Anthology of research
information sheets
2nd edition
A collection of BACP Information
Sheets to guide your practice
Introduction to the Anthology of Research Information Sheets
While a research base existed when I first trained in counselling and psychotherapy,
I didn’t know anything about it. Research did not feature in my training in any
form, and we were certainly not encouraged to engage with evidence to support,
challenge or understand practice. We were offered theory, were provided with
opportunities to develop skills, and of course attended a practice placement in which
we developed our competency as practitioners and collected training hours. We just
knew what we did ‘worked’ and did not feel the need to question that assumption.
The intervening years has seen a dramatic change in the context of counselling
and psychotherapy delivery, including an acknowledgement that questioning
assumptions about practice is an ethical imperative. Counselling and psychotherapy
is now seen by many as a positive choice for responding to psychological distress,
and national treatment guidelines cite the benefits of counselling and psychotherapy
for a number of mental health presentations.
Practitioners too are undertaking their own research, whether as part of a training
programme or their employment. The counselling and psychotherapy research base
in the UK is flourishing, and an evidence-base is building that demonstrates the
efficacy of talking therapies across the life span.
BACP have been prominent in that development. The annual research conference
has provided a platform for established and novice researchers alike to share ideas
and research outcomes, and the launch of Counselling and Psychotherapy Research
journal ten years ago has contributed to the dissemination of reflexive, pluralistic and
mixed-method research papers, as well as research commentaries and debates.
The last few years have seen the development and publication of a number of
research information sheets, collected here together in one volume for the first
time. The information sheets, written by experienced practitioners, researchers
and academics, provide the novice and experienced researcher alike with an
invaluable resource to inform and develop their own research process. From the
beginning of the research journey, titles include How to Write a Research Proposal
and Introduction to Conducting Qualitative Research; different methods include
Undertaking Systematic Reviews in Counselling and Psychotherapy and Statistics
in Counselling and Psychotherapy; while the final stage of the research process is
explored in Using Measures, and Thinking About Outcomes and How to Write a
Research Paper and Get it Published, for example.
These information sheets independently provide counselling and psychotherapy
researchers with guidance that is both accessible and comprehensive. Brought
together in this new Anthology they additionally become an invaluable resource.
I recommend them highly and welcome their role in supporting high-quality research
and in developing new researchers.
Dr Andrew Reeves
Editor, Counselling and Psychotherapy Research
Contents
Research
R1
How to do a literature search
Alison Brettle
1
R2
Evidence based practice in counselling and psychotherapy
Peter Bower
8
R3
Counselling older people: information for practitioners and
policy makers
Andy Hill
14
R4
Using measures, and thinking about outcomes
Tony Roth
23
R5
Research on counselling children and young people
Sue Pattison & Belinda Harris
31
R7
Writing a practice-based study for publication
John McLeod
39
R8
Counselling in higher and further education
Jane Cahill
47
R9
How to write a research proposal
Sara Perren
54
R10
How to write a research paper and get it published
Julia Buckroyd & Sharon Rother
58
R11
Undertaking systematic reviews in counselling and
psychotherapy
Peter Bower
63
R12
Finding research funding
Kaye Richards
70
R13
Statistics in counselling and psychotherapy
Stephen Joseph, Colin Dyer &
Hugh Coolican
76
R14
Introduction to conducting qualitative research
Rita Mintz
84
R16
How to design and conduct research interviews
Sheila Spong
92
R17
Practice-based evidence and practice research networks
Michael Barkham
100
R1
information sheet
How to do a literature search
by Alison Brettle
Aim
This information sheet aims to help
therapists carry out literature searches
for research or evidence-based practice
(Bower, P. soon to be published) by
identifying sources of and techniques for
accessing information.
thoughts and stay focused. In the long run
this will save you time as it will prevent
you missing key information and stop you
collecting masses of irrelevant material.
The five-stage plan in Figure 1 will help you.
Each of the stages in the plan will be
considered in turn.
When you have read this you will:
1. Why are you doing the search?
n Be aware of some relevant sources
of information.
n Be able to plan a literature search to
find relevant information.
n Understand some basic techniques
of doing a literature search.
Literature searching can be frustrating.
However, once you have an understanding
of some basic techniques, finding relevant
information should become easier. Practice
and familiarity with resources is essential.
Libraries and librarians are great sources of
help and advice and can often provide training.
Ideas for further reading are included.
Why carry out a literature search?
Literature searches are essential for
research and evidence-based practice.
A literature search will help you find the
best available evidence on which to base
your practice. In the case of research,
it will contextualise your work, prevent
duplication, provide ideas and help
validate your results. Poor searching can
be at best frustrating and at worst lead
to practice being based on incomplete or
incorrect evidence.
Planning the search
The key to a successful literature search
is to plan it. A few minutes planning
before going to the library or searching
the internet enables you to clarify your
Think about the reasons for doing a
literature search, as this will affect the
type of information you search for and
how you search. If you are basing your
practice on best available evidence you
may be looking for systematic reviews or
review articles or summaries of evidence
in a specific area. If these don’t exist
you may look for high quality research
such as randomised controlled trials.
Alternatively you may find information
related to the experiences of clients. If
you are doing a major research project
that requires a literature review you will
need to locate most of the literature
relevant to that project. This could also
include background policy documents and
other research. Or you may wish to find
a couple of articles to back up a point in
a lecture you are giving, in which case a
quick search may suffice. The reason for
undertaking the search will affect the way
you proceed through the search plan.
2. What are you searching for?
Think carefully about your search question.
The more focused the search question,
the easier the search. Searching on a
particular question is easier than looking
for a vague topic area or entering a few
terms on a topic you are interested in. You
may need to break down your topic area
into several questions and search on each
individually. Focusing the search question
is considered in greater detail below.
BACP Information Sheets
are intended to be read in
conjunction with the BACP
Ethical Framework for Good
Practice in Counselling and
Psychotherapy.
The Information Services
ethics helpdesk team is
available to members who
wish to explore any ethical
issues concerned with their
practice.
It should be noted that this
Information Sheet offers
broad guidance, which
sets out professional good
practice, but it should not
be substituted for legal
and for other professional
advice applicable to your
particular circumstances.
© BACP, September 2008
R1
information sheet
Figure 1
Planning your search (adapted from Brettle, A. and
Grant, M.J., 2003) Finding the evidence for practice:
a workbook for health professionals, Edinburgh:
Churchill Livingstone)
be detrimental to your project. If you are introducing
evidence-based practice and you can locate a
systematic review that covers all the areas you need, a
simple search of one resource will be sufficient.
Sources of information
A literature review will generally include searches
of a range of sources of information. Some sources
are more suited to particular questions and all cover
slightly different topic areas. Familiarising yourself
with your local health, social care or academic library
and its resources is advisable and library staff can be
helpful in highlighting relevant sources and showing
you how to use them. The National Library for Health
(NLH) provides access to evidence-based and
discipline-specific sources for all health professionals
(including access to databases and electronic
journals). Social Care Online provides access to social
care resources to anyone via the internet. Health and
academic libraries have access to a wide range of
resources and much information can be obtained via
the internet. Sources particularly useful for counsellors,
along with their advantages and disadvantages, are
highlighted below.
Books
3. What are your constraints?
You may have a limited amount of time to undertake the
search, or restricted access to resources. You may have
been given a topic to consider with little flexibility. If your
research is on a particular topic area and one particular
library holds many of the journals relevant to that
subject, you may be able to negotiate special access.
Inter-library loan facilities may also be useful.
4. What sources should you use?
Different sources cover different topic areas and some
are more suited for specific purposes than others. It is
necessary to become familiar with sources relevant to
you and your work, deciding which are appropriate and
those to which you can and should obtain access.
Books provide useful background and overviews to
topic areas. However, research texts can become dated.
They may be useful in helping to focus on a topic area
when embarking on a research project.
Journals
There are numerous journals containing up-to-date
information. Journals may be peer reviewed (i.e. each
article has been reviewed by experts in the field before
publication) and these are often judged as higher quality.
Some are evidence-based, providing summaries and
commentaries on research evidence. Many journals
are available electronically via the internet. Some are
available free of charge while others can be accessed
with a password if your library subscribes to the journal.
Increasingly, individuals can choose to download
individual articles, once they have paid by credit card
to the journal publisher. Examples of journals that are
relevant to counsellors and span various disciplines are
presented in Table 1.
