Issues In Evaluating The Effectiveness Of Counselling

Before moving to consideration of the research evidence for the effectiveness of counselling, it is necessary to take account of a number of issues and barriers associated with research in this area. It is clear that the level of control associated with randomised trials does not sit easily with everyday counselling practice. Formal assessment of clients, random non-negotiable allocation to treatment modalities, manualisation of therapist interventions, and fixed time lengths for therapy are all examples of essential features of well-run randomised trials that are in conflict with the values and conduct of counselling. One of the results of this conflict is that it has been difficult to achieve randomisation in controlled studies of counselling. For example, Fairhurst & Dowrick (1996) tried to set up a controlled study of counselling outcome in eight GP practices, comparing counselling with treatment as usual. They found that, five months after the start of the study, only one patient had been recruited. On conducting interviews with GPs on why this had happened, three main factors emerged: ethical dilemmas around refusing counselling to patients, patient refusal and a perception of counselling as a 'last resort', with the implication that referral to ongoing GP

care was perceived as futile. Similar randomisation issues were reported in a major study of counselling in primary care carried out by Simpson et al. (2000).

In an attempt to be faithful to the nature of counselling practice, some researchers have sought to conduct naturalistic studies, in which clients receiving counselling complete questionnaires at the beginning and end of their treatment. Often, the results of these studies are difficult to interpret due to the proportion of missing data arising from unplanned endings of counselling and lack of adherence to research protocols. For example, in a large-scale naturalistic study of workplace counselling carried out by Highley-Marchington & Cooper (1998), 179 clients completed pre-counselling questionnaires, 103 completed post-counselling questionnaires, and 28 at follow-up.

Another limitation of current research into counselling arises from the contextual nature of much counselling practice. In many situations, the rationale for funding counselling services relies in part on the possibility that counselling will yield community or system benefits as well as helping individual clients. For example, the rationale for student counselling services includes the hope that the presence of a counselling service will reduce pressure on academic staff, by giving them a ready source of referral for 'difficult' students. However, systemic, organisational or societal outcomes of counselling are not easy to measure.

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