Clinical Outcomes in Routine Evaluation (CORE) of Counselling and Psychotherapy: A Mixed Methods Evaluation of the Client Experience Summary of research submitted in partial fulfilment of the requirements of the University of East London for the degree of Professional Doctorate in Occupational Psychology 2008 Sponsored by Executive Summary The purpose of this study was to address a topic that had become, at one level, an unknown entity for practitioners and, at another level, a current topic in the world of EAPs, counselling and psychotherapy – outcome measurement and effectiveness. In a time of practice based evidence, accountability, duty of care and a need to demonstrate return on investment it had become apparent that the EAP and counselling professions required something more than the traditional satisfaction survey to prove effective. Stakeholders needed to know that services provided for their companies, organisations and employees did indeed add to the business need by assisting and supporting those employees whose personal difficulties interfered with their ability to perform at work. To demonstrate this, the study was designed to provide evidence that employees had improved in their functioning and overall well being following counselling and to identify what had helped during the process. The research study was designed and data collected using the Clinical Outcomes in Routine Evaluation (CORE) instrument. CORE is a measurement tool designed to measure overall well-being and taps four dimensions – subjective well being, problem severity, functioning and risk. It was used to collect quantitative data from 449 participants. In addition, qualitative data was gathered through a series of semi structured interviews with employees who had attended for counselling. Research results found EAPs and counselling intervention effective in assisting employees through demonstrating increases in subjective well-being and functioning and reduced problem severity. Risk did not prove to be a reported issue and the employees were shown, in many cases, to have resumed duty at work following a sick absence. Those who reported work related issues as contributing to their absence or lack of performance later reported a reduction in the severity of these issues following EAP/counselling intervention. The relationship formed with the EAP affiliate counsellor was found to be a major contributor in engaging the employee. In addition, it was found that employees were more likely to work towards improving their situation and learning coping strategies if they were satisfied that the EAP affiliate counsellor was properly trained and qualified and demonstrated an interest in the employee‟s overall improvement. A phased model of intervention is proposed which allows stakeholders monitor and track effectiveness and outcome of their EAP/Counselling service. Contents Introduction The Need for Evidence and Return on Investment What are Employee Assistance Programmes? The history of Employee Assistance Programmes and workplace counselling Measuring Outcomes of Counselling and EAPs Outcome measurement using CORE The Dimensions of the Measure The Phase Model Study Goals Does counselling and psychotherapy work? What works? The Relationship. Methodology - Research Design & Sample Participants Psychometric properties of the CORE–OM Procedure Results Discussion Limitations Conclusions Recommendations Impact on the Profession and Research Additional Workplace Data Extracted from the Research 5 5-7 7-8 8 - 10 10 - 11 12 - 13 13 - 14 14 - 15 15 - 16 16 - 17 17- 18 18 19 20 - 22 22 - 23 24 - 25 25 - 34 35 - 43 43 - 44 44 - 47 48 49 - 51 52 - 53 LIST OF CHARTS AND TABLES Description Page Chart 1 Spread of Agency Participation 21 Chart 2 Comparison of Risk with CORE 2002 Data Chart 3 Integrative Clinical / Private Practice Model Chart 4 Short Term EAP Work Based Practice Model Chart 5 Work Assessment for 139 Clients Chart 6 Presenting Work Issues for 172 Clients Table 1 Demographic Details of Participants Table 2 Reliability analysis for CORE 30 45 46 52 53 20 26 Table 3 Total CORE Outcome Measure-Comparison of Means Table 4 The Functioning dimension on the CORE Outcome Measure – comparing this evaluation with CORE Table 5 The Problems dimension on the CORE Outcome Measure – comparing this evaluation with CORE Table 6 The Subjective Well-being dimension on the CORE Outcome Measure – comparing this evaluation with CORE Table 7 The Risk dimension on the CORE Outcome Measure – comparing this evaluation with CORE Table 8 All items on the CORE Outcome Measure minus Risk – comparing this evaluation with CORE Table 9 Profile of Interview Participants 27 28 28 29 30 31 32 Introduction This research was conducted as part fulfilment or the requirements of the University of East London for the award of professional doctorate in occupational psychology. It was sponsored by the Irish Association for Counselling and Psychotherapy (IACP), Employee Assistance European Forum (EAEF), EAP Consultants and the Office of the Revenue Commissioners. The Need for Evidence and Return on Investment In a time of evidence-based practice and requirements under ethical practice, legislation and duty of care, therapists, particularly in Ireland, are faced with accountability in a way that is perhaps new and somewhat unfamiliar. Many counsellors source work from organisations, which offer short term counselling services as employee benefits while others work in private practice. Regardless of the setting, all are bound by professional ethics and legislation to provide the highest possible level of care for clients. This level of care can be enhanced and supported by a system that provides both therapist and client with evidence based quality assurance. This will assist both EAP providers in ensuring the delivery of quality service and purchasers of EAP and counselling services in choosing services or in making a decision to purchase these types of services. In reviewing literature on the topic of EAP outcome and effectiveness, one finds many studies offering explanations and support for the effectiveness of therapy and what makes therapy effective. Examples of this include research on the therapeutic relationship, skill of the therapist and the client‟s own resources. Investigations on this topic have been carried out in other jurisdictions on client experiences of what works in therapy (Gershefski, Arnkoff, Glass, & Elkin, 1996). However, no published data relating to this topic was found in Ireland. Studies and evaluations had been conducted in agencies and counselling services, but few has been published. With some exceptions (Bugge, Hendel and Moen, 1985), much of the current research about therapeutic process is based on the therapist‟s or researcher‟s experiences and assessments, rather than on the client‟s own perceptions (Dunkle and Friedlander, 1996). There were a number of reasons for conducting this piece of work. Among these were the ideas that it combined counselling and occupational psychology and it demonstrated a return on investment in EAP and counselling services to stakeholders. Where EAPs are concerned there appeared to be little research supporting the effectiveness in Europe and limited outcome research in the US. Other factors influencing the need for evidence include the Safety, Health and Welfare at work legislation introduced by Government in 2005. This placed a “duty of care” on both employer and employee to protect “insofar as is reasonably practicable” the mental condition of employees. (Ch. 1 (8), P. 18.) This research attempted to bridge the gap between evidence and the traditional belief that EAPs/counselling worked by providing evidence through the introduction of a measurement system combined with client accounts of what made their experience of therapy positive and effective. It included the use of short term interventions (two sessions) up to long term (forty sessions) of counselling and psychotherapy across a range of settings in work and in private practice. The current evaluation was conducted over a three year period in Ireland and addressed the question of outcome by examining the improvement shown over a number of sessions by the client. It also explored the question posed by Roth and Fonagy, (1996), „What Works for Whom?‟ Through the use of the Clinical Outcomes in Routine Evaluation (CORE) system and the exploration of the client experience of therapy, the evaluation examined outcomes in a more comprehensive way than client satisfaction feedback sheets traditionally used in EAP practice in Ireland. By implication the research is also an evaluation of CORE as a measurement tool in this type of setting. The evaluation begins with a definition of counselling and work based counselling systems often referred to as employee assistance programmes (EAPs). Current literature and studies are presented exploring the background to EAPs and the measure used to survey the participants. Components such as the value of the therapeutic relationship, techniques employed by therapists and theoretical approaches to counselling and psychotherapy are explored. The results and findings are presented and these are discussed with recommendations of a model of intervention and suggestions for the future. This research contributes to knowledge about the question of the effectiveness and outcome of counselling at work and counselling in private settings. It informs the profession about the process of therapy and what actually changes as the employee/client moves from a place of needing help and support to a greater level of coping. As an evaluation tool CORE is used to measure changes in subjective well-being and functioning. It also tracks changes in levels of problem severity and propensity to risk. It addresses the outcomes of counselling and the employee/clients‟ experience of the counselling process and employs a mixed methods, quantitative and qualitative, research approach. The Clinical Outcome in Routine Evaluation (CORE) instrument was used to measure outcome and it was predicted that counselling would positively influence well being and functioning and reduce problem severity and risk for participants. This, combined with client accounts of what helped and supported change, adds to the body of knowledge within the profession and supports both outcome measurement and effectiveness of counselling interventions. Some studies of workplace counselling have relied on brief client satisfaction questionnaires administered at the end of counselling. McLeod (2001) found that the data from such satisfaction surveys showed that around 80% of clients were highly satisfied, would return again, would recommend the service to a friend, perceived the counsellor as competent, etc. He suggested that these ratings were dominated by the client‟s appreciation of the efforts of the counsellor and the willingness of the counsellor to listen to them with acceptane but bore no relationship to the question of whether counselling had actually helped the person to deal with their problems. To develop an informed understanding of the helpfulness of counselling, it was necessary to move beyond satisfaction research and find ways of both tracking actual change in well-being over time through measures administered before and after counselling and of allowing clients to explore openly, and with depth, the meaning to them of the counselling received. One of the common criticisms of research evaluating the effectiveness of programmes aimed at enhancing well-being is that many factors other than the treatment programme itself can influence the results. This criticism is particularly valid when no comparison group is used and measures are only taken at the point of entry into a programme and at a single point in time immediately after completion (Carolyn, Highley-Marchington & Cooper, 1998). The use of both a control group and a qualitative component to this evaluation allowed comparison of the client experience with outcome measurement of well-being and allowed these findings to be compared with a control group of participants not presenting for therapy. What are Employee Assistance Programmes? Workplace counselling may be defined as the provision of brief, employerpaid, psychological therapy for the employees of an organisation. An „external‟ service, such as an Employee Assistance Programme (EAP), typically comprises face-to-face counselling, a telephone help line, legal advice and critical-incident debriefing. In an „in-house‟ service, counsellors may be recruited from within or directly employed by the organisation and provide similar services but they can also provide longer term counselling for employees, retired employees and their families of these groups. Workplace counselling offers employees a facility that is confidential, easily accessed (initial appointment normally offered within 5 days), provides a properly qualified and supervised practitioner, does not raise the threat of a diagnosis of psychiatric disorder and promises to alleviate distress within a reasonably short period of time (most services allow only 6-8 sessions in any one year). Workplace counselling offers the employer a service that is valued by employees, has the potential for savings by reducing sickness-related absence, restores productivity, takes pressure off managers through the availability of a constructive means of dealing with „difficult‟ staff or situations and contributes to an organisation‟s reputation as a caring employer. Workplace counselling is often viewed by employers as an insurance policy against the threat of compensation claims made by employees exposed to work-related stress, bullying and harassment or any other psychological threat. The provision of workplace counselling has steadily expanded over the past 20 years, with more than 75% of medium sized and large organisations in Britain and North America making counselling available to their staff (Carroll & Walton, 1999; Oher, 1999). The history of Employee Assistance Programmes and workplace counselling EAPs have their origins in the US where they were originally developed in the first half of the century to combat the adverse effects of alcoholism in the workplace (Carolyn Highley-Marchington & Cooper, 1998). Twenty five percent of the US workforce are now covered by or have