5. How comprehensive should your search be?
This depends on the search question and reasons for
undertaking the search. Clearly, if you are embarking on
a major research project or undertaking a systematic
review, you will need to search a wide range of sources
to locate all relevant research, as missing studies would
02
Databases
Databases are records of journal articles. Some also
provide details of books and reports. Databases are a
good way of locating research literature, and access
Anthology of research information sheets – 2nd edition
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information sheet
Table 1
Examples of journals relevant to counsellors
Counselling specific
Disciplines (examples)
Evidence based
British Journal of Guidance and
Counselling
Addiction
British Journal of Clinical
Governance
British Journal of Health Psychology
Age and Ageing
Clinical Evidence
British Journal of Psychology
Ageing and Mental Health
Evaluation Practice
Counselling Children & Young People
Children and Young People
Evidence Based Practice
Counselling at Work
Bereavement Care
Evidence Based Practice
Counselling Psychologist
Child Abuse and Neglect
Evidence Based Medicine
Counselling and Psychotherapy Research
Child and Family Social Work
Evidence Based Mental Health
Counselling Psychology Quarterly
Community Work and Family
Evidence Based Nursing
Therapy Today
Illness, Crisis and Loss
Evidence Based Practice
to records over a broad time-span. However, they can
be difficult to search. They are usually accessed via
the internet or your local health or academic library. A
number of databases (known as the core collection)
have been made available to all NHS staff via the
National Library for Health (NLH). Databases relevant to
social care are available via Social Care Online. There
are many databases relevant to counsellors, each
focusing on a slightly different topic area. Depending
on your search question, you may need to search
more than one database. Those particularly relevant to
counsellors are presented in Table 2 (over page).
in summarising information on particular topic areas.
In some cases they also provide information services
for members. Many professional bodies including the
British Association for Counselling and Psychotherapy
(BACP), British Psychological Society (BPS), and the
United Kingdom Council for Psychotherapy (UKCP)
provide information relevant to counselling and
psychotherapy. Consumer or patient organisations can
also be useful providers of information about particular
conditions that are useful to clients, e.g. Age Concern
and MIND. BACP produces a number of topic specific
Contact Sheets which list relevant organisations and
their contact details.
The internet (world wide web)
Undertaking the search
The internet allows worldwide access to a wealth of
information. This includes databases such as those
mentioned above, electronic journals, professional
organisations and their resources. Although there is vast
potential for obtaining information via the internet, it is
unregulated and some information may be unreliable.
Searching (via search engines) can retrieve lots of
information and it is important to appraise sites critically.
A good-looking website is not an indicator of content
quality. There are many reputable health-related sites.
These can be located via gateways (that check each
site listed to ensure it meets minimum quality criteria);
for example, the National Library for Health, Social Care
Online, BIOME, BUBL Psychotherapy resources.
There are a number of basic techniques involved in
undertaking a literature search. These are particularly
suited to electronic database searching, but once
mastered the skills can be transferred to any resource.
It is important to be systematic about your search;
the following approach will help by breaking down the
search into manageable components.
A literature search should be built up and refined
according to your results as you proceed:
n
n
n
n
Conduct a search.
Look at the results.
Add or remove terms that work or don’t work.
Repeat the search.
Organisations/societies
Professional organisations often provide specific
information and research reports that can be useful
© BACP 2008
This process can be repeated until you are confident
that you are not missing, or obtaining, too much
information. When examining your results, it is important
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information sheet
Table 2
Examples of databases useful to counsellors
Database
Coverage
Accessed via
ASSIA
Health, social services,
psychology, economics, race,
politics, education
Academic libraries
AGEINFO
Elderly people
Social Care Online (internet)
Cinahl
Nursing and allied health
Academic libraries
Direct from database provider such
as OVID
National electronic Library for Health
Direct from database provider such
as OVID
Cochrane Library
Systematic reviews, randomised
controlled trials of wide range of
health interventions
National Library for Health (internet)
International Bibliography of Social
Sciences
Social sciences research
Academic libraries
Intute: Social Sciences
Evaluated web resources including
sociology
Internet
Medline
Biomedical literature
National Library for Health
Direct from database provider such
as OVID
Academic libraries
Direct from database provider such
as OVID
Internet (pubmed)
Psycinfo
Psychological literature
National Library for Health
Academic libraries
Direct from database provider such
as OVID
Social Care Online
Social Care issues
Social Care Online (internet)
Social Services Abstracts
Social Work, Social Services and
related areas
Academic libraries
to achieve a balance between sensitivity (the amount of
information available on your topic area) and specificity
(the amount of relevant information you retrieve).
However, if you want a search to be comprehensive, it is
advisable to maximise sensitivity rather than specificity.
In other words you will have to accept that you will have
to wade through some irrelevant material to ensure you
do not miss anything important (this is, unfortunately,
the nature of database searching). The search can be
broken down into a number of stages:
04
Direct from database provider such
as Cambridge Scientific
Stage 1: Focusing the search question
Part of planning the search involves focusing the search
question. The clearer the question, the easier it is to
undertake a search. Search questions are often too
vague and result in thousands of references, particularly
in an area with a high volume of literature for example:
n I am looking for information on counselling older
people.
Anthology of research information sheets – 2nd edition
© BACP 2008
R1
In contrast, search questions can be too complicated or
result in too few references (but this does not mean that
nothing has been published on that particular subject)
for example:
n I am looking for information on counselling
older people with cancer and anxiety who live in
nursing homes.
One method to help clarify your idea is to phrase your
topic as a question.
In place of the above statement, you may try:
n How effective is counselling in treating anxiety in
older people?
Stage 2: Dividing the search into relevant concepts
It is then possible to divide your question into concepts
that can be used as a basis for your search terms, for
example:
n How effective is counselling in treating anxiety in
older people?
information sheet
types of studies; for example, systematic reviews or
randomised controlled trials. This can be done using the
concept model outlined above. For example:
n Are there any systematic reviews on the
effectiveness of counselling?
n Are there any systematic reviews on the
effectiveness of counselling for anxiety?
Stage 3: Finding relevant terms for searching
Use the database thesaurus (controlled list of terms) to
identify the term used by that database to describe your
topic of interest. This method will retrieve most of the
relevant information on your topic area. Some databases
call these keywords, subject headings or descriptors.
Add the relevant terms to your strategy. You may miss
some articles but it largely overcomes the problems of
varied spellings (described below) and will retrieve the
majority of information (think back to your search plan to
determine whether this approach is sufficient).
So if you wanted to undertake a simple search on the
question:
n How effective is counselling in treating anxiety?
Or you could use the PICO method that divides your
question into discrete components based on the
Population, Intervention, Comparison and Outcome that
can later be used as building blocks for your search. For
example for the question above:
Population: older people
Intervention: counselling
Comparison: pharmacological treatments
Outcome: reduced anxiety.
Words such as ‘effective’ or ‘management’ may retrieve
a large number of irrelevant articles. If you are interested
in the management of a particular condition, it is best to
focus on the condition. If you are interested in finding out
whether a treatment or procedure is effective, it is best to
look for systematic reviews (which summarise all available
evidence) or research studies such as randomised
controlled trials (which evaluate whether a treatment or
procedure is effective under certain conditions).
During the course of the search (based on the results
retrieved) you may find you need to modify your search
question to make it more general or more specific. For
example:
n How effective is counselling in treating anxiety?
(general)
n How effective is Gestalt therapy in treating
anxiety in older people? (specific)
You may also wish to limit your search to certain
© BACP 2008
You would find the following suggested terms (subject
headings) relating to counselling on the Medline
database (note that Medline is a US database and
therefore uses different spellings):
Psychotherapy
Autogenic training
Behavior therapy
Aversive therapy
Biofeedback
Cognitive therapy
Bibliotherapy
Biofeedback
Gestalt therapy
Non directive therapy
Psychotherapy, brief
Counseling
Directive counseling
Pastoral care
Sex counseling
For your search, you would use the terms counseling
and psychotherapy to identify all the literature relating
to counselling and then you would look up appropriate
terms to describe anxiety.
The terms are arranged reading from left to right from
more general to more specific on the right and records
on the database are allocated the most relevant and
specific subject headings possible. When selecting
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information sheet
subject headings on which to search it is important to
choose the subject heading that is most relevant to your
search question. For example if you are interested in
biofeedback, use that term rather than the wider term
behavior therapy.
