Counselling in primary care: A review of the practice evidence

Abstract

This paper describes the level of mental health problems that are encountered in primary health care. The limitations of using randomised control trials (RCTs) in evaluating effectiveness of psychological therapies in primary health care are described. Although the RCT may be useful in evaluating interventions in highly controlled situations, its use in evaluating clinically representative service delivery research is limited. A three-stage model of psychological therapies research is described to show that distinct stages require different methodologies in order to evaluate them, and this model is used to structure the review. The literature on research carried out in more naturalistic circumstances is then reviewed. Evaluating psychological interventions in this way shows there is considerable evidence that psychological therapies are effective in a number of ways in a primary care setting. The naturalistic studies that are more typical of clinical practice support the use of psychological interventions. The theme of the grey literature is almost entirely positive from the point-of-view of patients and GPs alike. However, there is considerable diversity in the sophistication of the methodology of the latter studies. Some were comprehensive evaluations, while others were more akin to audit. A major shortcoming is that few described their qualitative methodology. This said, the themes arising from the reports are very consistent and, had they been supported by a more robust qualitative methodology, would have added even more support, ® nancially and clinically, for the arguments for counselling provision in primary health care. The level of referred clients' distress, measured by a variety of measures, was shown to be moderate to severe and similar to the level of patients referred to Community Mental Health Teams (CMHTs) . When they were measured, there was a considerable reduction in subsequent psychiatric symptoms.

All you need is cognitive behaviour therapy? Commentary: Benevolent scepticism is just what the doctor ordered Commentary: Yes, cognitive behaviour therapy may well be all you need Commentary: Symptoms or relationships Commentary: The "evidence" is weaker than claimed

“…Recent studies comparing cognitive behaviour therapy with counselling in primary care showed no significant differences in outcomes 16. Such results show the dangers of tying government policies too closely to specific research findings.…”

Counselling outcomes in primary health care: a CORE system data profile

“…To date ve systematic research reviews, citing a plethora of research papers, have attempted to assess the ef cacy of counselling in primary care for a range of common mental health disorders (Friedli and King 1996;Godber 1996;Hemmings 2000;Roth and Fonagy 1996;Rowland et al 2000). The rst three publications that appeared in 1996 presented a consensus that there was no research evidence to suggest that counselling was either clinically or cost-effective despite its popularity with general practitioners and patients.…”

What Can Clients Tell Us about Seeking Counselling and Their Experience of It?

“…Research on unhelpful interactions in counselling is considerably less extensive than it is for helpful factors, possibly because clients are, on the whole, very positive about their counselling (Bowman & Fine, 2000;Hemmings, 2000;Seligman, 1995). Other reasons include the possibility that clients are reluctant to criticise their counsellors (Farber, 2003;Hill et al, 1993) and are tolerant of a less-thanperfect performance by their counsellor (Farber, 2003;Hill et al, 1993;Rennie, 1994).…”

“…Given the substantial gap that exists between those who need mental health services, including counselling, and those who actually seek such services (Alvidrez, 1999;Bayer & Peay, 1997;Bridgman, 1994;Clarkin & Levy, 2004;Hemmings, 2000;Vessey & Howard, 1993), there is a need to better understand the help-seeking behaviour of counselling clients. Previous research has found that most clients follow a similar process in seeking counselling, one that tends to fit with Saunders' (1993) four step model of help-seeking.…”