access to such programmes. Counselling services for employees have been a part of organisational life since the 1930s (McLeod, 2001) and there has been a steady growth over the past 20 years of organisations making use of in-house workplace counselling services. They began in the UK in the early 1980s as internal programmes and have gradually expanded to the externally provided programme. In some cases external programmes are chosen or favoured for economic reasons or because they match an organisation‟s needs. These programmes have developed into a „broad-brush‟ approach in that they no longer concentrate solely on alcoholism but have extended to cover a wide range of issues influencing employees‟ performance at work. Use of the current programmes has been dominated by „self-referral‟, unlike the original ones where management used them to enhance performance. This has set the UK provision of work placed counselling apart from those provided by the US (Berridge & Cooper, 1994). In Ireland, the history was somewhat different. At the turn of the century, the Quakers (Presbyterians and Methodists) first introduced pension plans and housing for their employees. In the 1800s, Jacobs appointed a welfare secretary to look after staff concerns. This was followed in the 1900s when Rowntrees appointed social workers and, in the 1950s, when the Irish civil service appointed matrons to cater for the personal needs of female staff. The 1970s saw a change towards formal and structured support when the civil service appointed the first welfare officers. In 1972, recognising that alcoholism in Ireland was an increasing social problem, the Irish Congress of Trade Unions instructed the Executive Council to enter into early negotiations with the Federated Union of Employers with a view to establishing agreed principles or procedures in the treatment of workers who were victims. In 1973, in response to the emerging alcohol problem, the Electricity Supply Board (ESB) introduced a programme to deal with alcohol related problems for their employees. This initiative, which had the full support of the Trade Unions, is recognised as the first programme of its kind in Europe and provided a model for other semi-state and public bodies. The civil service followed by appointing a staff welfare officer and formally expanded and established the staff welfare service in response to a trade union report in 1981. The Employee Assistance Service in the civil service followed in 1991. 1985 saw a decline in companies introducing EAPs resulting from the deepening recession when there was a major focus in business on reducing staff numbers. As a consequence, employee welfare was afforded a low priority. This changed with the introduction of the Health, Safety and Welfare at Work Act, which was introduced in Ireland in 1989. The initial focus of the Act was on physical hazards at work but the 2005 Act encompassed psychological hazards such as violence, stress and bullying in the workplace. By this stage, many Irish state and semi-state bodies had established staff welfare programmes in some form and the providers of these programmes met quarterly for networking and training. In 1993, it was decided to form a professional body of counsellors and welfare officers providing the programmes. This became a chapter of the Employee Assistance Professionals Association in 2001. The growth of workplace counselling, EAPs and support services has been influenced by legislation since the establishment of the Employment Equality Act (1998), outlawing nine areas of discrimination including sexual harassment. Other Acts driving employee respect and well being included The Equal Status Act (2000). Employee Assistance development in Ireland has also been driven by recent legislation requiring employers to observe a duty of care towards all employees, including a duty of care with regard to: work stress (work overload) critical incident stress (CIS) violence at work workplace bullying / harassment / sexual harassment employee drug testing This emphasis on the duty of care has been strongly influenced by the Safety, Health and Welfare at Work Act, 2005, prompting more employers to engage the services of both internal and external EAPs and workplace counselling services. It now means that both employer and employee have a duty of care to each other. The employer is required to provide, insofar as is reasonably practicable, a work environment free from physical and psychological threat and employees are required to take responsibility for their ability to attend work and perform to the best of their ability. (Ch. 1, p. 18.) Measuring Outcomes of Counselling and EAPs The earliest attempts to measure outcomes in counselling and psychotherapy can be traced to the work of Eysenck, which concentrated on the efficacy of therapy. Outcome measurement can be traced back to the earlier work of Rogers (1957). Research on the efficacy of counselling and psychotherapy from the 1960s to the 1980s tended to concentrate on specificity in outcome and process, focussing mainly on the different types of interventions. Attempts to evaluate the effectiveness of EAPs and workplace counselling have tended to concentrate solely on the quantitative measurement. This has also been the case in Ireland. For quantitative measurement, most counselling at work programmes have tended to use basic statistical reports concentrating on utilisation rates and demographics while very little outcome measurement was employed in private counselling settings. There has been a move towards cost effectiveness and quality assurance in recent years. Private companies have concerned themselves with value for money and increased productivity whereas service providers, such as the health service and civil service, have been more concerned with accountability, efficiency and effectiveness. Whether research has concentrated on workplace counselling or private counselling, it is still evident that people will bring their personal worries to work at times, just as they will take work problems home with them (Steiner & Truxillo, 1989). This has implications for employers, particularly those that subscribe to the view that a healthy employee is a happy employee or truly believe that employees are their greatest resource and therefore must be cared for. From the 1970s to the 1990s, research concentrated on cost effectiveness and change pathways. In other words what was the most cost effective route to helping clients improve and return to functioning? Research from the mid 1980s to date has moved towards meaningful change for the individual and effectiveness of outcome. Rather than a return to functioning, research has moved towards demonstrating sustained and reliable improvement for clients. Previous research generations explored the efficacy of particular interventions. Rowland, Godfrey, Bower, Mellor-Clark, Heywood & Hardy (2000) suggested that the standard approach to evaluating counselling in general practice was to measure change in mental health scores (such as depression or anxiety), change in social functioning (e.g. the quality of family and social relationships, work and leisure activity, etc), to assess patient or client satisfaction with counselling and to measure health service utilisation and cost as a proxy for success or failure of the intervention. They saw this as the use of a range of measures to measure a range of outcomes. This is typical of the manner in which psychometric measurement is used to explore pre and post conditions and to make claims of improvement. While this can be used to indicate movement from one condition (clinical) to another (Nonclinical or normal) it tells us nothing about how this occurs and misses the rich experience of the client. Although it is a vast improvement on simple feedback sheets requiring clients to rate the therapy it lacks a qualitative component that would add additional evidence to the research. According to Barkham (2003), these studies formed the basis of evidencebased practice and how the findings relate to routine practice. This has led to the development of the practice based evidence model where evidence of meaningful change is built up through practice. Barkham suggested that the development of practice-based evidence rested upon the widening acceptance by practitioners of the potential utility of collecting routine process and outcome data to inform clinical practice. Current measures of outcome seek to demonstrate that clients presenting for therapy return to a clinically significant level of improvement. If the employee/client ended up in a functional range by the end of therapy, but the magnitude of change was not statistically significant, then it was not possible to claim that a clinically significant improvement had occurred. This has obvious limitations for employers providing EAPs in relation to the legal requirement of „duty of care‟. If an employee returns to work having availed of an EAP, yet is still not „clinically improved‟ then the issue of care arises and the question of how far and to what extent an employer must go to fulfil the „duty of care‟ to the employee. Outcome measurement using CORE The 34 items that make up the CORE–OM tapped four domains: Subjective Well-being (4 items), Problems (12 items), Functioning (12 items) and Risk (6 items). Subjective Well-Being is seen as tapping one core construct. The Problem domain comprises items on depression, anxiety, physical aspects and effects of trauma. The Functioning domain contains items tapping close relationships, general functioning and social aspects. Risk taps two aspects: risk to self and risk to others. CORE did not lead this research but instead allowed the establishment of emerging themes from the study. As a measure of well-being and risk which included functionality it appealed from an organisational perspective because the first premise of EAP is to assist an organisation in addressing employee difficulties that may be impacting negatively on work performance. If it were possible to measure a return to normal and acceptable functioning then this would appeal to organisations. Few organisations are willing to buy counselling services that are perceived as open-ended and costly. Developing an instrument for the evaluation was considered, but time and resources were not available for this. There would also have been reliability and validity issues with this approach. It was also considered that organisations could identify with CORE as BUPA and AXA EAP are now using it for screening. A number of instruments, (general health questionnaire) GHQ, (symptoms check list revised) SCL R 90, and the (outcome rating scale) ORS, to name a few, were considered as possible measurement tools for this research and the Clinical Outcomes in Routine Evaluation (CORE) measure was chosen as a suitable instrument for several reasons. It was a validated and reliable measure of outcome. It was designed in response to the Department of Health UK report calling for measures of routine evaluation to be built into services. It included a workplace assessment and a system for evaluation of this type of intervention rather than a single measure. It provided a benchmarking facility and included short versions. It has been adopted as a measure of choice by many work based EAPs and counselling services. CORE has become widely used as a routine assessment measure in centres offering psychological services across the UK and is currently being normed in Ireland. It was designed as a quality assurance system for the therapy profession to measure reliable and clinically significant change. It was used in the study to explore whether the amount of change recorded by clients on the outcome measures was reliable and was sufficient to rule out the possibility of it occurring by chance. The second aspect of the study explored whether the client scores, following some therapeutic intervention, placed the client within the normal population. This was referred to as clinical change. Since the 1980s, the paradigm of evidence-based practice has been growing in dominance and, in recent years, a complimentary paradigm of practicebased evidence has emerged (Barkham & Mellor-Clark, 2000; Margison, Barkham, Evans, McGrath, Mellor-Clark, Audin, et al. 2000). The principle is that evidence must be practice-based; it must show that procedures work and are effective in improving the quality of care. Barkham and Mellor-Clark (2003) suggested that the two key components central to achieving this were effectiveness and practice. Effectiveness examines results across services and practice analyses results within a service with reference to clients, practitioners, problems etc. According to its publishers, CORE has the advantage of examining: Overall well-being Functioning Subjective well-being Risk Problems Type of therapy Possible changes in medication Waiting periods Number of sessions Therapist intervention Outcome The Dimensions of the Measure In CORE subjective well-being refers to clients feeling good about themselves, not feeling tearful, not feeling overwhelmed by problems and feeling more optimistic about the future. In other words they feel better able to cope. Problem severity or symptom level refers to reported levels of tension, anxiety, energy, panic, despair, happiness and intrusive thoughts and memories. It is usually accompanied by sleep disturbance. Functioning refers to feelings of support, enhanced coping, closeness to others, feeling capable, being able to cope with criticism and shame. Risk refers to a client‟s propensity to self-harm of harm others. This is consistent with the Phase model described by Howard, Lueger, Maling and Martinovich (1992). The phase theory posits that discrete, yet interacting, facets of clients‟ conditions change at different rates over the course of psychotherapy. The three-phase model of psychotherapy entails progressive (sequential) improvement in subjectively experienced well-being, reduction in symptomatology and enhancement in life functioning. Specific change processes and classes of interventions are appropriate for different phases of therapy. Certain tasks have to be accomplished before others can be undertaken. The Phase Model CORE was developed and based on the Phase model of intervention. In the Phase model, the client