Figure 2
Diagram for simple search on the question:
How effective is counselling in treating anxiety?
Stage 4: Using synonyms or alternative spellings
If there are no suitable subject headings for your
topic area or if you wish to ensure you are being
comprehensive (check your search plan) then it is
necessary to search on a range of terms or ‘free text’
in addition to a subject-heading search (as described
above). Some databases also refer to this method as
keyword searching.
For the question
n How effective is counselling in treating anxiety?
This could be translated into the following simple
(subject headings only) or more comprehensive (subject
headings and free text) searches:
Synonyms or alternative spellings could include
‘counseling’ or ‘anxious’.
Simple subject heading
search
More comprehensive
subject heading and
free text search
Be aware of alternative spellings. When doing a freetext search, databases will only retrieve the words
exactly the way you enter them. Therefore, if you
search on the term ‘counselling’ you will miss all the
American articles that are spelled ‘counseling’. Ways to
overcome this problem include using subject headings
(as described above) or functions called truncation and
wildcards, which replace various letters.
1. Counseling
2. Psychotherapy
3. 1 OR 2
4. Anxiety
5. Anxious disorders
6. 3 OR 4
7. 3 AND 6
1. Counseling
2. Counsel*
3. Psychotherapy
4. 1 OR 2 OR 3
5. Anxiety
6. Anxious disorders
7. Anxious*
8. Panic disorder
9. 5 OR 6 OR 7 OR 8
10. 4 AND 9
Truncation involves typing the stem of a word and
then a symbol (usually an * or $) to retrieve all words
beginning with that stem.
For example, counsel* will retrieve counsel, counseling,
counselling, counsellor, counsellor, etc.
Stage 6: Reviewing and refining
Stage 5: Combining your terms
Review your results and refine the strategy as necessary
(see example below). This could include adding further
synonyms or subject headings to focus the search, or
removing a term. The limit function can also be used to
restrict the search to particular languages or publication
years. It is also possible to limit by publication
type – including systematic reviews and clinical trials
– particularly useful if you are conducting an evidencebased study.
Combine your concepts using the Boolean operators
OR, AND. The operator OR is used to represent the
union of a set (i.e. retrieves records with any term
representing the same concept and, therefore, will
find all the records with counselling related words).
The term AND is used for the intersection or overlap
of the sets (i.e. to combine different concepts, thus
it will find all the records discussing counselling and
anxiety). Stages 3–5 are represented as diagrams in
Figures 2 and 3.
More comprehensive subject heading and free text
search
1. Counseling
2. Counsel*
3. Psychotherapy
4. 1 OR 2 OR 3 above
5. Anxiety
6. Anxious disorders
7. Anxious*
8. Panic disorder
Wildcard replaces individual letters in the middle of
words to retrieve alternative spellings: Counsel*ing
would retrieve counseling and counselling
Ag*ing would retrieve aging and ageing
06
Anthology of research information sheets – 2nd edition
© BACP 2008
R1
Figure 3
information sheet
Conclusion
Diagram for more complex search: How effective
is counselling in treating anxiety
Using the above systematic approach to searching
should help you keep your literature searches on
track and ensure you retrieve manageable amounts
of relevant information. It is important to familiarise
yourself with resources that are likely to be of use
to you.
References
BIOME website http://www.institute.ac.uk/
healthandlifesciences
Key:
BUBL Psychotherapy Resources. http://bubl.ac.uk/
link/p/psychotherapy.htm
sh = subject heading
* = truncation symbol
Focusing clinical questions. Oxford Centre for Evidence
Based Medicine. http://cebm.net/
focus_quest.asp
9. 5 OR 6 OR 7 OR 8 above
10. 4 AND 9 above
11. Systematic review
12. 10 AND 11 above
Bower, P. soon to be published. Evidence-based practice.
BACP information sheet R2. Lutterworth: BACP.
In many systems it is possible to automatically save
your search strategies, and print, save or email your
results. Saving your strategy is worthwhile, particularly if
you wish to revisit at a later date.
National Library for Health (NLH). http://www.library.nhs.uk
About the author
Further information
Alison Brettle is currently Research Fellow (Information)
within the Institute for Health and Social Care Research
University of Salford. Her research portfolio covers
information skills training, the evaluation of library
services and effective literature searching. She has
co-authored a book entitled “Finding the Evidence
for Practice: a workbook for health professionals”
published by Churchill Livingstone. She has worked
on a range of systematic reviews including one on
counselling older people for the BACP. She is also Book
Reviews Editor for Counselling and Psychotherapy
Research and Associate Editor for journal Evidence
Based Library and Information Practice.
Brettle, A. and Grant, M.J. (2003) Finding the evidence
for practice: a workbook for health professionals.
Edinburgh: Churchill Livingstone.
Social Care Online. http://www.scie-socialcareonline.
org.uk
Gash, S. (2000) Effective literature searching for
research (2nd ed). Aldershot: Gower.
Hart, C. (2001) Doing a literature search. London: Sage
Publications.
A web-based interactive tutorial to develop literature
searching skills on Medline: http://www.fhsc.salford.
ac.uk/hcprdu/interactive
September 2008
It should be noted that this information sheet offers broad guidance, which sets out professional good practice, but it should not be
substituted for legal and other professional advice, including supervision, applicable to your particular circumstances.
BACP is aware that law and practice are always in a process of development and change. If you have evidence that this information
sheet is now inaccurate or out of date feel free to contact us. If you know of any impending changes that affect its content we
would also be pleased to hear from you.
© BACP 2008
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information sheet
Evidence based practice in counselling and
psychotherapy
by Peter Bower
Introduction
Clients, therapists and those who fund
therapy services are all in agreement that
clients deserve the best treatment for their
presenting problems. However, deciding
on the best treatment for a client is a
complex task.
Counsellors and therapists have traditionally
made decisions about treatment on
the basis of their existing knowledge,
prior experience and reference to the
accumulated knowledge of their profession.
The BACP Ethical Framework for Good
Practice in Counselling and Psychotherapy
(2009) (the Ethical Framework) captures this
approach in its statement that therapists
must act ‘in the best interests of the client
based on professional assessment. It
directs attention to working strictly within
one’s limits of competence and providing
services on the basis of adequate training
or experience’. Professionals are expected
to demonstrate ‘reflective practice’,
involving critical reflection on their own
practice and the development of consensus
among professional colleagues (Harrison,
2002).
Recently there has been interest in
changing the basis of decisions about
treatment in the helping professions such
as medicine, nursing and counselling and
psychotherapy. This new approach goes
by the name of ‘evidence based practice’.
‘the conscientious, explicit, and
judicious use of current best
evidence in making decisions about
the care of individual patients’
(Sackett et al., 1996)
There is much in this statement that is in
line with the BACP Ethical Framework,
which ‘requires practitioners to keep up
to date with the latest knowledge and
respond to changing circumstances.’
However, evidence based practice is
controversial because the definition
of ‘current best evidence’ and ‘latest
knowledge’ is heavily weighted towards
certain forms of information derived from
certain types of research methods.
Counselling and psychotherapy can
be studied using many different types
of research, including quantitative
research, individual therapy case studies
and indepth analysis of therapeutic
work. Many practitioners are interested
in questions relating to how their
treatments work. However, the focus of
evidence based practice is on whether
treatments work i.e. evidence based
practice is concerned with treatment
effectiveness. For a variety of reasons,
determining whether a treatment is
effective is best achieved through
a particular type of study called a
randomised controlled trial.
What is a randomised controlled trial?
This information sheet defines evidence
based practice, outlines the implications for
counselling and psychotherapy, considers
the advantages and disadvantages, and
speculates how evidence based practice
might develop in the future.
What is evidence based practice?
Evidence based practice was originally
defined by its proponents in medicine as:
The simplest way of evaluating a therapy
is to measure client wellbeing before and
after therapy. If therapy is effective, client
wellbeing should improve after treatment.
However, there are other reasons why
clients might improve. They might have
received support from friends and family,
or their finances may have improved. It
is possible that some problems improve
simply through the passage of time.
Because these other factors will impact
BACP Information Sheets
are intended to be read in
conjunction with the BACP
Ethical Framework for Good
Practice in Counselling and
Psychotherapy.
