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
5
The Need for Evidence and Return on Investment
5-7
What are Employee Assistance Programmes?
7-8
The history of Employee Assistance Programmes
and workplace counselling
8 - 10
Measuring Outcomes of Counselling and EAPs
10 - 11
Outcome measurement using CORE
12 - 13
The Dimensions of the Measure
13 - 14
The Phase Model
14 - 15
Study Goals
15 - 16
Does counselling and psychotherapy work?
16 - 17
What works?
17- 18
The Relationship.
18
Methodology - Research Design & Sample
19
Participants
20 - 22
Psychometric properties of the CORE–OM
22 - 23
Procedure
24 - 25
Results
25 - 34
Discussion
35 - 43
Limitations
43 - 44
Conclusions
44 - 47
Recommendations
48
Impact on the Profession and Research
49 - 51
Additional Workplace Data Extracted from the Research
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
30
Chart 3 Integrative Clinical / Private Practice Model
45
Chart 4 Short Term EAP Work Based Practice Model
46
Chart 5 Work Assessment for 139 Clients
52
Chart 6 Presenting Work Issues for 172 Clients
53
Table 1 Demographic Details of Participants
20
Table 2 Reliability analysis for CORE
26
Table 3 Total CORE Outcome Measure-Comparison of Means
27
Table 4 The Functioning dimension on the CORE Outcome Measure –
comparing this evaluation with CORE
28
Table 5 The Problems dimension on the CORE Outcome Measure –
comparing this evaluation with CORE
28
Table 6 The Subjective Well-being dimension on the CORE Outcome
Measure – comparing this evaluation with CORE
29
Table 7 The Risk dimension on the CORE Outcome Measure –
comparing this evaluation with CORE
30
Table 8 All items on the CORE Outcome Measure minus Risk –
comparing this evaluation with CORE
31
Table 9 Profile of Interview Participants
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
Gender
Age Range
Mean Age
SD
Clinical Group
48% Male
16-76
36.49
11.646
19-66
40.16
11.630
362 Participants
Control Group
87 Participants
52% Female
48% Male
52% Female
TOTAL n = 449
Participants
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%
Irish Family Planning Association
4%
2%
3%
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
Alpha
Coefficient
PostCounselling
CORE OM
318 - 232
34
.9463
.9424
Functioning
328 - 240
12
.8843
.8773
Problems
328 - 243
12
.8931
.8913
Well-Being
342 - 242
4
.8010
.7916
Risk
340 - 245
6
.7135
.4514
Comparison
Group
87
34
.9158
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.
PreTherapy
Outcome
Measure
PostTherapy
Outcome
Measure
N
Minimum
Maximum
Mean for
Current
Study
318
0
4
1.80
232
0
3
.85
CORE IMS
Benchmark
(2007)
1.81
.88
Standard
Deviation
.740
.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
N
Minimum
Maximum
Mean
for
Current
Study
CORE IMS
2002
Standard
Deviation
Pre-Therapy
Functioning
328
0
4
1.86
1.86
.865
PostTherapy
Functioning
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
N
Minimum
Maximum
Mean
for
Current
Study
Pre-Therapy
Problems
338
0
4
2.24
2.31
.888
PostTherapy
Problems
243
0
4
1.08
.90
.663
CORE IMS
2002
Standard
Deviation
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
N
Minimum
Maximum
Mean
for
Current
Study
PreTherapy
Well
Being
342
0
4
2.35
2.37
1.006
PostTherapy
WellBeing
242
0
4
1.10
.91
.778
CORE IMS
2002
Standard
Deviation
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
N
Minimum
Maximum
Mean
for
Current
Study
PreTherapy
Risk
340
0
3
.41
.63
.570
PostTherapy
Risk
245
0
2
.09
.20
.204
CORE IMS
2002
Standard
Deviation
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.