experiences subjective well-being enhancement first, followed by reduction in symptomatology, with lasting changes in life functioning occurring more gradually. The model is composed of three phases that Howard et al labelled as remoralisation, remediation and rehabilitation. Frank and Frank (1991) described demoralisation as a stage wherein patients “are conscious of having failed to meet their own expectations or those of others, or of being unable to cope with some pressing problem. They feel powerless to change the situation or themselves and cannot extricate themselves from their predicament” (p. 35). Many patients who present for treatment have experienced painful symptomatology, resulting in perceptions of powerlessness and hopelessness (pessimism) and they have become distressed about the persistence of their negative emotional reaction. Therefore, clients present to counselling / psychotherapy for a variety of reasons and are usually demoralised when arriving at therapy. Work-based counselling services recognise the fact that a clear distinction between work-based problems and personal problems is not possible and that people bring their personal worries to work and their work worries home. The outcome measurement system used in this evaluation included a measure of the home/work relationship. Clients with personal issues presented to both internal and external organisational counselling programmes. The CORE system assessed the impact of counselling on wellbeing. It combined the reliable and clinical change reported by the client/participant group with a comparison group of participants not presenting for therapy. It also explored the client experience of what worked and what made the difference to improving well-being and functioning. The outcomes measured by CORE have been compared to outcomes of a random sample of the Irish population (n=87). It is unknown if these people were attending counselling or not and therefore it is assumed that they were functioning at a „normal level‟. The quantitative component utilised the CORE system. CORE involved collecting data on a number (n=362) of the clients seen by therapists in work and private settings across the country. The client group were those who agreed to participate in the study. Some EAP settings require therapists to use CORE as a matter of course and, in these situations; clients were asked for their permission to include the outcomes in the research. Before and after measures were taken at time one start of counselling and at time two during or at the finish of counselling. This provided a picture of therapy as it was provided for the clients from start to finish. Study Goals The goal of this piece of research was to measure outcome in terms of improvement or disimprovement across a number of dimensions with employees/clients attending EAP and private counselling services. In addition it sought to establish what made the difference to clients attending these services. 1. Does EAP/counselling positively affect employee / client well-being? 2. Does EAP/Counselling positively affect functioning? (CORE measures functioning by asking clients to rate the following on a five point scale; their level of feelings of support, enhanced coping, closeness to others, feeling capable, being able to cope with criticism and shame) 3. Does problem severity reduce following counselling? (CORE measures changes in problem severity on a five point scale by asking clients to report levels of tension, anxiety, energy, panic, despair, happiness and intrusive thoughts and memories usually accompanied by sleep disturbance) 4. Does EAP/counselling positively affect employee / client subjective well-being? (CORE measures subjective well being by asking clients to rate themselves on a five point scale with regard to feeling good about themselves, not feeling tearful, not feeling overwhelmed by problems and feeling more optimistic about the future. In other words if they feel able to cope) 5. Does the propensity for risk severity reduce following counselling? (Core measures client‟s level of risk, on a five point scale, by rating a propensity to self-harm of harm others) 6. What has contributed to improvement with clients who have used counselling services for help with problems? What has the client‟s experience of counselling been? Does counselling and psychotherapy work? Initially, a major question for practitioners was whether psychotherapy was effective. Ever since Eysenck (1952) suggested that psychotherapy is not only ineffective but might even have a detrimental effect on some clients, questions concerning the effectiveness of psychotherapy have been examined and debated. Therapeutic efficacy greatly depends upon factors that are independent from patient/client, extra-therapeutic and therapist-based factors. The term „extra-therapeutic‟ refers to client history, supports, motivation and anything beyond the technique used by the therapist or the therapeutic relationship. This evaluation used therapists from a range of disciplines and backgrounds and many reported progress with clients who had additional supports beyond therapy. With regard to therapy in Ireland the question has also been posed „what makes the difference‟? How do some clients progress and others don‟t or in some cases even deteriorate. Often this is the case with clients attending the same therapist. This leaves therapists questioning approach, personal style and duration of therapy. It places ethical requirements on therapists to work within competence and refer on when clients require some different intervention. The evidence accumulated over the last 50 years seems to be relatively clear. Studies have shown that psychotherapy is a process from which most clients who remain involved for at least a few sessions will benefit (Lambert, Sharpiro and Bergin, 1986, Dush, Hirt and Schroeder, 1983, Proleau, Murdoch and Brody, 1983; Shapiro and Shapiro 1982, Smith, Glass and Miller 1980) However, even though most clients make substantial improvements, it is also relatively clear that some clients get worse. The reported percentage of clients who deteriorate ranged from 6% to 7% (Orlinsky and Howard, 1980) to 11.3% (Shapiro and Shapiro, 1982). With such evidence supporting the finding that clients who remain involved for a few sessions benefit one wonders what causes them to benefit and in what way. Why do 6% to 7% get worse? Research has attempted to inform us about the „process‟. What is it that happens behind closed doors, shrouded in confidentiality, over short and sometimes long periods of time that sees clients emerging feeling better? Clients finishing therapy seem to report feeling better and improved. When this is investigated it seems that they report abilities to cope, not feel overwhelmed by life‟s difficulties, don‟t experience intrusive unpleasant thoughts and feel better able to cope with life. Psychotherapy outcome research has been so compelling that the debate regarding whether it is effective is no longer a major issue. Instead, the more important questions are; which aspects, methods and factors make significant contributions to the changes made in psychotherapy from the client‟s perspective (Lambert, 1991). There is no doubt that some clients gel with particular types of therapist and particular types of therapy more than they do with others. Is it therefore a „shopping around‟ exercise until a client finds something that meets his or her expectations? What works? One of the most important questions that can be asked about psychotherapy is what makes it work; what are the key ingredients that lead to therapeutic change? These questions have long been debated in the literature and much of the focus has centred on two primary components that are thought to lead to change: therapeutic techniques and the therapeutic relationship (Goldfried & Davila, 2005). Therapy works and is effective but it is still unclear as to what actually helps clients improve. Some hold the view that the therapeutic approach is paramount, others the skill of the therapist. Some therapists argue that improvement occurs when the client is ready and is motivated to change. Regardless of what works we do know that clients do not attend therapy to tell a therapist how great their life is or how happy they are. They usually attend when they find they are unable to cope without help and often have tried other avenues for help and resolution of their problems. So what does the research evidence teach us about what works for them? Previous research has found that there are aspects of therapy common among all models that are important to therapeutic change (Hubble, Duncan and Miller, 1999). These therapeutic aspects are derived from 40 years of outcome research (Lambert, 1991). Client improvement in therapy could be attributed to four crucial and common factors. These factors are extratherapeutic change, hope and expectancy (placebo effects), therapy technique and therapeutic relationship. Hubble, Duncan and Miller (1999) also point to the existence of these four factors common to all forms of therapy in order of their relative contribution to change. Broken down into percentages, these elements include (1) placebo, hope, and / or expectancy – 15%; (2) structure, model, and / or technique – 15%; (3) extra therapeutic – 40% and (4) relationship – 30%. This evaluation reviewed studies of these factors from literature on client accounts of how they experienced successful and unsuccessful therapy outcomes. It seems from compiling years of research we know that there is no one element that makes a difference and guarantees change. What seems to emerge from this research is the suggestion that individual differences play a significant role not only in the type of therapy for individuals but also the therapist. Also significant is the client factors, social and personality, motivation and the type of issue presented. The Relationship. Research has shown that a client‟s ability to engage in positive interpersonal relationships is one pre-treatment factor that may influence the development of a therapeutic alliance (Marmar, Weiss & Gaston, 1989). The impact of the alliance has been demonstrated in treatments ranging from 4 to over 50 sessions. The length of treatment, however, does not appear to influence the relation between the quality of the alliance and the therapy outcome (Horvath & Symonds, 1991). Clients‟ attitudes toward their treatment are likely to influence the development of the alliance. A feeling of dissatisfaction from having an undesired treatment imposed on them, or a feeling of disappointment from not receiving a desired treatment, could conceivably lead clients to be reluctant to engage in therapy and form a strong alliance. This may be significant when employees are referred through management referral to EAPs. The therapeutic alliance has emerged as one of the most viable and robust predictors of change and, potentially, outcome, in psychotherapy (Horvath & Symonds, 1991; Martin, Garske, & Davis, 2000). It has repeatedly been found to be a consistent predictor of treatment outcome. Methodology Research Design & Sample This evaluation was interested in not only the question of effectiveness and outcome, but the broader question posed by Evans, C and colleagues (2000) which asked „can different therapists, motivated by different theories and working in different settings, find a single measure – a core – for monitoring their work?‟ It was, therefore, important that this research incorporated a measure of work-based assessment and this was a feature of the CORE system. Many of the studies purporting to support evidence of outcome have been either quantitative in nature in that they utilised a pre- and postmeasure of improved subjective well being or reduction in problem severity. Others have relied on qualitative accounts of client experience. While both are valid and deliver supporting evidence for the profession, an evaluation that combined both methodologies could only serve to provide the profession with a greater knowledge of the process while, by implication, establish a tool such as CORE as a measure of outcome. A combination of both forms of data can provide a more complete analysis of a problem or question. The current evaluation employed a mixed methods research approach because a qualitative study could miss the richness of data derived from clients‟ reported experience (the voice of the client) and a qualitative study alone would have lacked the complementary value of a large number of statistically significant instruments. It aimed to utilise the strengths of both approaches. Data was collected from both the workplace and private practice settings. The study was carried out in one phase, with both quantitative data and qualitative data collected during the same time period. Different, but complementary, data was collected on the same topic. The clinical outcome in routine evaluation (CORE) instrument was used to measure outcome and it was predicted that counselling would positively influence well-being and functioning and reduce problem severity and risk for participants. Concurrent with this data collection, interviews explored the experience of participants who had attended counselling as clients. A grounded theory data analysis was chosen for analysis of interviews as the study sought to access client experience without influencing the client accounts. The reason for collecting both quantitative and qualitative data was to bring together the strengths of both forms of research and compare the results from two different perspectives. Participants These participants were drawn from work-based counselling and employee assistance programme (EAP) practices in various organisations and from private practices and agencies nationwide. Many clients accessing counsellors in private practice were doing so through employee assistance programmes. The result was a clinical sample of 362 clients and 87 comparison group. Had more time been assigned, it would have been possible to collect a much larger sample. The current evaluation, therefore, has measured findings from clients across Ireland (n = 449) representing a response rate of 38%. 