The Information Services
ethics helpdesk team is
available to members who
wish to explore any ethical
issues concerned with their
practice.
It should be noted that this
Information Sheet offers
broad guidance, which
sets out professional good
practice, but it should not
be substituted for legal
and for other professional
advice applicable to your
particular circumstances.
© BACP, January 2010
R2
on client wellbeing at the same time as they are
receiving therapy, they make it difficult to tell whether
the therapy is responsible for change. Technically,
these other factors are known as confounders (Bower
& King, 2000).
The randomised controlled trial is a research method
that can overcome the problems of confounders and
determine whether a treatment (such as therapy) is
having a genuine effect.
In brief, a randomised controlled trial of therapy works
as follows. First, one group of clients is given a therapy,
while another (the ‘control’ group) is not. Where
possible, both groups of clients are treated identically in
every other way apart from the therapy itself.
Secondly, clients are allocated to the groups through
randomisation. This means that they have an equal
chance of being put in either group. The function of
randomisation is simple, but powerful. When clients
are randomised, the two groups will include clients
who on average do not differ systematically on any
characteristic. For example, each group will contain
similar numbers of men and women, younger and
older clients, those with severe problems and those
with more minor ones. Not only will randomisation
ensure similarity in characteristics that we know
about (such as age, sex and initial severity of the
problem), it also ensures that the groups are similar
on characteristics that may not be measured or
understood (such as client personality) but which are
important in terms of their eventual outcome (Bower,
2003; Bower & King, 2000).
The randomised controlled trial allows researchers
to test differences in outcomes (such as depression,
well-being, or quality of life) between the two groups.
The presence of the control group ensures that changes
found in the clients receiving therapy cannot be
explained by the mere passage of time, as this would
influence both groups equally. Any differences found
between the groups in outcomes after therapy cannot
be due to any differences in their characteristics at the
start of therapy, because randomisation ensures that
their characteristics are very similar.
What is a systematic review?
Although randomised controlled trials are very powerful
research methods, sometimes a single trial is not
enough to determine whether a treatment is effective. It
may be necessary to conduct trials in different settings
to check that a therapy works in a variety of places and
with a wide range of therapists. Researchers also like
to repeat their results to ensure that they are reliable.
Recruiting clients to trials is sometimes difficult, and
some trials are simply too small to give a definitive
© BACP 2010
information sheet
answer. When more than one trial exists on a particular
treatment, evidence based practice uses a technology
called a systematic review to make sense of this
literature.
Systematic reviews draw together a number of
individual randomised controlled trials to provide an
overview that is more comprehensive and accurate
than the results of individual trials (Gilbody & Petticrew,
1999). Further details concerning systematic reviews
can be found in Bower, 2010.
Where can I find information about randomised trials
and systematic reviews?
Randomised controlled trials and systematic reviews
are regularly published in academic journals, but details
of trials and systematic reviews in health care can be
found on the Cochrane Library. The Cochrane Library
is advertised as ‘the best single source of reliable
evidence about the effects of health care’, and is a
source of information on many thousands of trials and
systematic reviews of various treatments, including
counselling and psychological therapy. The Cochrane
Library is freely available through the National Library for
Health (http://www.library.nhs.uk).
How are randomised controlled trials and systematic
reviews used in evidence based practice?
As noted earlier, evidence based practice has been
defined as ‘the conscientious, explicit, and judicious
use of current best evidence in making decisions
about the care of individual patients.’ Current best
evidence thus complements ‘reflective practice’ and
‘professional consensus’ as another key guide to
decision making. When adopting evidence based
practice, professionals were expected to search out
the best evidence from randomised controlled trials
and systematic reviews (using sources such as the
Cochrane Library), and use that evidence to make
a judgement about what treatment to provide for an
individual client.
Although that happens on occasion, it was quickly
realised that professionals (including therapists) may
not have the expertise to search for evidence routinely
in their clinical practice and certainly would not have
the time to do so. Therefore, in settings such as the
NHS, searching for and interpreting the evidence is
generally done centrally by organisations such as the
National Institute for Health and Clinical Excellence
(NICE), which uses teams of researchers (assisted by
clinicians and patients) to summarise ‘current best
evidence’ about the effectiveness of treatments. To
assist clinicians, these recommendations are placed
into clinical guidelines.
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What are clinical guidelines?
Clinical guidelines are ‘systematically developed
statements to assist practitioner and patient decisions
about appropriate health care for specific clinical
circumstances (Field & Lohr, 1990). Guidelines are
often based around particular diagnoses or problem
areas, and summarise ‘current best evidence’ to assist
professionals to decide what treatment is most likely
to benefit a client. For example, the NICE clinical
guidelines for depression describe the role of different
psychotherapies for clients with different severity of
depression. In the United States, counselling and
psychological therapy treatments, that have been
shown to be effective in randomized controlled
trials and are recommended for use, are known as
‘empirically supported treatments’ (Chambless &
Ollendick, 2001; Weston, Novotny, & ThompsonBrenner, 2004).
The relationship between clinical guidelines and
individual clinical decision making is sometimes unclear.
Generally, clinical guidelines are thought of as the
default position for decision making. Exceptions to the
recommendations in the guideline are possible, but
they would require the professional to justify why the
guideline has not been followed (Roth & Fonagy, 1996).
The expected result of the use of guidelines is both an
increase in the overall quality and effectiveness of the
treatments, provided to clients, and a reduction in the
variability among professionals, so that clients receive
more consistent treatment.
Although most guidelines are concerned with identifying
those treatments that lead to the best outcomes for
clients, economic issues are increasingly informing
guidelines. This means that the guideline may identify the
most costeffective treatment. This is to ensure that the
limited resources available to provide treatments such as
psychological therapy are used to the best effect.
What is the hierarchy of evidence?
A term often used in evidence based practice is the
hierarchy of evidence. When considering evidence
of the effectiveness of treatments, evidence based
practice imposes a hierarchy of trustworthiness, with
those forms of evidence lower in the hierarchy only to
be used when higher forms of evidence are unavailable.
The hierarchy prioritises the ability of research to
provide answers about the effectiveness of treatments
unaffected by confounding variables. At the top of
the hierarchy is the systematic review of randomised
controlled trials, followed by individual randomised
trials. Forms of data such as clinical case series are
given much lower priority, and would generally only be
used where other forms of evidence are unavailable.
Some forms of research (such as qualitative research
10
and in depth analyses of the process of therapy)
may not even appear on the hierarchy of evidence
concerning the effectiveness of treatments.
It is important to recognise that evidence based practice
has a somewhat limited focus. It is designed to reduce
bias in decisions about what treatments produce the best
outcomes in clients. There are many questions about
therapy beyond this limited focus, where the hierarchy
has much less relevance. For example, randomised
controlled trials are much less helpful in showing how
a treatment works. There are many issues where data
from randomised controlled trials are scarce or difficult
to collect and some aspects of guidelines are still based
on professional consensus as to what is ‘good clinical
practice’. Questions relating to the wider value placed on
human well being and the role of therapy in achieving that
cannot be answered using the ‘hierarchy of evidence’.
What are the advantages of evidence based
practice?
Psychological therapists and their clients stand to gain
from the use of evidence based practice in a number
of ways.
Evidence based practice is a way of achieving the
‘scientist practitioner’ model espoused by some
segments of the psychological therapy community
(Barlow, Hayes, & Nelson, 1984). Adopting evidence
based practice can avoid dogmatic adherence to
particular therapies and can be an impetus to further
development of treatments (Weston, Novotny, &
Thompson-Brenner, 2004).
As well as identifying treatments that are effective,
randomised controlled trials may be able to indicate
when therapies are actually doing more harm than good
(Roth & Fonagy, 1996) and thus can help to protect
clients. Evidence based practice can provide protection
for professionals in terms of legal challenges to their
practice (Persons & Silberschatz, 1998).
Evidence based practice can provide support for
effective treatments that might otherwise be under
threat (either in general, or from alternatives such as
pharmacological treatments). The standards required of
treatments to be considered ‘evidence-based’ can be
made explicit and transparent and the guidelines can
be made available to clients to help them decide on
treatments.
What are the disadvantages of evidence based
practice?
There are a number of criticisms of evidence based
practice. Some are general criticisms of the approach,
Anthology of research information sheets – 2nd edition
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whereas others are specific to counselling and
psychotherapy.