Chart 2. Comparison of Risk with CORE 2002
Data
0.8
0.75
0.7
0.63
0.57
0.6
0.5
0.45
0.41
0.4
0.3
0.2
0.2
0.2
0.1
0.09
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
Minimum
Maximum
Mean
CORE IMS
2002
Standard
Deviation
Total-Pre
Therapy –
All minus
Risk
321
0
4
2.10
2.12
.836
Total-Post
Therapy –
All minus
Risk
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
Male
36 - 45
Full time paid
White Irish
Work Based
Male
36 - 45
Full time self employed
White Irish
Private
Male
46 - 55
Retired
White Irish
Private
Male
26 - 35
Full time paid
White Irish
Work Based
Male
18 - 25
Student
White Irish
Private
Female
18 - 25
Full time paid
White Irish
Private (EAP)
Female
36 - 45
Full time paid
White Irish
Work Based
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
Initial
assessment
using
CORE or
similar
evaluation
tool CORE
34 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
Chart 4. Short-term EAP / work-based practice model
Self,
OHS,
HR,
union,
manager
referral
Initial
assessment
using CORE
or similar
evaluation
tool
Subjective wellbeing
intervention
using brief
therapy
Clinician
interview
with referrer
(other than
self referred
clients)
Consultation
with Manager
Client
returns to
work
Symptom
reduction,
problem,
severity
reduction using
CBT
Functioning
enhancement
using integrative
therapy
Clinician
interview
with referrer
(other than
self referred
clients)
Reassessment
using CORE
or similar
evaluation
tool
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.
Employees reported difficulty with work relationships on a scale of 0 to 4 where 0
represented no difficulty and 4 represented severe difficulty. On arriving at the EAP
these employees were reporting difficulty at a moderate level. In a small number of
cases this was at a severe level. The same applied with bullying and harassment,
health issues, trauma and legal proceedings. Following EAP intervention there was
imprevement across all these areas with some no longer a problem and others at a
minimal to mild level.
This is represented by Chart 6 below.
REFERENCES
Asay T. P., & Lambert, M. J. (1999). The empirical case for the common factors in therapy: Qualitative
findings. In M. Hubble, B. Duncan, & S. Miller (Eds.). The heart and soul of change: What works in
therapy. Washington D.C. : American Psychological Association.
Bandura, A. (1982). Self-efficacy mechanism in human agency. American Psychologist, 37, 122-147.
Barkham, M. (2003). Quantitative research on psychotherapeutic interventions; methods and findings
across four research generations. Handbook of counselling psychology. London: Sage.
Barkham, M. Mellor-Clark, J. (2000).
Rigour and relevance: Practice-based evidence in the
psychological therapies in N. Rowland & S. Goss (Eds.). Evidence-based counselling and
psychological therapies: Research and applications (pp. 127 – 144). London: Routledge. Cited in
Counselling and Psychotherapy Research. 6, 3.
Barkham, M., & Mellor-Clark, J. (2000). Bridging evidence-based practice and practice-based
evidence: Developing a rigorous and relevant knowledge for the psychological therapies. Clinical
Psychology & Psychotherapy, 10, 319 – 327.
Berridge, J. & Cooper, C. L. (1994). The employee assistance programme – its role in organisational
coping and excellence. Special Issue of Personnel Review, 23, 7.
Bugge, I. Hendel, D., & Moen, R. (1985). Client evaluations of therapy processes and outcomes in a
university mental health center. Journal of American College Health, 33, 141-146.
Buon, T., & Taylor, J. (2007). A review of the employee assistance programme (EAP) market in the
UK and Europe. Research report presented to The Employee Assistance European Forum Annual
Conference, Amsterdam. Robert Gordon University, Aberdeen, Scotland.
Carolyn Highley-Marchington, J., & Cooper, C. L. (1998). An assessment of employee assistance and
workplace counselling programmes in British organisations. Manchester School of Management,
University of Manchester and the Health & Safety Authority.
Carroll, M., & Walton, M. (Eds.) (1999). Handbook of counselling in organisations. London: Sage.
CORE System Group. (1998). CORE system (information management) handbook. CORE IMS Ltd,
Rugby, UK.