1,200 questionnaires were distributed by post and by hand to therapists who had agreed to participate. It is worth noting that the remaining 62% could not be considered missing data as many of the 1,200 distributed measures were never used for a variety of reasons. Some therapists did not get around to it or could not deliver data within the time frame. Others had second thoughts about the use of measures and in some cases, circumstances had changed. The unused measures were returned with an apology. Table 1 outlines the demographic details of the participants. The resulting participant sample was drawn from work-based and private counselling sites across Ireland. Participants ranged were a balanced mix of male and female. The majority had presented for counselling voluntarily even though they were accessing private counsellors through work-based programmes. This would be typical of EAPs which usually attract 65% to 75% self referral. All completed CORE as part of their contact with their counsellors. Table 1. Demographic Details of Participants Category Clinical Group 362 Participants Control Group 87 Participants TOTAL n = 449 Participants Gender 48% Male 52% Female Age Range 16-76 Mean Age 36.49 SD 11.646 48% Male 52% Female 19-66 40.16 11.630 The sample was very varied. All, with the exception of some of the adult students, were in either part-time or full-time employment. Age ranged from 16 years to beyond retirement and participants were of mixed gender, work grade and residential location (rural and urban) across Ireland. The average age of the clinical group was 36 years, almost equally weighted between male and female. Comparison group average was 40 years with a similar gender weighting. The majority were availing of a work based EAP or counselling programme, whereas others were accessing therapy privately and on a longer term basis. Some of the participating therapists were employed by government agencies, health boards, voluntary funded bodies and trauma centres, so their client base formed a very specific and participant group. The Chart 2 outlines and illustrates the range of participating agencies and their contribution to the research. Chart 1. Spread of agency participation Spread of Agency Participation 3% 6% 4% 3% 2% 4% 2% 3% Irish Family Planning Association Spirasi CCST IACP Northern Ireland Health Services Executive Sligo Institute of Technology Dublin Institute of Technology Stephanie Regan & Associates EAP Consultants 5% Abate Counselling & EAP Therapists in Private Practice 68% Over 50 therapists from the agencies outlined in the diagram gathered CORE data from the 449 participant pool. The largest group were those in private practice who saw clients both as part of an EAP system and privately. Most of the client base accessing the private practices did so through work-based EAPs. Due to the diversity of counselling services in Ireland, it was decided to aim for a large participant pool. It was originally intended to access 1,200 participants using CORE. 1,100 of these participants were to form a clinical population across Ireland. These were adult males and females seeking the support and help of therapists for a range of difficulties. The remaining 100 formed a comparison / control group from the general population. It was decided to use a control group for comparison purposes. The use of a non-clinical group of participants facilitated comparison between those presenting for therapy, receiving therapy and completing a second outcome measure following therapy. It was felt that the post-therapy group would correlate well with a randomly selected group from a non-clinical population. This is supported by Carolyn Highley-Marchington & Cooper (1998), who claim that a common criticism of research evaluating the effectiveness of programmes aimed at enhancing well-being is that many factors other than the treatment programme itself can influence the results. This is particularly valid when no control group is used. Therapists working in a range of agencies, including adult student services, were invited to participate by asking clients of their services if they would care to participate. Some participants were seen for short-term therapy and others for longer term therapy. The co-operation of some of the sponsors and professional bodies was sought in gaining access to a participant pool. As the research progressed, the researcher realised that many of the participating therapists did not have the client base nor access to clients as was previously planned. As a result, a time scale from February 2006 to August 2006 was set by the researcher for therapists to collect CORE data. The questionnaire / instrument The term CORE stands for Clinical Outcomes in Routine Evaluation (CORE) system and was developed in the UK to measure overall outcome of therapy and the sub components of well-being, functioning, problems and risk. As a complete tool it is a 34 item likert type measure of overall well-being. The tool is commonly referred to as the CORE OM (CORE Outcome Measure). Psychometric properties of the CORE–OM Reliability In establishing reliability for CORE Internal reliability is indexed most often by coefficient alpha (Cronbach, 1951), which indicates the proportion of the variance that is covariant between items. Low values indicate that the items do not tap a nomothetic dimension of individual differences. Very high values (near unity) indicate that too many items are being used or that items are semantically equivalent (i.e. not adding new information to each other). All domains show an alpha of >0.75 and <0.95 (i.e. appropriate internal reliability). Confidence intervals show that the values are estimated very precisely by large sample sizes. Despite this, in establishing reliability for the CORE instrument, the publishers found only the problem domain showed a statistically significant lower reliability in the clinical than the non-clinical sample. Validity In terms of concurrent validity, the mean item score for the CORE–OM was correlated with scores across a range of other measures. Overall, the CORE– OM correlated highest with measures of symptoms (SCL–90–R, ρ = .88; BSI, ρ = .81) and depression (BDI, ρ = .85; BDI–II, ρ = .81) which were higher than for measures of other specific presenting problems: for example, anxiety (Beck Anxiety Inventory [BAI]; Beck & Steer, 1990, ρ = .65) and interpersonal (IIP–32, ρ = .65). Further studies using CORE found it to be reliable as a measure. In a study involving 2,140 clients who attended counselling at NHS centres across the UK, CORE returned alpha coefficients of .74 for subjective well-being, .87 for problem assessment, .85 for functioning assessment, .77 for risk assessment and .93 for overall psychological distress (Lyne, Barrett, Evans & Barkham, 2006). In a study comparing CORE with the Beck Depression Inventory (BDI) across 2,234 clients, CORE was found to correlate highly with the BDI leading to the conclusion that the CORE OM and BDI can be compared with acceptable accuracy in routine clinical settings (Leach, Lucock, Barkham, Stiles, Noble & Iveson, 2006). In this evaluation CORE was found to be a reliable and valid measure. In the current evaluation, CORE was used to examine and compare the therapeutic intervention used with the client and to explore the main models (including behavioural, humanistic, psychodynamic and cognitive). CORE was chosen because it is an outcome measurement system and was designed as a quality assurance system rather than a single Likert-type scale instrument. CORE was not utilised in a European setting due, primarily, to language and interpretation difficulties. It had been normed in the UK, but had been subjected to question in Ireland. Currently a working group of Irish users is adapting it for use here in Irish settings, and this project is ongoing. It was therefore, necessary to use it in its current unmodified state for the purposes of the research to allow benchmarking and ensure consistency. Procedure CORE was chosen, above other measures, due to its range of reporting data on outcomes. The complete system using therapy assessment, before and after, Likert-type outcome measures (34 point), before and after, and work assessment, before and after, facilitated examination of outcome of the intervention and its possible influence on the client / participant at work. The CORE–OM was designed to be scored by hand (for individual practitioners) or to be scanned by computer (for large-scale batch data). In addition to the CORE–OM, a comprehensive hub system has been devised, named the CORE System (Mellor-Clark, Barkham, Connell, & Evans, 1999). This provided further information from assessment and end of therapy forms completed by therapists. Issues covered include socio-demographic variables, previous and current service usage and idiographic accounts of presenting difficulties and helpful aspects of the therapy at completion. Nationwide seminars were held by the researcher. Counsellors, psychotherapists, psychologists and EAP professionals were trained in the use of the CORE system and, subsequently, a database of members willing to participate was established. Within the CORE system, a letter of invitation was issued to clients to engage with CORE as a research tool and an instrument to assist with therapy. In addition, the researcher also provided a letter inviting the clients to participate. Participation was entirely voluntary and clients could engage with CORE but opt not to have their details included in the research. There was no financial reward offered to clients for participation but if they wished they were given feedback on their CORE results (via their therapist) before CORE was returned for data entry. All data was anonymised. For the purposes of a comparison / control group, participants were invited, at random, to complete the first part of the CORE system, i.e. the therapy initial assessment and the first outcome measure. Having trained therapists nationwide, using CORE training material in the use of the CORE system, a database of therapists / practitioners willing to participate and use CORE with clients was compiled by the researcher. This was done for two reasons. It allowed the researcher to track the therapists using CORE with participants and it helped to increase the response rate as only those on the database had voluntarily participated. The expectation was that this would generate a greater response rate rather than sending questionnaires to therapists at random in the hope that they would utilise and return them. Permission was sought, through various agencies (e.g. Health Services Executive) to use CORE in their agencies. Therapists were asked to accept a realistic number of instruments, depending on whether they engaged in shortterm solution-focussed type work, EAP 4-, 6- or 8-sessional work or long-term work with clients. Numbers of sets of CORE were distributed nationwide by the researcher to all participating therapists and a tracking database established to monitor their use. Data was collected over a period of 9 months, ranging from 5 CORE sets to 100 CORE sets, depending on the level of work of the therapist. The therapist used CORE with clients who had agreed to participate by delivering and completing the therapy assessment, work assessment and first outcome measure at the start of therapy. An end of therapy assessment, end of work assessment and second outcome measure were completed when clients had participated in some counselling or completed counselling. All documents were returned to the researcher for analysis. The therapist was identified by a site ID code to enable specific reports to be returned to the therapist or agency. Results & Discussion The findings in this research study were drawn from work-based counselling and employee assistance programme (EAP) practices in various organisations and from private practices and agencies nationwide. Many clients accessing counsellors in private practice were doing so through employee assistance programmes. The result was a clinical sample of 362 clients and 87 comparison group. Detailed description of the sub-components of CORE outcomes with Irish clients Several important results emerge from the data and are discussed below. CORE was used in this evaluation with 449 participants, 362 of whom formed a clinical population. The remaining 87 represented a non-clinical population or comparison group. A descriptive account of their responses to CORE and its sub-components are presented below to aid understanding of CORE outcomes of counselling. Reliability analysis was conducted on all dimensions within the data and the coefficients are listed below. Many measures have been used in the past to collect data supporting improvement and outcome and, therefore, it was important that the measure used in this study was measuring what it was intended to. In order to support the hypotheses, it was important to establish reliability of the instrument in the current context. Table 2. Reliability analysis for CORE Measure Number of Participants Number of Items Alpha Coefficient PreCounselling .9463 .8843 .8931 .8010 .7135 Alpha Coefficient PostCounselling .9424 .8773 .8913 .7916 .4514 .9158 CORE OM Functioning Problems Well-Being Risk Comparison Group 318 - 232 328 - 240 328 - 243 342 - 242 340 - 245 87 34 12 12 4 6 34 The table indicates strong reliability across the overall 34 item measure used with the clinical group and the non-clinical group. Of the four dimensions, three, with the exception of the risk dimension, are again reliable in measurement. Here it was noted that the post therapy measure of risk was an unreliable measure and had to be treated with caution despite there being significant statistical difference between it and the pre-therapy risk measure. Total CORE outcome measure The mean values in this evaluation were 1.80 (SD.740) and 0.85 (SD .524) for pre-first session clients and post-last session clients. Based on an analysis of mean scores relative to the scale minimum, clients have made progress and fall within the parameters of a non-clinical population. They fall below the clinical cut-off score of 1.19. The minimum score of 0 and maximum score of 4 on the CORE measure is also relevant as post-therapy clients score a maximum of 3 overall (0 = „not at all‟ and 4 = „most or all of the time‟). A score of 3 indicates a shift from „most or all of the time‟ to „often‟. Both the mean values