Randomised controlled trials are particularly suited
to the evaluation of certain types of treatments and
clients. For example, trials are easier to run with short
term treatments, where the treatment can be specified
in a written manual and delivered to clients with
discrete problems or diagnoses. There is concern that
this creates a gap between the research evidence and
the realities of clinical practice, where treatments are
longer, unstandardised and clients present with more
complex problems (Weston, Novotny, & ThompsonBrenner, 2004).
There are concerns that the emphasis on evidence
based practice can distort decisions about how
treatment is provided. For example, clinical guidelines
may suggest that certain problems should be treated
using certain ‘brand name’ therapies that have been
tested in trials. However, a therapist who delivers such
a ‘brand name’ therapy may be ineffective if they do not
attend to other issues of relevance to the effectiveness
of the treatment, such as the quality of the therapeutic
alliance (Roth & Fonagy, 1996).
A reliance on randomised controlled trials may also
downplay the contribution of other research methods.
The sort of research which is prioritised by evidence
based practice may often be seen as irrelevant to
clinical professionals. For example, randomised
controlled trials and clinical guidelines may provide no
assistance with issues such as engaging with difficult
clients, overcoming a therapeutic impasse or dealing
with multiple problems (Persons & Silberschatz, 1998).
There are a number of situations in which randomised
controlled trials are inappropriate (Black, 1996). For
example, trials are less helpful when events are very rare
(e.g. client suicide).
Clinical innovations require an understanding of how
therapies achieve change, which may require in depth
analysis of individual cases of therapy (Persons &
Silberschatz, 1998;Rice & Greenberg, 1984). Evidence
based practice has traditionally paid little attention
to the benefits of qualitative research (Pope & Mays,
1995) and has focused almost entirely on quantitative
research designs. However, there is some evidence that
this is beginning to change. For example, NICE now
includes work on patient and client experience in its
clinical guidelines, and there is increasing interest in the
way in which quantitative and qualitative research can
be combined (Dixon-Woods et al., 2005). However, the
relative importance placed on each type of evidence is
still the subject of controversy.
Randomised controlled trials that show a therapy
can work may need to be complemented by other
methodologies (such as audit and benchmarking) that
© BACP 2010
information sheet
can ensure that their delivery in routine settings is still
producing positive outcomes (Barkham & Mellor-Clark,
2000; Seligman, 1996).
Randomised controlled trials are expensive and time
consuming. Clinical innovation tends to occur at a
faster pace than research and trials which are published
after long delays may provide evidence which does not
reflect current clinical practice. Therapies may not be
evaluated if there is insufficient impetus to fund studies.
Users of evidence based practice are cautioned that
‘no evidence of effectiveness’ does not mean ‘evidence
of no effectiveness’ (Persons & Silberschatz, 1998).
However, in practice, lack of evidence often means
that a therapy will receive little support from those who
purchase or provide therapy and there will be a focus on
those therapies that have received the bulk of attention
from researchers.
Professionals often complain that evidence based
practice leads to an excessive reliance on the results
of research and downplays clinical judgement
(Tanenbaum, 1993). This can lead to a ‘cookbook’
approach to therapy, where clients with complex
problems are reduced to a few broad categories written
into a clinical guideline. Randomised controlled trials are
based on the average responses of groups of clients,
whereas clinicians are faced with individual clients
and have to make decisions which are sensitive to the
client’s needs, preferences and the context in which
they live and work (Greenhalgh & Worrall, 1997).
Therapists are not alone among the professions
in resenting the effect of evidence based practice
in restricting their professional freedom. However,
this tension may be heightened in counselling and
psychological therapy. When evidence based practice
is applied to a profession such as medicine, the results
of trials of particular treatment do not challenge the
legitimacy of medical professionals per se. The situation
is different in counselling and psychological therapy
because most practitioners are more firmly wedded to
particular theoretical orientations. A doctor can easily
replace one medication with another, but it is difficult for
counsellors and therapists to be so flexible. Providing a
different ‘evidence-based therapy’ may have significant
implications for retraining, and may require changes
in fundamental values as well as new technical skills
(Bower & Barkham, 2006).
What is practice based evidence?
Evidence based practice involves the translation of
research evidence into clinical practice. Some believe
that clinical practice should feed more actively into
research. The model of ‘practice based evidence’
involves taking data from routine practice (such as
outcome measures routinely completed by clients)
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and using that to inform research, policy and practice
(Barkham & Mellor-Clark, 2000).
Counselling and Psychological Therapies, N. Rowland &
S. Goss, eds., London: Routledge. pp. 127–144.
How will evidence based practice change in the
future?
Barlow, D., Hayes, S., & Nelson, R. (1984). The
Scientist-Practitioner: research and accountability in
clinical and educational settings. New York: Pergamon
Press.
Although clients are likely to be as interested in
effective treatments as professionals, evidence based
practice is fundamentally a professional issue. Although
evidence of effectiveness is an important determinant
of choice about treatments, there are other factors
that need to be taken into account. Health services
often try to be ‘client-centred’, where services are
designed to be delivered in line with the needs, wishes
and preferences of clients (Laine & Davidoff, 1996).
Policy makers are also very interested in issues of
client choice. Guidelines such as those developed
by NICE often explicitly discuss the importance of
choice. Practicing in a way that is both ‘evidence
based’ and ‘client-centred’ remains a key challenge for
professionals (Bensing, 2000).
Bensing, J. (2000). “Bridging the gap: the separate
worlds of evidence-based medicine and patientcentered medicine”, Patient Education and Counseling,
vol. 39, pp. 17–25.
Black, N. (1996). “Why we need observational studies
to evaluate the effectiveness of health care”, British
Medical Journal, vol. 312, pp. 1215–1218.
Bower, P. (2003). “Efficacy in evidence-based practice”,
Clinical Psychology and Psychotherapy, vol. 10, pp.
328–336.
Bower, P. (2010). Undertaking systematic reviews in
counselling and psychotherapy. BACP Information sheet
R11. Lutterworth, BACP.
Conclusion
Evidence based practice has had a major impact on
many of the helping professions, including counselling
and psychotherapy. Although there are many aspects
of counselling and psychotherapy that make the
application of the principles of evidence practice
more difficult, it is likely that the evidence based
practice approach will continue to be an important
driver of clinical practice in the future. It is important
to understand the strengths and limitations of the
approach to ensure that research has an appropriate
impact on clinical practice in the future.
Bower, P. & Barkham, M. (2006). “Evidence based
practice in counselling and psychotherapy: definition,
philosophy and critique,” in The SAGE Handbook of
Counselling and Psychotherapy, 2 edn, C. Feltham &
I. Horton, eds., London: SAGE Publications. p. 207.
Bower, P. & King, M. (2000). “Randomised controlled
trials and the evaluation of psychological therapy,”
in Evidence-Based Counselling and Psychological
Therapies, N. Rowland & S. Goss, eds., London:
Routledge., pp. 79–110.
BACP (2009). Ethical framework for good practice in
counselling and psychotherapy. Lutterworth: BACP.
About the author
Peter Bower is a psychologist and health services
researcher working at the University of Manchester.
He conducts research work into the effectiveness
of psychological therapy and other mental health
interventions in primary care, and has a special
interest in the use of randomised controlled trials
and systematic reviews in this area. He works as a
consultant on systematic review work conducted
by the British Association for Counselling and
Psychotherapy and is a member of the BACP
Research Committee.
Chambless, D. & Ollendick, T., (2001). “Empirically
supported psychological interventions: controversies
and evidence”, Annual Review of Psychology, vol. 52,
pp. 685–716.
Dixon-Woods, M., Agarwal, S., Jones, D., Young, B.,
& Sutton, A. (2005). “Synthesising qualitative and
quantitative evidence: a review of possible methods”,
Journal of Health Services Research and Policy, vol. 10,
no. 1, pp. 45–53.
Field, M. & Lohr, K. (1990). Clinical practice guidelines:
directions for a new program. Washington: National
Academy Press.
References
Barkham, M. & Mellor-Clark, J. (2000). “Rigour and
relevance: the role of practice-based evidence in
the psychological therapies,” in Evidence-Based
12
Gilbody, S. & Petticrew, M. (1999). “Rational decisionmaking in mental health: the role of systematic reviews”,
Journal of Mental Health Policy and Economics, vol. 2,
pp. 99–106.