Cronbach, L. J. (1951). Coefficient alpha and the internal structure of tests. Psychometrika, 16, 297334. Cited in C. Evans, J. Connell, F. Margison, J. Mellor-Clark, (2002). The British Journal of Psychiatry,
180, 51-60.
Dunkle, J. H. & Friedlander, M. L. (1996). Contributions of therapist experience and personal
characteristics to the working alliance. Journal of Counselling Psychology. 43, 456-460.
Dush, D. M., Hirt, M. L. & Schroeder, H. (1983). Self statement modification with adults: a meta
analysis. Journal of Consulting and Clinical Psychology, 94, 408-422.
Employment Equality Act. Ireland (1998).
Equal Status Act, Ireland, (2000).
Evans, C., Connell, J., Barkham, M., Margison, F., Mellor-Clark, J., McGrath, G., & Audin, K. (2002).
Toward a standardised brief outcome measure: Psychometric properties and utility of the CORE–OM. British
Journal of Psychiatry, 180, 51-60.
Eysenck H. J. (1952). The effects of Psychotherapy: An evaluation. Journal of Consulting Psychology,
16, 319-324.
Frank, J. D. (1968). The role of hope in psychotherapy. International Journal of Psychiatry, 5, 383–
395.
Frank, J. D., & Frank, J. B. (1991). Persuasion and healing: A comparative study of psychotherapy.
Baltimore, MD: Johns Hopkins University Press.
Gershefski, J. J., Arnkoff, D. B., Glass, C. R., & Elkin, I. (1996). Clients’ perceptions of treatment for
depression: Helpful aspects. Psychotherapy Research, 6, 233-247.
Goldfried, M. R., & Davila, J. (2005). The role of relationship and technique in therapeutic change.
Psychotherapy: Theory, Research, Practice, Training, 42, 421-430.
Goldstein, A. P. (1962). Therapist-patient expectancies in psychotherapy. Elmsford, NY: Pergamon
Press.
Horowitz, L. M., Rosenberg, S. E., Baer, B. A., Ureno, G., & Villasenor, V. S. (1988). Inventory of
Interpersonal Problems: Psychometric properties and clinical applications. Journal of Consulting and
Clinical Psychology. 56, 885–892.
Horvath, A. O. (1994). Research on the alliance. P. 259-286. In A. O. Horvath & L. S. Greenberg
(Eds.). The working alliance: Theory, research and practice. New York. Wiley.
Horvath, A. O., & Bedi, R. P. (2002). The alliance. P 37–70. In J. C. Norcross (Ed.), Psychotherapy
relationships that work. New York: Oxford University Press. Cited in A.O. Horvath (2006). The Alliance
in Context: Accomplishments, Challenges, and Future Directions. Psychotherapy: Theory, Research,
Practice, Training. 43, (3), 258-263.
Horvath, A. O., & Symonds, B. D. (1991). Relation between working alliance and outcome in
psychotherapy: A meta-analysis. Journal of Counseling Psychology. 38, 139–149.
Howard, K. I., Lueger, R. J., Maling, M. S., & Zoran M. (1992). A phase model of psychotherapy
outcome: Causal mediation of change. Journal of Consulting and Clinical Psychology, 61, 678-685.
Hubble, M., Duncan, B. L., & Miller S. D. (1999). The heart and soul of change: What works in
therapy. Washington, DC: American Psychological Association.
Lambert, M. J. (1991). Introduction to psychotherapy research. In L. E. Beutler & M. Cargo (Eds.)
Psychotherapy research: An international review of programmatic studies (pp. 1–11). Washington,
DC: American Psychological Association.
Lambert, M. J., Shapiro, D. A., & Bergin, A. E. (1986). The effectiveness of psychotherapy. IN S. L.
Garfield & A. E. Bergins (Eds.) Handbook of psychotherapy and behaviour change. New York: Wiley.
Lyne, K. J, Barrett, P., Evans, C., & Barkham, M. (2006). Dimensions of variation on the CORE OM.
British Journal of Clinical Psychology, 45, 185-203.