and standard deviation values are close to those found in CORE research. Table 3. Total CORE outcome measure – Comparison of Means. Mean for Current Study CORE IMS Benchmark (2007) N Minimum Maximum Standard Deviation PreTherapy Outcome Measure 318 0 4 1.80 1.81 .740 PostTherapy Outcome Measure 232 0 3 .85 .88 .524 Recent correspondence with CORE IMS Ltd (UK) has revealed that the preand post-therapy means for the current CORE database of 34,000 clients is now 1.81 pre-therapy and 0.88 post-therapy for the overall measure. The figures found in the current evaluation benchmark well against the CORE figures at 1.80 and 0.85. Analysis found significant differences between the group termed „clinical‟ and the post therapy measure of the same group, which had been deemed to shift from a clinical to non-clinical or normal functioning population. Clients had significantly improved following counselling. CORE measures client functioning over twelve items on the 34 item instrument. The mean values for functioning in this evaluation were 1.86 and 0.98 for pre-first session clients and post-last session clients. Based on an analysis of mean scores relative to the scale minimum, clients have made progress and improved in everyday functioning and fall within the parameters of a non-clinical population. They fall below the clinical cut-off score of 1.29. Table 4. The Functioning dimension on the CORE outcome measure – comparing this evaluation with CORE Mean for Current Study N Minimum Maximum CORE IMS 2002 Standard Deviation Pre-Therapy Functioning PostTherapy Functioning 328 0 4 1.86 1.86 .865 240 0 4 .98 .85 .626 Analysis found significant differences in terms of increased levels of functioning between the group termed „clinical‟ and the post therapy measure of the same group, which had been deemed to shift from a clinical to nonclinical or normal functioning population. Clients‟ daily functioning had significantly improved following counselling. The mean values for „problems‟ in this study were 2.24 and 1.08 for pre-first session clients and post-last session clients. Based on an analysis of mean scores relative to the scale minimum, clients have made progress and improved in everyday functioning and fall within the parameters of a nonclinical population. They fall below the clinical cut-off score of 1.44. Table 5. The Problems dimension on the CORE outcome measure – comparing this evaluation with CORE Mean for Current Study 2.24 N Minimum Maximum CORE IMS 2002 Standard Deviation Pre-Therapy Problems PostTherapy Problems 338 0 4 2.31 .888 243 0 4 1.08 .90 .663 Analysis found significant differences in terms of a decrease in levels of problem severity between the group termed „clinical‟ and the post therapy measure of the same group, which had been deemed to shift from a clinical to non-clinical or normal functioning population. The impact of clients‟ daily problems had significantly improved following counselling. CORE measures client subjective well-being over four items on the 34 item instrument. The mean values for well being in this study were 2.35 and 1.10 for pre-first session clients and post-last session clients. Based on an analysis of mean scores relative to the scale minimum, clients have made progress and improved in everyday well being and fall within the parameters of a nonclinical population. They fall below the clinical cut-off score of 1.37. Table 6. The Subjective well-being dimension on the CORE outcome measure – comparing this evaluation with CORE Mean for Current Study N Minimum Maximum CORE IMS 2002 Standard Deviation PreTherapy Well Being PostTherapy WellBeing 342 0 4 2.35 2.37 1.006 242 0 4 1.10 .91 .778 Analysis found significant differences in terms of increased subjective wellbeing between the group termed „clinical‟ and the post therapy measure of the same group, which had been deemed to shift from a clinical to non-clinical or normal functioning population. Clients‟ daily subjective well-being had significantly improved following counselling. CORE measures client risk over six items on the 34 item instrument. The mean values for risk in this evaluation were 0.41 and 0.09 for pre-first session clients and post-last session clients. Based on an analysis of mean scores relative to the scale minimum, clients are less at risk and fall within the parameters of a non-clinical population. They fall below the clinical cut-off score of 0.31. One would expect this to indicate an improvement. However, analysis of the 6 risk items questions this. Table 7. The Risk dimension on the CORE outcome measure – comparing this evaluation with CORE Mean for Current Study N Minimum Maximum CORE IMS 2002 Standard Deviation PreTherapy Risk PostTherapy Risk 340 0 3 .41 .63 .570 245 0 2 .09 .20 .204 The reliability coefficients for risk in this evaluation are marginal at 0.7135 for pre-therapy and significantly below the acceptable scores at 0.4514 for posttherapy. In addition the (SD) standard deviations for both pre and post therapy risk dimensions are greater than the mean in both cases indicating pre-and post-therapy risk as different. It did not correlate with any of the other three pre-therapy dimensions. The Chart below shows the differences in mean and standard deviations for the Risk Dimension. 0.8 Chart 2. Comparison of Risk with CORE 2002 Data 0.75 0.7 0.63 0.6 0.57 0.5 0.45 0.41 0.4 0.3 0.2 0.2 0.09 0.2 0.1 0 CORE Std. Current Current CORE Std. 2002 Mean Deviation Study Study Std. 2002 Mean Deviation NonMean Non- Deviation Clinical Clinical Clinical Current Study Mean Clinical Current Study Std. Deviation While there was a significant difference between pre- and post-therapy risk, the dimension was found to be an unreliable measure in this evaluation. Accordingly, further analysis, which excluded the risk dimension, was conducted on the measure. . CORE measures client well-being over four items on the 34 item instrument. The measure contains 28 items making up the dimensions of functioning, problems and well-being when the risk items are removed. The values for all, minus risk, in this evaluation were 2.10 and 1.02 for pre-first session clients and post-last session clients. Based on an analysis of mean scores relative to the scale minimum, clients have made progress and improved in everyday functioning, problem and well-being and fall within the parameters of a nonclinical population. They fall below the clinical cut-off score of 1.36. Table 8. All items on the CORE outcome measure minus risk – comparing this evaluation with CORE N Total-Pre Therapy – All minus Risk Total-Post Therapy – All minus Risk Minimum Maximum Mean CORE IMS 2002 Standard Deviation 321 0 4 2.10 2.12 .836 233 0 4 1.02 .88 .616 Having removed the 6 risk items, differences in the group means of clients presenting for counselling at first and last sessions were compared and significant differences were found for pre- and post-counselling. Clients‟ daily well being had significantly improved following counselling. The evaluation concluded that the intervention of counselling in work and private settings improved client subjective well-being and functioning and reduced symptom / problem severity. Risk was also shown to decrease. However, the measure was questionable in terms of reliability for the measurement of this dimension in this evaluation. In addition to the collection of CORE outcome data some of the participants in the research were interviewed about their experience of attending EAP/Counselling. Seven clients were interviewed, forming a cross-section of work-based and private participants. The participants in the sample were drawn from the adult population nationwide. All, with the exception of some of the adult students, were in either part- or full-time employment. Age ranged from 16 years to retirement and participants were of mixed gender, grade at work and residential location (rural and urban). The average age range 36-45 was comparable to the participants in the quantitative study. Therapists working in a range of agencies, including adult student services, were invited to participate by asking clients of their services if they would care to participate. Participants were presenting for support, counselling, EAP and psychotherapy services for a range of difficulties. Some were seen for solution focussed short-term therapy and others for longer-term therapy. Four of the seven participants were accessing therapy through EAPs. One of the four had decided to continue privately. The table below outlines the profile of the participants. Table 9. Profile of interview participants GENDER AGE EMPLOYMENT RANGE STATUS NATIONALITY WORK-BASED or PRIVATE COUNSELLING Work Based Private Private Work Based Private Private (EAP) Work Based Male Male Male Male Male Female Female 36 - 45 36 - 45 46 - 55 26 - 35 18 - 25 18 - 25 36 - 45 Full time paid Full time self employed Retired Full time paid Student Full time paid Full time paid White Irish White Irish White Irish White Irish White Irish White Irish White Irish The participant interviews, which were based on a semi-structured interview around four core themes, were approximately 45 minutes to one hour in length. The four core themes were; 1. Personal experience of counselling 2. The difference the counselling may have made to their personal and professional life 3. What, in their opinion, actually made a difference 4. The impact on their lives for the future. These themes were explored through a series of questions focussed towards the process of counselling experienced. The interview started with the single question “What has been your experience of using the counselling service”? An emerging account of what happened during their time with the therapists is outlined as follows; People (clients) attend counselling when they have reached a point in life when they feel they are unhappy, not coping very well or struggling with some particular issue that is making them miserable. Often they feel they are no longer in control of their lives. They have become demoralised and have sought various means of dealing with problems. They have developed a poor image of themselves, regarding themselves as flawed and unable to function. Sometimes the means they use to cope are self depreciating or self destructive and can include alcohol and drugs. They have also reported trying other supports including speaking with friends and family, and attending their doctors, which often resulted in prescribed medication. When they still find themselves unhappy and not functioning as well as they would like they turn to therapy in the hope that it will help. For some, apprehension exists around therapy at first and they find the whole process of speaking with a mental health or psychological professional a frightening experience. It is seen by some as a support for people who are losing their mind in some way. As they engage with therapy however, over a period of time they gradually find that this impartial relationship allows them space to explore specific issues and plan towards more satisfying and resourceful ways of living. They can explore various aspects of their life and feelings, talking about them freely and openly in a way that is rarely possible with friends or family. It is important that the therapy is conducted in a private and confidential setting with a properly trained professional to explore a difficulty they are having, distress they may be experiencing or, perhaps, their dissatisfaction with life or loss of a sense of direction, purpose and control. Acceptance, respect and caring for the client are essentials and help a trusting relationship develop between client and therapist. This particularly involves clients feeling that they are not being judged in any way. As this relationship develops it enables clients to look at many aspects of their life, their relationships and themselves, which they may not have considered or been able to face before. The therapist helps clients, through a range of interventions and techniques, to examine in detail the behaviour or situations, which are proving troublesome, and to find an area where it would be possible to initiate some change. Effectively the therapist becomes a teacher, teaching the client new coping skills and options for improving their situations. Effectively, the process of counselling seeks to initially support and then teach clients to draw on their own resources and rebuild their own coping strategies. It does this by first listening to the client, developing a safe and respectful relationship, teaching the client through practical means and experiential means and working with a client until the client has returned to a point where he feels resourceful enough to take charge of his life situation by himself. This is usually a staged process where clients feel comfortable and trusting before they engage with disclosure or any practical tasks. When they have reached a point where they can engage with strategies or tasks to address their issues they feel better able to cope, empowered and return to a normal level of functioning. (Davy 2008) The accounts of the clients interviewed suggested that counselling was effective and had been helpful. CORE indicated progress with the client group across three of the four dimensions, subjective well-being, reduction in problem severity, and increased functioning. This is consistent with previous research by the developers of CORE. It was found that clients attending counselling experienced an increase in subjective well-being, an increase in overall functioning and a significant improvement in problem severity. The factors that proved positive and determined good outcome for clients included hope and expectancy, the therapeutic relationship between client and therapist, the skill of the therapist and other factors termed “extra therapeutic”. Extra therapeutic referred to various aspects of clients and their experiences, such as their history, supports, coping skills and life stressors, clients‟ motivational level and expectation ego strength, the ability of the client to identify the problem on which to focus, the manner of client participation in the therapeutic relationship, the severity of the clients presenting problem and the client / therapist match. The quality of the patient, or client support, network and self-help literature was also found