Anthology of research information sheets – 2nd edition
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information sheet
Greenhalgh, T. & Worrall, J. (1997). “From EBM to CSM:
the evolution of context-sensitive medicine”, Journal
of Evaluation in Clinical Practice, vol. 3, no. 2, pp.
105–108.
Sackett, D., Rosenberg, W., Gray, J., Haynes, B., &
Richardson, W. (1996). “Evidence-based medicine: what
it is and what it is not”, British Medical Journal, vol. 312,
pp. 71–72.
Harrison, S. 2002, “New Labour, modernisation and the
medical labour process”, Journal of Social Policy, vol.
31, pp. 465–485.
Seligman, M. (1996). “Science as an ally of practice”,
American Psychologist, vol. 51, no. 10, pp. 1072–1079.
Laine, C. & Davidoff, F. (1996). “Patient-centered medicine:
a professional evolution”, Journal of the American Medical
Association, vol. 275, no. 2, pp. 152–156.
Persons, J. & Silberschatz, G. (1998). “Are
results of randomised controlled trials useful to
psychotherapists?”, Journal of Consulting and Clinical
Psychology, vol. 66, no. 1, pp. 126–135.
Pope, C. & Mays, N. (1995). “Reaching the parts other
methods cannot reach: an introduction to qualitative
methods in health and health services research”, British
Medical Journal, vol. 311, pp. 42–45.
Rice, L. & Greenberg, L. (1984). Patterns of change New
York: Guildford Press.
Roth, A. & Fonagy, P. (1996). What Works for Whom?
A Critical Review of Psychotherapy Research. London:
Guildford.
Tanenbaum, S. (1993). “What physicians know”, New
England Journal of Medicine, vol. 329, no. 17, pp.
1268–1270.
Weston, D., Novotny, C., & Thompson-Brenner, H.
(2004). “The empirical status of empirically supported
psychotherapies: assumptions, findings, and reporting
in controlled clinical trials”, Psychological Bulletin, vol.
130, no. 4, pp. 631–663.
Further information
Information about the Cochrane Collaboration can
be found at http://www.cochrane.org/
The Cochrane Library is freely available at
http://www.library.nhs.uk
Clinical guidelines for many disorders can be found at
http://www.nice.org.uk/
January 2010
It should be noted that this Information Sheet offers broad guidance, which sets out professional good practice, but it should not be
substituted for legal and other professional advice, including supervision, applicable to your particular circumstances.
BACP is aware that law and practice are always in a process of development and change. If you have evidence that this Information
Sheet is now inaccurate or out of date feel free to contact us. If you know of any impending changes that affect its content we
would also be pleased to hear from you.
© BACP 2010
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information sheet
Counselling older people: information for
practitioners and policy makers
by Andy Hill
Introduction
The purpose of this information sheet is
to provide practitioners and policy makers
with a brief summary of recent research
into counselling with older people. The
intention is to inform counselling practice
and to help shape therapeutic services
for older people using research findings
as guiding principles. The information
presented is derived from a systematic
review of research into counselling older
people which included studies published
between 1985 and 2004 (Hill, A. and
Brettle, A., 2004).
Statistics
The ageing of the UK population is well
documented. In England alone, since the
early 1930’s, the number of people aged
over 65 has more than doubled. Between
1995 and 2025 the number of people over
the age of 80 is set to increase by up to
50 per cent and the number of people
over 90 will double (Department of Health,
2001). The National Service Framework for
Older People (Department of Health, 2001)
has been developed in response to these
demographic trends and the consequential
need to expand health and social care
services for older people.
There is a tendency for mental health
problems in older people to be left
undetected, indicative of a widespread
perception that such incapacities are the
inevitable consequences of ageing, rather
than routinely occurring health problems
which may be amenable to treatment
(Department of Health, 1999).
Counselling is particularly valuable with
older clients who may already be taking
prescription drugs for a variety of health
problems. As the side effects produced
by taking several drugs in combination
can be unpredictable it is vital to avoid the
addition of yet another pharmacological
treatment. Counselling can facilitate
and support psychological well being in
older people, helping them to face the
psychological and other problems which
may arise as part of the ageing process.
At what age do we become old?
In our subjective world there are times
when we feel our life has shifted into a
new phase; we sense that we have moved
on. In the external world governments
determine at what age we are eligible to
receive the state pension and hence be
defined as old. Both of these ways of
knowing produce definitions which are
subject to change and interpretation. Many
people don’t like to think of themselves as
old, whatever age limit is proposed may
be unacceptable to some. The body of
research which underpins this information
sheet (Hill, A. and Brettle, A., 2004) used
50 years as a definition of when old age
begins. Current research studies would
tend to view 60. The terms young-old
and old-old tend to be prevalent in the
literature, expressing the wide span the
term ‘old age’ can cover.
Some of the problems faced by older
people
There is evidence that as a group older
people experience lower rates of most
mental health disorders than do younger
adults (Bourdon, K.H. et al, 1992). For
example, 15 per cent of adults as a
whole are reported as having a common
mental disorder, whereas a prevalence of
just 10 per cent has been estimated for
those between 60 and 74 years. Similarly
16 per cent of adults as a whole are
thought to suffer from neurotic disorders
compared with just 12 per cent of those
BACP Information Sheets
are intended to be read in
conjunction with the BACP
Ethical Framework for Good
Practice in Counselling and
Psychotherapy.
The Information Services
ethics helpdesk team is
available to members who
wish to explore any ethical
issues concerned with their
practice.
It should be noted that this
Information Sheet offers
broad guidance, which
sets out industrial good
practice, but it should not
be substituted for legal
and for other professional
advice applicable to your
particular circumstances.
© BACP, May 2010
Previous version, September 2008
R3
aged between 60 and 74 years (Evans, O. et al, 2003).
Within these broader trends research studies highlight
certain psychological problems as being common
among old people.
information sheet
service provision for the elderly, denial by the older
person of the condition, or simply failure to detect and
diagnose the condition (Cuijpers, P., 1998).
Anxiety
Depression
Estimates of the prevalence of depression in older
people vary, many researchers and clinicians holding
that it is the most common mental health condition of
late life (Blazer, D.G., 1989). In UK older populations a
prevalence of between 10 per cent and 15 per cent has
been estimated (Mental Health Foundation, 2004a). It
has been found to be particularly common in women,
people who are single, those suffering bereavement
and other stressful life events and in those lacking an
adequate social and emotional support network (Zisook,
S. and Schucter, S.R., 1994). Although diagnosable
major depressive disorders are relatively less frequent
among older rather than younger adults, depressive
symptoms and adjustment disorders with depressed
mood are prevalent (Koenig, H.G. and Blazer, D.G.,
1992). Depression is a spectrum disorder ranging from
low mood resulting from a loss (older people being
prone to such losses: retirement, status, bereavement,
independence) to a chronic, debilitating and lifethreatening condition. Prevalence of the different levels
of severity among older people has been estimated
at about three per cent for major depression and
10–15 per cent for mild to moderate depression (Cole,
M.G. and Yaffe, M.J., 1996).
Blazer, D.G. (1989) noted that the majority of depressed
older adults have symptoms associated with physical
illness and adjustment to life stresses. The prevalence
of depression is high among those dwelling in nursing
homes, with their multiple illnesses and functional
disabilities (Mozley, C.G. et al., 2000). Parmalee, P.A.
et al. (1989) found 26.5 per cent of nursing home
residents suffered from diagnosable major or minor
depression. In this particular setting, depression with
its associated apathy, decreased attention span and
diminished concentration, may contribute to cognitive
decline, even in those without dementia (Blazer, D.G.,
1989). It has long been recognised that depression can
lead to impairments in functional abilities such as social
adjustment (Weissman, M.M. et al., 1974). Furthermore
a decline in physical functioning in the depressed
elderly has been observed (Pennix, P.W.J.H et al., 2000)
and suicide rates, two-thirds of which are thought to be
depression-related (Blixen et al, 1997), are higher among
elderly people than any other age-group (McIntosh, J.L.,
1992). In almost all cultures, the suicide rate rises with
age, the highest rates in the UK being among those
over 75 (Mental Health Foundation, 2004b). As regards
treatment, only 10 per cent of elderly people in need of
psychiatric help actually receive it (Friedhoff, A., 1994).