Margison, F. Barkham, M, Evans, C. McGrath, G. Mellor-Clark, J., & Audin, K. (2000). Measurement
and psychotherapy: Evidence-based practice and practice-based evidence. British Journal of
Psychiatry, 177, 123 – 130.
Marmar, C. R., Weiss, D. S., & Gaston, L. (1989). Toward the validation of the California Therapeutic
Alliance Rating System. Psychological Assessment: A Journal of Consulting and Clinical Psychology,
1, 46–52.
Martin, D., Garske, J., & Davis, M. (2000). Relation of the therapeutic alliance with outcome and other
variables: A meta-analytic review. Journal of Consulting and Clinical Psychology, 68, 438–450.
McLeod, J. (2001). Counselling in the workplace: The facts, a systematic study of the research
evidence. Report published by the British Association for Counselling and Psychotherapy.
McLeod, J. (2001). Qualitative research in counselling and psychotherapy. London: Sage.
Mellor-Clark, J., Barkham, M., Connell, J., & Evans, C. (1999). Practice-based evidence and need for
a standardised evaluation system: Informing the design of the CORE System. European Journal of
Psychotherapy, Counselling and Health, 3, 357–374.
Oher, J. M. (Ed.) (1999). The employee assistance handbook. New York: Wiley.
Orlinsky, D. E., & Howard, K. I. (1980). Gender and psychotherapeutic outcome. P. 3-34. In A. M.
Brodsky & R. Hare-Mustin (Eds.) Women and psychotherapy: An assessment of research and
practice. New York: Guildford Press.
Peake, T. H., & Archer, R. P. (1984). Clinical training in psychotherapy. New York: Haworth Press.
Peake, T. H., & Ball, J. D. (1987). Brief psychotherapy: Planned therapeutic change for changing
times. Psychotherapy in Private Practice, 5, 53–63.
Prioleau, L., Murdoch, M. & Brody, N. (1983). An analysis of psychotherapy versus placebo studies.
The Behaviour and Brain Sciences, 3, 272-310.
Rogers, C. (1957). The necessary and sufficient conditions of therapeutic personality. Psychology,
21, 95-103.
Roth, A. & Fonagy, P. (2006). What works for whom? A critical review of psychotherapy research.
New York: Guilford Press.
Rowland, N., Godfrey, C., Bower, P., Mellor-Clark, J., Heywood, P., & Hardy, R. (2000), Counselling
In Primary care: A systematic review of the research evidence. British Journal of Guidance and
Counselling, 28, (2), 216-217.
Safety, Health and Welfare at Work Act, Ireland, (2005). Ch. 1 (8), P. 18.
Shapiro, D. A. & Shapiro, D. (1982). Meta- analysis of comparative therapy outcome studies. A
replication and refinement. Psychological Bulletin, 92, 581-604.
Smith. M. L., Glass. G. V. & Miller. T. I. (1980). The benefits of psychotherapy. Baltimore, MD: John
Hopkins University Press.
Steiner, D. D., & Truxillo, D. M. (1989). An improved test of the dissaggregation hypothesis of job and
life satisfaction. Journal of Occupational Psychology, 62, 33-40.
Strupp, H. Fox, R., & Lessler, K. (1969). Patients view their psychotherapy. Baltimore, MD: John
Hopkins University Press.
Wickramasekera, I. (1985). A conditioned response model of the placebo effect: Predictions from the
model. P. 255–287). In L. White, B.Tursky, & G. Schwartz (Eds.) (1985). Placebo: Theory, Research
and Mechanisms. New York: Guilford Press.
Wilkins, W. (1979). Expectancies in therapy research: Discriminating among heterogeneous nonspecifics. Journal of Consulting and Clinical Psychology, 47, 837–845.
Wilkins, W. (1985). Placebo controls and concepts in chemotherapy and psychotherapy research. P.
83–109. In L. White, B. Tursky, & G. Schwartz (Eds.). Placebo: Theory, Research and Mechanisms,
New York: Guilford Press.