to influence the experience as did therapists‟ credibility, skill, empathic understanding and affirmation of the client, together with their ability to engage the client, to focus on the client's problems and to direct the client‟s attention to the affective experience as being highly related to successful treatment. Demographic variables (including social class, race, intelligence, gender, age and marital status) and the way that the client becomes involved in the therapeutic relationship were found to play a role in the treatment process and treatment outcome. Finally, some research claimed that of the common factors extra-therapeutic factors play the biggest part and have an influence on 40% of outcomes (Asay and Lambert, 1999). Does this answer the question; „What works for whom‟? What do we now know that we did not know already? Through the use of CORE as an evaluation tool this study shows how clients progress through therapy, how their subjective well-being improves, their problems reduce and their functioning is enhanced. In addition, the voice of the client lends support for the process informing us of what made the difference. It provides a theory of counselling based on measurement that adds to our knowledge of the process and by implication shows that CORE can be used as a suitable measure in these settings. Discussion In this evaluation, the Clinical Outcome in Routine Evaluation (CORE) instrument was used to measure outcome and predicted that counselling would positively influence subjective well-being and functioning and reduce problem severity and risk for participants. Initial results indicated that CORE had done exactly that – it showed that clients had improved across the four dimensions of subjective well-being, problem severity, functioning and risk. While the research intended to measure therapy outcome with a particular client group; those people accessing counselling through workplace EAPs and inform us about the process, it did not set out to test the CORE measure as a suitable tool for measurement in these settings. By implication, however, it did exactly that. To begin with, CORE indicated progress with the client group in across three of the four dimensions, subjective well-being, reduction in problem severity, and increased functioning. This is consistent with previous research by the developers of CORE. In their study to establish reliability, validity and sensitivity to change for CORE, Evans, Connell, Barkham, Margison, McGrath, Mellor-Clarke and Audin (2002) found the measure to be reliable with an alpha coefficient of 0.94 for both clinical and non-clinical populations. It was found that clients attending counselling experienced an increase in subjective well-being. In other words, they were less prone to being tearful and upset about their situations, less overwhelmed by them, they feel better about themselves and were optimistic about the future. It was also found that attending counselling services, either at work or privately, would result in an increase in clients‟ overall functioning. This meant the client felt less isolated and felt supported by someone. The client was more likely to engage with other people without being angry or annoyed, felt better able to cope and face difficulty, did not feel shamed or criticised and believed in his capacity to achieve. Attending EAP / counselling services in work and private settings resulted in a significant improvement in problem severity for clients. In other words, the severity of the symptoms of problems became less intense or resolved as counselling progressed. Clients reported feeling less tense, anxious and nervous and more enthusiastic and energetic. They experienced less physical and cognitive symptoms such as aches, pains, sleep disturbance, panic, intrusive thoughts and worries that would reduce their ability to function normally. Instead of feeling hopeless, they looked forward to the future and felt happier. When it came to risk, the result was somewhat different. While analysis showed significant differences in risk severity before and after counselling, the reliability of the 6 items on the measure (risk dimension) in this study had to be treated with caution due to the low reliability coefficient. It had to be considered that the clients sampled in this evaluation were primarily employed and accessing counselling under EAP schemes at work or choosing to attend counselling privately and were unlikely to have been physically violent towards themselves or others, intimidated others or wished / thought that they would be better off dead. It would be unusual and unlikely to find employed people who are holding down jobs accessing their workplace EAP scheme for support and then reporting that they intend to physically harm themselves or others in the workplace. As an example the risk items on the instrument are divided into two domains, risk or harm to self and to others. Harm to others includes being physically violent, threatening or intimidating. Not many people admit to engaging in this type of behaviour in the workplace. Self harm refers to thoughts of hurting oneself up to thoughts that one was better off dead. It is unusual to find this reported by client groups in these settings. Those who do have suicidal ideation have often been to their doctor and are taking medication. They would often be on sick absence from work and may be under psychiatric care. The majority of participants in this evaluation did not present in this way. With this in mind, the use of CORE in its complete unaltered form (34 items, 6 of which are risk) proved unsuitable as a risk measure and a tool within EAP workplace settings. However, if the risk items are removed or modified to reflect the environment it has proved to be a suitable and reliable measure of outcome. The developers of the instrument support this. Lynn, Barrett, Evans and Barkham (2006), found that the utility of CORE-OM had already been demonstrated as a widely used benchmarking measure and reliable indicator of change in psychotherapy research and practice. They found the scoring method that had proved most useful in this regard was that in which all 28 non-risk items are scored as one scale and the risk items as the other. Their research confirms that the scale quality of CORE-OM when scored in this way is satisfactory. This is consistent with the findings of this evaluation. As an overall measure, CORE found significant improvement across all domains with the exception of risk. The „All non-risk items‟ mean scores of 2.10 and 1.02 for pre-first session clients and post-last session clients compare favourably with the original CORE means (2002) of 2.12 and 0.81 for pre-first session clients and post-last session clients. These results were significantly different for pre- and post-therapy clinical clients. There are several possible explanations for the lack of reliability of the risk dimension. Despite undergoing training in the use of CORE prior to conducting the research, it was found that many counsellors / psychotherapists were uncomfortable asking the „risk‟ questions of clients, particularly in a workplace environment and examination of CORE assessment documents for pre- and post-therapy revealed a difference in reported risk levels by clients compared to assessed risk by therapists. This may well have affected outcome in terms of reported risk. On data entry, for example, clients‟ reported levels of risk differed from the therapist assessment. Factor analysis on the dimension of risk showed that it loaded or divided across two factors, harm to self and harm to others and conversations with therapists that had participated in the study revealed that many of the clients in the clinical sample were from a white Irish employed group and did not see their problems as risk orientated. In other words, they did not feel suicidal nor did they report wanting to harm others. Another possibility considered was the fact that at least half the clinical group were accessing work based EAP / counselling services and may not have wanted to appear too psychopathological in their responses. This could also be supported by the qualitative findings during interview where clients reported a lack of understanding of counselling, a stereotypical view of the type of person needing the help of a counsellor and the need to build trust with the therapist. Another consideration was that the CORE instrument used in the study had been normed in the UK with a clinical population, many of whom, up to recently, had been drawn from patients / clients accessing National Health Service. The client groups in this evaluation were different in that they were employed and often paying clients accessing services by choice. It may be necessary to develop an EAP specific version of the CORE instrument. Overall, the quantitative evaluation showed that the client group moved from a clinical to non-clinical status following counselling. How much they improved and what caused that improvement was explored in the qualitative evaluation. If the purpose of the research was to show an improved outcome, then the quantitative evaluation showed this. However, it fell short in its explanation of how this happened. The qualitative evaluation, therefore, explored the client experience with these considerations in mind and began with the client / therapist relationship. Clients reported counselling as an unknown, misunderstood and anxiety provoking experience at the start but as they began to trust the therapist a relationship of respect and caring developed. As a result, they engaged with the therapist who allowed them space to safely examine life issues. Through talking, being listened to and learning new approaches they developed awareness, valued themselves, took control of their lives and learned to cope and function better. Many had tried speaking with family and friends but found they were not skilled to deal with the problems counselling could address and those on medication found it alone did not solve the problem. It would seem from the analysis of the client interviews, that no one factor was attributed to helping. It was more a combination of factors that led a process over a short or, in some cases, long period of engagement with therapy When exploring accounts of these clients we find links with previous research reiterating a range of factors that contributed to outcome. For example, Lambert‟s (1991) meta-analysis of research attributed improvement in therapy to four crucial common factors. These factors are extra therapeutic change, hope and expectancy (placebo effects), therapy technique and therapeutic relationship. Although researchers had shown that the alliance played a significant role in just about any form of therapy (Horvath, 1994; Horvath & Bedi, 2002; Martin et al, 2000), the questions of how the alliance would articulate with the healing process in general and how it would interact with specific healing practices were less often addressed directly. Research has shown that factors other than the alliance, placebo and therapist skill, have been found to play the biggest part among the common factors and have an influence on 40% of outcome results (Asay and Lambert, 1999). These include client history, supports, coping skills, life stressors, motivational level and expectation ego strength, the ability of the client to identify the problem on which to focus, the manner of client participation in the therapeutic relationship, severity of the clients‟ presenting problems and the client / therapist match. The clients also needed to be ready to make changes in their lives, both inside and outside therapy. (Asay and Lambert, 1999; Strupp, Fox and Lessler, 1969), Research by Hubble, Duncan and Miller (1999) also points to the existence of these four factors common to all forms of therapy in order of their relative contribution to change. Broken down into percentages, these elements include (1) placebo, hope, and / or expectancy - 15%; (2) structure, model, and / or technique - 15%; (3) extra-therapeutic - 40%, and (4) relationship 30%. The current evaluation is consistent with research in that it identified, through grounded theory analysis, a number of factors that clients stated had contributed to them feeling therapy had helped. Having established the existence of many of the factors outlined in the current evaluation it still remained unclear as to how, if at all, the use of CORE to measure progress and outcome linked with these client accounts and how client accounts of their journey through therapy indicated movement from a stage of not coping to feeling better and more in control of their lives. The Phase Model – linking the studies In reviewing the literature and the background to CORE, the Phase Model was introduced. The phase theory posits that discrete, yet interacting, facets of clients‟ conditions change at different rates over the course of psychotherapy. The three-phase model of psychotherapy entails progressive (sequential) improvement in subjectively experienced well-being, reduction in symptomatology and enhancement in life functioning. Specific change processes and classes of interventions are appropriate for different phases of therapy. This research has shown that clients attending therapy have improved and moved from a clinical to non-clinical population. Specifically, they increased in subjective well-being, reported a reduction in symptom severity and increased in functioning. In addition, clients have given first hand accounts of what changed. This is consistent with the Phase model described by Howard, Lueger, Maling and Martinovich (1992). In the Phase model, the client experiences subjective well-being enhancement first, followed by reduction in symptomatology, with lasting changes in life functioning occurring more gradually. In CORE subjective well-being enhancement refers to clients rating themselves on the intensity of the following four statements over the last week. I have felt OK about myself. I have felt like crying. I have felt overwhelmed by my problems. I have felt optimistic about my future. Therefore, clients present to counselling / psychotherapy for a variety of reasons and are usually demoralised when arriving at therapy. Their subjective well-being is at a low. Research has indicated that clients