There may be a variety of reasons for this, such as poor
© BACP 2010
Estimates of the prevalence of anxiety disorders in
older adults range from four per cent (Bland, R.C. et
al., 1988) to six per cent (Regier, D.A. et al., 1988). As
with depression, rates are lower for older adults than
for younger people (Fuentes, K. and Cox, J.B., 1997).
The use of medication is common in the treatment
of late-life anxiety (Pearson, J.L., 1998). Indeed,
evidence indicates that older adults with emotional
problems are prescribed drugs at a disproportionately
higher rate than is the case with younger people with
similar diagnoses (Hersen, M. and Van Hasselt, V.B.,
1992). Anxiety can be non-specific, as in the case of
generalised anxiety disorder or specific as in phobia,
obsessive compulsive disorder and panic disorder.
Estimates of the prevalence of symptoms rather than
disorders (sub-clinical anxiety) among older people in
the community range from 10 per cent to 20 per cent
(Fuentes, K. and Cox, J.B., 1997).
Dementia
The Alzheimer’s Society estimates that there are
currently over 750,000 people in the UK with dementia,
of which only 18,500 are aged under 65. The chances
of having the condition rises sharply with age: one in
20 people aged 65 and over, and one in five people
aged 80 and over will develop dementia (Age Concern,
2003). The death rate from this condition and related
dementias is increasing significantly. In people aged
65 and over in England and Wales between 1979
and 1996 there were 171,590 deaths from dementias
and neurodegenerative disorders, with the number
of deaths per year increasing from 3,021 in 1979 to
10,415 in 1996. Age standardised death rates for
all diagnoses combined increased from 39 to 96
per 100,000 for men and from 45 to 101 for women
between 1979 and 1996. The most dramatic increase
was seen in death rates from Alzheimer’s disease
which increased from less than one per 100,000 in
1979 to 19 for men and 21 for women in 1996 (Kirby, L.
et al., 1998).
The prevalence of dementia among nursing home
residents is high, estimated at between 40 per cent and
70 per cent (Rovner, B. et al,, 1990; Rovner and Katz,
1993). Cognitive impairment, mostly due to Alzheimer’s
disease and related dementias, affects over 60 per cent
of nursing home residents and 15 per cent suffer
from cognitive impairment with comorbid depression
(Parmelee, P.A. et al., 1989). Many older people suffering
from dementia have difficulties with communication and
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exhibit disturbances in behaviour which at times may be
aggressive.
Similarly, hospitalised older adults invariably suffer from
either physical or psychiatric illnesses.
Physical illnesses
Community
Life-threatening physical illnesses such as cancer,
heart disease and chronic obstructive pulmonary
disease (COPD) are more common among older
people than younger populations (Yohannes, A.M.
et al., 1998). Such physical illnesses are associated
with relatively high rates of anxiety and depression.
For example, about 40 per cent of COPD patients
in general medical practice have depressive
disorders, compared with 13 per cent of all patients
in general practice (Yohannes, A.M. et al., 1998).
There is evidence to indicate the prevalence of panic
(20 per cent) and generalised anxiety (30 per cent)
disorders in this population is greater than that in the
general population (three per cent and 15 per cent,
respectively) (Wingate, B.J. and Hansen-Flaschen,
J., 1997). Physical and psychological problems are
interrelated, the latter being associated with delayed
recovery among those with physical complaints and,
even in the absence of a physical illness, older adults
with depressive symptoms are more likely than older
adults without depressive symptoms to perceive
their physical health as poor and consequently make
significantly higher use of health services (Callahan, C.
et al., 1994).
Evidence indicates that community-dwelling older
people with mental health needs are under served
(Black, B.S., et al., 1997) and that those who do seek
help would tend to access their primary care provider
(Callahan, C. et al., 1994). In England, between 1 April
2001 and 31 March 2002, 501,000 clients over the age of
65 received home help or home care services, 151,000
received day care and 205,000 received meals (Age
Concern, 2003). Such people may experience problems
with mobility, poor physical health, social isolation,
problems managing a household and difficulties in
performing the activities necessary for daily living
(Gatz, M. et al., 1996). In the light of such difficulties it
is important that counselling services can be delivered
in people’s own homes. There are significant numbers
of older people without disabilities who may also be
homebound and dependent on at home services as a
result of being a caregiver to someone with a disability.
In England and Wales, in 2001, it was estimated that
342,032 people aged 65 and over provided 50 hours
or more of unpaid care per week (Age Concern, 2003).
Counselling may have an important role to play in
supporting such people and generally helping older
people to live independently in the community and
avoiding a premature nursing home placement.
The general well-being of older people
Nursing and care homes
Although the bulk of research in this field tests the
effects of counselling on particular psychological
problems there are a number of studies which
investigate counselling with non-clinical populations
(O’Leary, E. and Nieuwstraten, I.M., 2001; O’Leary, E. et
al., 2003; Rattenbury, C. and Stones, M.J., 1989; Young,
C.A. and Reed, P.G., 1995). The focus here is upon the
general well being and quality of life of older people,
rather than the treatment of specific disorders. Such
studies have found that counselling impacts positively
on older people’s sense of well being, life-satisfaction
and functional abilities, highlighting the fact that old age
is not always associated with problems and disabilities
and that counselling is effective in supporting and
enhancing the naturally occurring maturation processes
evident in later life (O’Leary, 1996).
Settings
There is often an association between the type
of psychological problem older people may be
experiencing and where they are resident; for example
dementia is more prevalent in nursing homes than
among those older adults dwelling in the community.
16
It is estimated that in the UK in 2001, four per cent of
people aged 65–69, seven per cent of people aged
70–74, 10 per cent of people aged 75–79, 13 per cent
of people aged 80–84 and 19 per cent of people
aged 85 and over lived in sheltered accommodation
(Age Concern, 2003). In April 2003, in the UK, there
were an estimated 13,385 registered care homes for
older people and an estimated 501,900 places for
the nursing, residential and long-stay hospital care of
older, chronically ill and physically disabled people (Age
Concern, 2003). Nursing homes are a major source of
social care when family caregivers are overburdened or
family resources are exhausted (Rovner, B. et al., 1986).
Consequently, nursing home residence is associated
with high rates of cognitive impairment and dementia.
Some estimates are as high as 60 per cent of residents
being affected (Parmelee, P.A. et al., 1989). Other
estimates are more conservative and put the figure at
somewhere around one third (Evans, G. et al., 1981). The
separation of nursing home residents from their homes
and families may contribute to the psychological decline
of residents, a tendency which may be reinforced if the
nursing home focuses solely on providing good quality
physical care rather than psychosocial support.
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Hospitals
Hospital residents tend to fall into two groups; those
with a psychiatric disorder and those with physical
illnesses. The high prevalence of psychological
symptoms among those with physical illnesses
highlights the need for psychological as well as medical
treatment in such settings. The association between
psychological improvements such as a reduction in
depression and a speedier physical recovery is of key
interest here, especially if this means that the length of
stay in hospital can be reduced.
Is counselling effective with older people?
In the literature relating to older people cognitive
behavioural therapy and reminiscence therapy are the
most widely researched of the different counselling
approaches. A number of good quality studies,
mostly systematic reviews, investigate the effects of
counselling as a generic treatment. Less frequently
researched interventions are interpersonal therapy (IPT),
client centred counselling, psychodynamic therapy,
validation therapy, task centred therapy, gestalt therapy
and group psychotherapy based on the work of Yalom,
I. (1985). Over 50 per cent of relevant studies are of
group interventions as opposed to investigations of
individual therapy.
Counselling as a generic form of treatment
Counselling as a generic form of treatment has been
found to be effective in the treatment of depression in
older people. A number of well conducted systematic
reviews have concluded that counselling promotes
improvements in depression and psychological well
being, the effect size of psychotherapeutic interventions
being moderate to large (Engels, G.I. and Vermey, M.,
1997; Pinquart, M. and Sorensen, S., 2001; Scogin,
F. and McElreath, L., 1994). Scogin, F. and McElreath,
L. (1994), in a statistical meta-analysis of 17 studies,
found that psychological interventions with older
depressed people produced an overall mean effect size
of 0.78, comparing favourably with the figure of 0.73
obtained by Robinson, L.A. et al. (1990) in their review
of psychotherapy for depression across all adult ages.
