care.
At 12 months there were no significant differences in outcomes between treatments.
There were no significant differences in direct costs between the three treatments
Chilvers, C., Dewey, M., Fielding, K., et al. (2001)
To compare the effectiveness of antidepressant drugs and generic counselling for treatment of major depression
Generic counselling was found to be as effective as antidepressant medication
Patients who chose counselling did better than those randomised to it
Holden, J.M., Sagovsky, R. & Cox, J.L. (1989)
To determine whether counselling by health visitors is helpful in managing post-natal depression
A larger proportion of women who were randomised to eight weekly sessions of counselling for post-natal depression displayed improvements in depression than the control group
Miller, P., C. Chilvers, et al. (2003)
Comparison of the cost-effectiveness of counselling with routinely prescribed anti-depressant drugs
There were no significant differences between the mean observed costs of patients randomised to anti-depressants or to counselling.
Roijen, Van Straten, et al. (2006)
Comparison of the cost utility of brief therapy with CBT and care as usual in the treatment of depression and anxiety
The direct costs of brief therapy were significantly lower than for CBT or for care as usual.
Simpson, S., Corney, R., Fitzgerald, P., et al. (2000)
To examine the effectiveness and cost-effectiveness of short-term counselling in general practice for patients with chronic depression or combined depression and anxiety, compared with general practitioner (GP) care alone.
There was an overall significant improvement in the actual scores over time but no difference between groups or between CBT and psychodynamic counselling approaches at either 6 or 12 months.
In addition, most patients were very positive about the counselling and considered it helpful.
There were no significant differences in the mean total costs, aggregate costs of services, or any of the service-group costs, except for primary care, between the experimental and control groups over time. The cost-burden to GP practices was significantly higher in the experimental than the control group at 6 months.
Unutzer, J., Katon, W. Et al. (2003)
To evaluate whether patients receive adequate treatment and to identify patient treatment preferences
51% of participants indicated a preference for counselling over antidepressant medications.
Ward, E., King, M., Lloyd, M., et al. (2000)
Comparison of counselling versus GP care.
The results indicate a significant medium effect in self-report depression scores at post treatment (SMD -0.49; 95% CI -0.83, -0.15) but no significant differences between the two treatment groups on discontinuation and self-report depression scores at follow-up.
Wickberg, B. & Hwang, C. P. (1996)
To determine the effectiveness of counselling for post-natal depression as compared to routine primary care.
Twelve (80%) of 15 women with major depression in the study group were fully recovered after the intervention compared to 4 (25%) of 16 in the control group.
Table 3. Summary of Systematic reviews/meta analyses
Bower, P., Rowland, N. & Hardy, R. (2002)
Also report in:
Rowland et al., (2001)Bower & Rowland (2006)
To compare the effectiveness of counselling in primary care with ‘usual care'
Counselling was found to be significantly more effective than usual care. People receiving counselling were more likely to be satisfied immediately after treatment than those receiving usual GP care Total costs associated with counselling and usual care over the long-term were comparable.
Cape, J., Whittington, C., Buscewicz, M., Wallace, P. & Underwood, L. (2010)
To compare the effectiveness of different types of brief psychological therapy administered within primary care across and between anxiety, depressive and mixed disorders.
Brief CBT, counselling and PST were all found to be effective treatments in primary care, but effect-sizes are low compared to longer length treatments. The exception is brief CBT foranxiety, which has comparable effect-sizes.
Harkness, E. F., and Bower, P.J. (2010).
To assess the effects of on-site MHWs delivering psychological therapy and psychosocial interventions in primary care on the clinical behaviour of primary care providers (PCPs).
When there were mental health workers on-site,patients may reduce the number of visits to their doctors; doctors may reduce how often they refer patients to off-site mental healthspecialists; doctors may reduce the number of drugs they prescribe to the patients who see the mental health workers; and the costsrelated to those drugs may be lower. However, these reductions were small and not found consistently in all the studies.