need to believe that therapy will be helpful before they even engage in any therapeutic process. (Frank, 1968, Goldstein, 1962; Peake & Archer, 1984; Peake & Ball, 1987; Wickramasekera, 1985; Wilkins, 1979, 1985).) It appears that there are therapeutic processes that exert their influence before the process of formal psychotherapy begins or in the early stages of psychotherapy. These are processes that lead to enhancement in the patient's sense of subjective well-being. The process of subjective well-being enhancement tends to occur relatively quickly in response to a variety of interventions: setting up an appointment, medication, advice and so forth. For some clients, enhancement of subjective well-being (remoralisation) will allow them to mobilise their own coping resources in a way that facilitates resolution of the triggering events that led to help seeking in the first place and they will require no further formal treatment. Other clients will move on to a second phase of therapy with a sense that now they are better able to work on the original (reframed) precipitating problem. Examples of the subjective well-being phase in the current study were consistent with research. In addition to the client accounts accessed through interview, the CORE measure also indicated improvement in subjective well-being with clients reporting feeling better about themselves, less tearful, less overwhelmed by problems and more optimistic. The remediation, middle or second phase focussed on symptom reduction or resolution. In CORE problem severity refers to clients rating themselves on the intensity of problems through the following twelve statements over the last week. I have felt tense anxious and nervous. I have felt totally lacking in energy and enthusiasm. I have been troubled by aches, pains or other physical problems. Tension and anxiety have prevented me from doing important things. I have been disturbed by unwanted thoughts and feelings. I have felt panic or terror. I have had difficulty getting to sleep or staying asleep. My problems have been impossible to put to one side. I have felt despairing and hopeless. I have felt unhappy. Unwanted images and memories have been distressing me. I have thought I am to blame for my problems and difficulties. In this evaluation most of the clients presenting to workplace counselling were experiencing sleep disturbance and worry/anxiety about some issue or life event. This was interfering with their overall happiness and preventing them from moving forward. The intervention focussed on helping them develop greater coping skills and greater awareness. During this phase (remediation), treatment is concerned with facilitating mobilisation of clients' coping skills, encouragement of more effective coping skills or both. Examples of interventions that focus on the second phase include cognitive therapy to eliminate depressogenic cognitions, interpersonal therapy for enhancing assertiveness, desensitisation of phobic avoidance, empathic reflection to promote dissolution of conditions of worth and interpretation to promote adaptive understanding. Examples of enhancing coping and the symptom reduction / problem severity reduction phase in the current evaluation were consistent with research. Here clients recount practical interventions by the therapist, setting action plans, developing awareness and receiving help to identify and draw on their own resources. In addition to the client accounts accessed through interview, the CORE measure also indicated reduction in problem severity. Clients reported feeling less tense, anxious and nervous and more enthusiastic. They felt more able to do the things they wanted and were not as bothered by thoughts and feelings. They reported sleeping better and feeling happier. The third phase of intervention, developing enhanced functioning, is probably what has traditionally been thought of as “psychotherapy” in that it is focussed on the unlearning of troublesome, maladaptive, longstanding patterns and the establishment of new ways of dealing with various aspects of self and life. Here clients have reached a point of effective functioning and may be happy with that or they can continue to work on issues in therapy over extended periods of time. In CORE functioning enhancement refers to clients rating themselves on the improvement in functioning on the following twelve statements over the last week. I have felt terribly alone and isolated. I have felt I have someone to turn to for support when needed. I have felt able to cope when things go wrong. Talking to people has felt too much for me. I have been happy with the things I have done. I have felt warmth or affection for someone. I have been able to do most things I needed to. I have felt criticised by other people. I have thought I have no friends. I have been irritable when with other people. I have achieved the things I wanted to. I have felt humiliated or shamed by other people. Many of the clients in this evaluation had friends and were working. In terms of functioning they needed support and coping skills, needed to control moods and re-establish a sense of achievement. Many presented with issues of selfesteem and confidence but felt their symptomatic worry and inability to cope was affecting their ability to function. Some clients may enter therapy at this point, having had no precipitating problem or acute distress. This psycho-educational or preventative phase of therapy may last many months or years, depending on the accessibility and malleability of these maladaptive patterns. In short-term work-based EAPs, this phase is addressed with a cognitive approach usually involving goaling. There is also a supportive - maintenance track in the rehabilitation phase. Clients in this track may settle into a long-term case-management mode in which they are no longer working towards the improvement of adaptive resources. Intervention aimed at the maintenance of gains or the prevention of deterioration falls into this latter category. Life-functioning improvements can assume the goal of either resuming a former functional role and capacity or in assuming new roles. In addition to the client accounts accessed through interview, the CORE measure also indicated an improvement in functioning. Clients reported feeling less alone and isolated and more supported. They felt more able to cope with life and engage with others. They felt more connected to others. The phase theory hypothesises that, different facets of clients' conditions change at different rates over the course of psychotherapy. Improvement in subjective well-being would occur quickly, improvement in symptomatology would occur more slowly and improvement in life functioning would occur even more slowly. This was also found to be the case in this evaluation. When compared to the comparison group sample, the clients who participated in this research still remained less functional despite having moved from a clinical to non-clinical population. This may be accounted for by the limited number of sessions (8 maximum) afforded to clients under EAP schemes. These clients may have required further counselling / psychotherapy. Half of the sample, however, were attending for longer term work but had still not reached the level of well-being reported by the comparison group. It would appear that short-term intervention was successful in reducing symptoms but change took longer to occur and was gradual. This is consistent with research by Horowitz, Rosenberg, Baer, Ureño, and Villaseñor (1988) who found reports of symptomatic distress abated dramatically after the first 10 sessions of brief time-limited psychotherapy but reports of interpersonal problems changed more slowly. From the client accounts of therapy it would seem that a process of change has occurred before they even attend the therapist. In the beginning it would seem that clients engage in a process of hope and expectancy. In the early interventions a rapport is established and the client responds to techniques used by the therapist. Learning occurs at this early stage and it seems that much of the work takes place at stage 2 when symptoms and problem severity is addressed. The more the client engages with the process the more awareness occurs. Functioning returns to an acceptable level as the client and therapist work together setting tasks, teaching and developing insight into the client‟s problems. Limitations Several issues have emerged since completing the evaluation and it is worth noting the impact that they may have had in influencing the outcome. The issue of lost data may lead to an alternative explanation or interpretation of the findings. For example, in the quantitative evaluation, 24% of clients failed to complete the second outcome measure following therapy. This may have been because they only attended one session or they may have refused to complete the second measure. They may still be in therapy but had not completed the second outcome measure by the time the final data was collected. There is every possibility that the therapists did not deliver the second outcome measure, either because the client dropped out of therapy and did not attend the last session or the therapist was reluctant to deliver the measure or forgot to do so. It does pose the question that not having all of the data or having a larger sample may have affected the outcome. Nonetheless, the results benchmark favourably with the CORE database in the UK suggesting consistency in current findings. It is not possible to establish precisely when improvement began for individuals. For some, positive change began in the first and second sessions, while for others it was a slow process. It would have proved impractical to use CORE at each session but had it been done we would have greater insight into the change process. The evaluation was also limited to Ireland due to resources and time. This limited the participant sample to a culturally white Irish population overall. There were no control measures for ethnicity, age, educational level and gender and this is evident in the qualitative study. All participating therapists fell into this category and this has limited the outcome to Ireland and Northern Ireland. The CORE instrument used was the standard 34 item measure normed in the UK and there are questions around its suitability for other cultures in this unadjusted form. Limiting the study to the Irish and Northern Irish clients may be biased in that these clients live in areas where EAP and counselling services are well established. Therapists who participated reported that many clients needed longer-term work to address their issues and could not make significant improvements within a short-term EAP framework. Whether this is a flaw within the initial EAP assessment system or the therapists‟ reluctance to remain focussed on the purpose of the short-term contract is unclear but it raises an issue of both clinical and ethical focus. While this may not be a limitation of this research, it may have had a limiting effect on outcome. Examination of the raw data indicated that at least one third (33%) of the clinical sample had accessed counselling under the short-term EAP service provided by the employer. While the study found clients accessing counselling from 4 to 40 sessions it did not however show where the optimum number of sessions occurred. Raw data indicated this to be 8 sessions. This work could be described as generic in design and nature in that it did not explore in any depth the nature of the client‟s problem nor the type of intervention used. Research has indicated that specific interventions are more effective in the treatment of specific human conditions (Roth & Fonagy, 2006). These could still be accommodated within the proposed phase models but it is important to note that the therapist is required to work within competence. Conclusions Consistent with the Phase model, this evaluation has demonstrated that If a person encounters a situation that taxes his or her coping resources, there will be a decrement in that person's life functioning (at least in the area that includes this situation). This decrement in life functioning, if it is extreme or persistent, will cause stress that will lead to the development of emotional or psychological symptoms. These symptoms, if they are extreme or persistent, will lead to a sense of helplessness and desperation (i.e. to a significant decrement in subjective well-being). This later condition will lead some people to seek professional help. The sequence of the helping process is basically the reverse of the sequence of this development of psychopathology. The enhancement of subjective well-being will lead to an increment in personal efficacy (Bandura, 1982) and may be enough to mobilise the client's coping resources to such an extent that the client can handle his or her symptoms (e.g. sleep better, have less difficulty concentrating, ruminate less) and cope more effectively with the relevant parameters of the precipitating life situation. At the least, enhancement of subjective well-being will allow the client to work more effectively with the therapist in dealing with distress and symptoms. The phase model has been used as a system to demonstrate change at various points throughout the counselling intervention and return to functioning took place for many clients in the early stages of counselling. It is proposed, therefore, that a variation (outline below) of the phase model be introduced as a means of measuring outcome in counselling settings. The new short 10 item version of the CORE instrument could be used from session to session giving a clear indication of what happens for clients. It would also be important to include the valuable account of the client as part of the process. Chart 3. Integrative clinical / private practice model Self, GP, other health referral Subjective wellbeing intervention using brief therapy CORE 10 Item Symptom reduction, problem, severity reduction using CBT - CORE 10 Functioning enhancement using integrative therapy CORE 10 Item Reassessment using CORE or similar evaluation tool CORE 34 Item Client interview with clinician Initial assessment using CORE or similar evaluation tool CORE 34 Item Chart 4. Short-term EAP / work-based practice model Consultation with Manager Client