Hill, A., Brettle, A., Jenkins, P., & Hulme, C. (2005)
To appraise and synthesise diverse research evidence in order to obtain a reliable overview of the effectiveness, cost-effectiveness and acceptability of counselling in primary care.
Brief counselling was found to be more effective than routine primary care in the short termEvidence relating to counselling's long term effects is equivocal and further research is neededCounselling and CBT found to be equally effectiveCounselling and medication in combination may be most effective
Leichsenring, F., S. Rabung, et al. (2004).
To test the efficacy of short-term psychodynamic psychotherapy (STPP) in specific psychiatric disorders by performing a meta-analysis of more recent studies
STPP was found to be effective in the treatment of psychiatric disorders, compared to waiting list controls, treatment as usual and other forms of psychotherapy.
Table 4. Summary of Practice based research
Gibbard, I. and T. Hanley (2008)
A 5-year evaluation of the effectiveness of person-centred counselling
Significant increase in effect size pre- to -post- therapy for clients receiving person-centred counselling compared to a wait-list.
Person centred counselling reported to be effective for clients with common mental health problems, such as anxiety and depression
Effectiveness extends to people with moderate to severe symptoms of longer duration.
NICE guideline for depression
Baker, R., E. Baker, et al. (2002). "A naturalistic longitudinal evaluation of counselling in primary care." Counselling Psychology Quarterly 15 (4): 359-373.
Banerjee S, Hellier J, Dewey M, Romeo R, Ballard C, et al., (2011). Sertraline or mirtazapine for depression in dementia (HTA-SADD): a randomised, multicentre, double-blind, placebo-controlled trial. Lancet, 378(9789):403-11.
Bedi, N., Chilvers, C., Fielding, K., Williams, I and Duggan, C. (2000). Assessing effectiveness of treatment of depression in primary care. The British Journal of Psychiatry, 177: 312-318
Bower Peter, J. and N. Rowland (2006) Effectiveness and cost effectiveness of counselling in primary care. Cochrane Database of Systematic Reviews
Bower, P., Rowland, N. & Hardy, R. (2002) The clinical effectiveness of counselling in primary care: A systematic review and meta-analysis. Psychological Medicine, 33, 203-215.
Bower, P., Byford, S., Sibbald, B., et al. (2000) Randomised controlled trial of non-directive counselling, cognitive-behaviour therapy, and usual general practitioner care for patients with depression. II: Cost-effectiveness. British Medical Journal, 321, 1389-1392
Cape, J., Whittington, C., Buszewicz, M., Wallace, P. & Underwood, L. (2010). Brief psychological therapies for anxiety and depression in primary care: meta-analysis and meta-regression. BMC Medicine, 8:38
Chilvers, C., Dewey, M., Fielding, K., et al. (2001) Antidepressant drugs and generic counselling for treatment of major depression in primary care: Randomised trial with patient preference arms. British Medical Journal, 322, 1-5.
Chrisholm, D., and Godfrey, E., et al (2001). Chronic fatigue in general practice: economic evaluation of counselling versus cognitive behaviour therapy. British Journal of General Practice. 51 (462): 15-18.
Friedli, K., King, M.B. & Lloyd, M. (2000) The economics of employing a counsellor in general practice: Analysis of data from a randomised controlled trial. British Journal of General Practice, 50, 276-283.
Gibbard, I. and T. Hanley (2008). "A five-year evaluation of the effectiveness of person-centred counselling in routine clinical practice in primary care."
Glover G, Webb M, Evison F. Improving access to psychological therapies: a review of the progress made by sites in the first roll-out year. July 2010. http://www.iapt.nhs.uk/wp-content/uploads/iapt-year-onesites-data-review-final-report.pdf
Greenberg, L.S. & Watson, J. (1998) Experential therapy of depression: Differential effects of client-centered relationship conditions and process experiential interventions. Psychotherapy Research, 8, 210-224.
Goldman, R.N., Greenberg, L.S. & Angus, L. (2006) The effects of adding emotion-focused interventions to the client-centered relationship conditions in the treatment of depression. Psychotherapy Research, 16, 537-549.