returns to work Clinician interview with referrer (other than self referred clients) Self, OHS, HR, union, manager referral Subjective wellbeing intervention using brief therapy Symptom reduction, problem, severity reduction using CBT Functioning enhancement using integrative therapy Reassessment using CORE or similar evaluation tool Initial assessment using CORE or similar evaluation tool Clinician interview with referrer (other than self referred clients) Client interview with clinician In the integrative model of counselling, clients are referred, either by general practitioners, self referred or referred by other health professionals and these undergo an assessment at intake. The assessment, carried out by the counsellor, includes a well-being battery (questionnaire) before the client begins therapy. The first phase of therapy concentrates on enhancing client well-being through the use of CBT or brief therapy techniques used in conjunction with the questionnaire. As the client becomes more aware and agrees to certain interventions between himself and the therapist, the second phase of therapy addresses symptoms and uses CBT to help the client reduce the severity of problems. The client then moves to the third phase where work on client functioning is addressed using a range of techniques drawn from the various schools of therapy. CORE is used to measure progress throughout this series of meetings, which can range from two to eight in the case of workplace EAP or more in the case of private therapy. Clients are usually re-assessed, typically after 6 – 8 sessions of counselling. A clinical interview is conducted with the client at this point. Ideally, this is carried out by another clinician but there are obvious ethical considerations concerning confidentiality, for example. The client interview may well be conducted by the attending counsellor and would concentrate specifically on the client experience of the usefulness of the therapy received. This outcome is then combined with the re-assessment questionnaire and used as a recommendation for further direction or intervention for the client. At this point, clients would either re-engage with some further sessions or enter a longerterm therapy contract. In the proposed work-based model, clients engage in a similar process but, this time, the concept of the dual client relationship is accommodated. In EAP work and organisational counselling, the second client is often the manager or the human resources department. It could be particularly useful for return to work, risk management and compulsory referral, as organisations now have a duty of care to all employees under safety, health and welfare at work legislation. Here, the line manager or HR manager is involved in the process at the start and at re-assessment. This supports clarity and openness. In cases of self-referral, the normal counselling model could prove effective provided there is no compromise to the organisation such as breach of regulations, fraud or threat to the organisation or its employees, including the employee presenting to the EAP for counselling. The proposed introduction of these models, particularly in work place settings, is supported by recent research conducted by Taylor & Buon (2007) who found that HR managers want face-to-face counselling provided for employees. In their study examining the views of HR managers about EAPs, they summarise the main reasons why employers have these services as providing support for staff / employees (39%), providing EAP as part of the staff benefit package (14%) and absence management (7%). They viewed this as a necessary component to supporting employees in dealing with difficult or stressful experiences or events, taking a pro-active approach to the encouragement of work-life balance, minimising disruption to work performance and productivity and enhancing the perception as a caring employer. Only 3% felt EAPs were necessary to protect the organisation from litigation under duty of care. Recommendations - Counselling in the workplace / EAPs The inclusion of a qualitative component in the assessment of outcome is necessary to gain a greater overall picture of the client / counsellor intervention. The inclusion of HR / line manager input would provide both organisation and employee with a greater understanding of expectation and intervention in workplace issues. A version of the Clinical Outcomes in Routine Evaluation (CORE) instrument specifically designed for EAP settings and work performance is warranted. Outcome measurement using normed and validated measures should be employed in the EAP system to support the most effective intervention with a short version available for use at each session. A re-assessment and follow up system should be introduced to support and maintain the EAP intervention and should include both employee and manager. EAP providers, internal or external, need to review the range of services included in their EAPs to ensure that they are providing what the client wants and not what the traditional EAP model dictates. This research needs to be developed and extended to cover other European countries. Recommendations - Counselling in private settings Incorporate a mixed assessment approach with clients using measurement tools before, after and throughout therapy, combined with a semi-structured clinical interview with the client to support evidence-based practice and continuing professional development. Utilise different intervention methods at the various stages of therapy, particularly in the early stages. Utilise a means of progress measurement from session to session (i.e. CORE short version or similar). Introduce and establish suitable risk assessment for clients. Explain the construct of counselling to clients at the beginning of therapy. Include outcome findings in clinical supervision to enhance and improve the quality of service to clients and to aid continuing professional development for therapists. Conduct further research in the area of multi-cultural counselling in Ireland and extend this study beyond Ireland and Northern Ireland. Include the therapist experience of sessions as part of the process. The impact on the profession This research will be of interest to anyone currently in practice or planning to work in the counselling, psychotherapy, EAP counselling or related professions and to those therapists required to provide work-based employee assistance and short-term counselling, as it puts forward the clients‟ analysis of what they have found to be helpful and unhelpful from their therapy experience. It will also be of interest to prospective clients and to community groups and medical practitioners who may refer people to therapy and who may gain an insight into the history and practice of psychotherapy as well as the role, rights, and responsibilities of clients and therapists in the process. I see this work impacting on the counselling and psychotherapy profession in two ways. The first is on the services provided within and through the workplace. Traditionally, support for effectiveness and outcome of work based services relied on client satisfaction questionnaires where clients rated the telephone response of the service, the counsellor and the overall counselling or EAP on a scale. Some EAP companies have developed their own satisfaction surveys, which go into more depth, but it‟s only in the past year that outcome measurement has been introduced in Ireland. The aspect of qualitative enquiry is not usually covered in any depth or structured way in the assessment of outcome. I would see this research offering a framework through which providers of EAPs could market the product as a viable employee and company benefit. The evidence indicates that these programmes are effective in improving functioning and well-being which can equate to cost savings from absence and productivity perspectives. Whatever a company‟s motivation may be to include a work-based counselling programme in its range of employee benefits, it would, at the very least, serve to meet the legislative requirements with regard to the duty of care. The second area includes services provided by national health and services provided by private therapists. This research could support voluntary agencies and community based services in applications to government for funding of counselling services. It provides an evidence base that demonstrates effectiveness of therapy in a range of settings. It will also serve private practitioners as a system of gathering practice-based evidence to support the discipline of counselling. It could also be used as a quality assurance system for practice to ensure high quality care for clients and to provide a clinical intervention to enhance work with clients. For long-term work with clients, it provides a model supporting monitoring and effectiveness and allows therapists and clients assess progress and need as therapy progresses. It effectively follows and could guide the client / therapist journey through re-assessment on a regular basis, perhaps even at each session. It could also be viewed as a system that supports transparency and best practice in that it forms an assessment tool, which can guide intervention. The application of the Phase model supports the suggestion that different change processes and interventions are appropriate for different stages of therapy and on changing problems at different stages in the process. In other words, brief therapy might be more effective in addressing well being in the early stages of intervention, but longer integrative intervention might be better to address deep rooted issues and sustain therapeutic change for the future. This is also supported by therapist reports of clients entering short term EAP or work-based services and realising their issues are not being suitably addressed within this limited contract (4 – 8 sessions). This has been my experience and that of colleagues who have used the CORE system in clinical work and it is supported by discussion with clients. It has been found to be an effective system to aid therapy and give direction to both therapist and client. In summary this evaluation informs us as follows, It delivers a structured scientific model of EAP delivery which is time limited and focussed. It validates the Clinical Outcomes in Routine Evaluation (CORE) as a suitable tool in these settings. By nature, the structured model is measurable, thus delivering a system that shows outcome. It can be uniform across EAP companies and can be shown to deliver a return on investment for employers. It supports employers in their requirement under “duty of care”. A practice based evidence approach is included in the structure and contributes to the growing body of evidence supporting psychological intervention for employees. In the EAP world it can serve as a system that allows EAP providers identify the types of affiliate clinicians suitable to deliver these services. It is a useful marketing tool for psychologists, counsellors, psychotherapists and EAP providers who deliver these specialist services to organisations. The model can be expanded to include manager input. This research is unifying across the divisions in psychology and provides a system whereby counselling psychologists in private practice can use it for developing practice based evidence and enhanced intervention. Occupational psychologists can use it in organisational work to structure intervention while, at the same time, demonstrate value for money. Included in this research is the qualitative component “voice of the client” The impact on future research McLeod (2001) suggested that existing research had not been able to find any consistent link between EAP / counselling provision and organisational outcomes. This research has shown that symptom relief had occurred and the client‟s sense of well-being had improved. In addition, the client‟s overall functioning had increased and this had manifested itself by a return to work in many cases. Although not reported in this study, the raw data indicated a change in half the participants‟ work attendance patterns. They had returned to work having been absent on sick leave. In his systematic study of the research evidence on counselling in the workplace, McLeod informs us that the voice of the client had not been heard in any of the studies. This study included the voice of the client and highlighted another dimension to research in this area. Absent from this research was the voice of the manager and the voice of the therapist. Future research could include these components. This evaluation has contributed to research by providing, The evidence that counselling intervention is effective in a range of settings can be used to further research delivery of these types of services by psychologists. CORE is a suitable and viable measure of subjective well-being, symptom reduction and enhanced functioning in these settings. The combination of methods in this evaluation has shown that it is valuable to cover both aspects of a question. Additional Data Extracted from the Research following Submission. The following data was extracted after the research had been submitted and passed by the University. It‟s important that it be included for EAP purposes as it relates specifically to work outcomes and will be of particular interest to the EAP companies and organisations that sponsored this study. Of the main group of clients who presented for counselling, 172 also presented with work related issues. Of the 172, 139 responded to questions related to work performance and the responses indicated that 27 were on sick absence from work when they accessed the EAP. The remainder were attending work but their work performance was impaired at some level and in the case of 5 employees it was severely impaired. Following intervention of EAP these numbers changed significantly. 13 of those on sick absence returned to work. Five no longer had their work affected by the issues and the majority reported their work returning to a normal or satisfactory level. This is represented by Chart 5 below. The range of difficulties presented by clients accessing the EAP is outlined in a similar manner. The greatest issue impacting on work was workplace relationships. 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