Harkness EF, Bower PJ. (2010). On-site mental health workers delivering psychological therapy and psychosocial interventions to patients in primary care: effects on the professional practice of primary care providers. Cochrane Database of Systematic Reviews.
Hill, A., Brettle A., Jenkins, P., et al. (2008) Counselling in Primary Care: A Systematic Review of the Evidence. Leicestershire: BACP.
Holden, J.M., Sagovsky, R. & Cox, J.L. (1989) Counselling in a general practice setting: Controlled study of health visitor intervention in treatment of postnatal depression. British Medical Journal, 298, 223-226.
Howey, L. and J. Ormrod (2002). "Personality disorder, primary care counselling and therapeutic effectiveness." Journal of Mental Health 11(2): 131-139
King, M., Sibbald, B., Ward, E., et al. (2000) Randomised controlled trial of non-directive counselling, cognitive-behaviour therapy and usual general practitioner care in the management of depression as well as mixed anxiety and depression in primary care. Health Technology Assessment, 4, 1-83.
Leichsenring, F., S. Rabung, et al. (2004). "The Efficacy of Short-term Psychodynamic Psychotherapy in Specific Psychiatric Disorders: A Meta-analysis." Arch Gen Psychiatry 61(12): 1208-1216.
Lin, P., Campbell. D., et al. (2005). The influence of patient preference on depression treatment i primary care. Annals of Behavioural Medicine. 30 (2): 164-173.
Mellor-Clark, J., Connell, J., Barkham, M. & Cummins, P. (2001). Counselling outcomes in primary health care: a CORE system data profile. European Journal of Psychotherapy & Counselling, 4 (1): 65-86.
Miller, P., C. Chilvers, et al. (2003). "Counseling versus antidepressant therapy for the treatment of mild to moderate depression in primary care - Economic analysis." International Journal of Technology Assessment in Health Care 19(1): 80-90
Roijen, Van Straten, et al. (2006). "Cost-utility of brief psychological treatment for depression and anxiety." British Journal of Psychiatry 188(4): 323-329
Rowland, N., P. Bower, et al. (2001). "Effectiveness and cost effectiveness of counselling in primary care." Cochrane Database of Systematic Reviews 3(3)
Simpson, S., Corney, R., Fitzgerald, P., et al. (2003) A randomized controlled trial to evaluate the effectiveness and cost-effectiveness of psychodynamic counselling for general practice patients with chronic depression. Psychological Medicine, 33, 229-239.
Simpson, S., Corney, R., Fitzgerald, P., et al. (2000) A randomised controlled trial to evaluate the effectiveness and cost-effectiveness of counselling patients with chronic depression. Health Technology Assessment, 4, 1-83.
Unutzer, J., Katon, W. Et al. (2003). Depression treatment in a sample of 1801 depressed older adults in primary care. Journal of the American Geriatrics Society, 51 (4), 505-514.
Ward, E., King, M., Lloyd, M., et al. (2000) Randomised controlled trial of non-directive counselling, cognitive-behaviour therapy, and usual general practitioner care for patients with depression. I: Clinical effectiveness. British Medical Journal, 321, 1383-1388.
Watson, J.C., Gordon, L.B., Stermac, L., et al. (2003). Comparing the effectiveness of process-experiential with cognitive-behavioral psychotherapy in the treatment of depression. Journal of Consulting and Clinical Psychology, 71, 773-781.
Wickberg, B. & Hwang, C. P. (1996) Counselling of postnatal depression: A controlled study on a population based Swedish sample. Journal of Affective Disorders, 39, 209-216.
Cooper, M. (2008) Essential Research Findings in Counselling and Psychotherapy: The Facts are Friendly. London: Sage.
McLeod, J. (2008) Counselling in the Workplace: A Comprehensive Review of the Research Evidence (2nd edn). Lutterworth: BACP.
BACP Information Sheet R2 Evidence Based Practice By Pete Bower (2010)