Thompson, L.W. et al. (1987) found similar results in
a study of depression, concluding that despite older
people being likely to experience a high frequency
of physical and psychological stressors in their lives,
therapeutic outcomes are consistent with results
reported for younger patients treated with similar types
of counselling.
When comparing different counselling approaches
Scogin, F. and McElreath, L. (1994) found no clear
superiority for any one system of psychotherapy in
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information sheet
the treatment of old-age depression. Likewise, Gorey,
K.M. and Cryns, A.G. (1991) in their meta-analysis of
19 studies found all types of group therapy equally
effective in the treatment of depression, the age of
participants having no impact on the effectiveness of
the intervention. This equivalence of outcomes among
therapeutic approaches also holds true in the treatment
of anxiety in older people (Stanley, M.A. et al., 1996;
Thompson, L.W. et al., 1987).
Cognitive-behavioural and related therapies
Cognitive behavioural therapy (CBT) is the most
widely researched single counselling approach with
older people and has been found to be effective in
the treatment of various psychological problems.
As a treatment for depression, positive effects have
been discerned (Cuijpers, P., 1998; Engels, G.I.
and Vermey, M., 1997; Zerhusen, J.D. et al., 1991).
Pinquart, M. and Sorensen, S. (2001) conclude that
cognitive behavioural therapy is particularly effective
in improving the subjective well being of older adults.
When used in combination with anti depressants CBT
has produced significantly greater improvements than
the drug treatment alone (Thompson, L.W. et al., 2001).
A study by Lynch, T.R. et al. (2003) which combined
anti depressant medication with dialectical behaviour
therapy in the treatment of depressed older adults has
produced similar results.
CBT has produced beneficial effects in the treatment
of anxiety among older people. Stanley, M.A. et al.
(2003) found improvements not only immediately
post treatment but later, at one year follow up. These
results are supported by Barrowclough, C. et al. (2001)
who found that at 12 month follow up, 71 per cent of
patients showed a good treatment response with regard
to anxiety symptoms.
In the treatment of older people suffering from physical
illnesses and co-morbid psychological problems CBT
has been found to be effective. Kunik, M.E. et al. (2001)
discovered positive outcomes from a brief group CBT
intervention with older people suffering from chronic
obstructive pulmonary disease. When comparing
the effects of CBT on two groups of depressed older
people, one with disabling physical illnesses and one
without, Kemp, B.J. et al. (1992) found substantial and
equivalent decreases in depression in both groups,
concluding that the existence of physical illnesses does
not dilute the effects of counselling.
Reminiscence therapy and life-review
As distinct from many of the other approaches
investigated in the literature, reminiscence and life
review therapies are techniques specifically and
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information sheet
exclusively designed for use with older people, helping
them achieve a sense of integration through looking
back over their lives. Evidence as to the effectiveness
of these therapies is equivocal. Positive effects were
discerned by Baines, S. et al. (1987) finding that to treat
confused elderly people firstly with reality orientation
and subsequently with reminiscence therapy led to
significant improvements on measures of cognition,
communication and behaviour even at four weeks post
treatment. Watt, L.M. and Cappeliez, P. (2000) tested
two types of reminiscence therapy which integrate
cognitive approaches and found that the interventions
led to significant improvements among depressed older
adults. Moderate to high effect-sizes were maintained
at three months’ follow up. However Spector, A. et al.
(2003) in their Cochrane review found insufficient data
to reach firm conclusions about the effectiveness of
reminiscence therapy as a treatment for dementia and
acknowledged the need for further research.
Other therapies
There are a number of counselling approaches which
have not been widely tested with older people but are
nonetheless noteworthy as they are commonly used
in practice. The evidence which does exist is mainly
positive, particularly in the treatment of depression, but
more research is needed.
Interpersonal therapy (IPT)
A number of studies have found positive outcomes for
this therapy. Mossey, J.M. et al. (1996) treated a large
sample of medically ill, hospitalised patients suffering
from sub clinical depression with brief interpersonal
counselling and found significant improvements
six months from the beginning of the treatment.
Miller, M.D. et al. (2003) investigated the use of IPT in
maintaining recovery from major depression, finding that
IPT was superior to medication alone in preventing a
recurrence of depression in those patients experiencing
role conflict. This suggests that IPT may be particularly
effective with certain types of psychological problems.
Psychodynamic therapy
There are very few published studies on the effects
of psychodynamic interventions with older people,
as noted by Pinquart, M. and Sorensen, S. (2001).
The evidence which is available suggests that
psychodynamic therapy is as effective as cognitive or
behavioural approaches in the treatment of depression
(Thompson, L.W. et al., 1987).
Client-centred counselling
Similarly the need for more research into client
centred counselling has been noted (Pinquart, M.
and Sorensen, S., 2001). Comparisons with CBT in
the treatment of anxiety indicate that both CBT and
client centred counselling provide effective treatment
18
(Barrowclough, C., et al., 2001). Stanley, M.A. et al.
(1996) found both client centred counselling and
CBT produced large effect-sizes and no significant
differences in outcomes between the two interventions
could be discerned in the treatment of anxiety and
depression and the enhancement of quality of life.
Validation therapy
Like reminiscence and life review therapy, validation
therapy (Feil, N., 1982) is an approach specifically
designed for older people, particularly those with
dementia. Evidence as to its effectiveness is weak. A
Cochrane review by Neal, M. and Briggs, M. (2003)
located only two studies of sufficient quality thus finding
insufficient evidence to draw any firm conclusions as
to the efficacy of validation therapy for older people
with dementia or cognitive impairment. One of these
two studies (Toseland, R.W. et al., 1997) is in itself
inconclusive, finding that although nursing staff caring
for clients noted improvements in the behaviour of those
treated with the intervention, these findings were not
supported by independent observers.
Task-centred therapy
Just two studies of what may be termed task-centred
therapy (Kaufman, A.V. et al., 2000 and Klausner, E.J.
et al., 1998) were included in the review. Kaufman, A.V.
et al. (2000) tested the feasibility of providing therapy
in clients’ own homes and Klausner, E.V. et al. (1998)
compared task centred therapy with reminiscence
therapy for depression. The studies were only fair in
quality and so it is difficult to draw any firm conclusions
about the efficacy of this type of intervention with older
people.
Gestalt therapy
Research into gestalt therapy with older people is
scant. Just one good-quality study (O’Leary, E. and
Nieuwstraten, I.M., 2001) using a qualitative design
explored the types of memories emerging during gestalt
reminiscence therapy, finding that the intervention
elicited certain types of memory posited as being
therapeutic.
Individual versus group therapy
Just over half of the studies are of group interventions,
the remainder being investigations of either individual
therapy or a mixture of group and individual. Some
systematic reviews consider both group and individual
treatments (Gatz, M. et al., 1998; Pinquart, M. and
Sorenson, S., 2001; Scogin, F. and McElreath, L.,
1994) and as such are in a position to compare the
relative effectiveness of the two modalities. Two studies
(Pinquart, M. and Sorensen, S., 2001; Engels, G.I. and
Vermey, M., 1997) assert that individual interventions
were more effective than interventions in groups.
Gorey, K.M. and Cryns, A.G. (1991) found significant
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improvements as a result of group therapy but no
difference across types of group therapy. These findings
are supported by Abraham, I.L. et al. (1992), Rattenbury,
C. and Stones, M.J. (1989) and Toseland, R.W. et al.
(1997). Neal, M. and Briggs, M. (2003) suggest that
the benefits of group therapy may be a result of group
activity per se or the attention received by an individual,
rather than the application of a therapeutic technique.
Conclusions
The effectiveness of counselling with older people
Research evidence indicates that counselling is
effective with older people, particularly in the treatment
of anxiety, depression and in improving subjective well
being. The fact that outcomes are consistent with those
found in younger populations indicates that age is not a
factor in being able to benefit from counselling. Of the
various counselling approaches CBT has the strongest
evidence base and is efficacious with older people in
the treatment of anxiety and depression. Evidence as
to the efficacy of reminiscence therapy in the treatment
of dementia is weak, but consideration should be
given to the chronic and debilitating nature of this
condition as compared with more treatable disorders
such as anxiety and depression. Inevitably, the growth
in numbers of older people in the UK population will
lead to an increase in cases of dementia, which in turn
drives the need for early intervention and the search
for effective treatments. Although counselling does
not appear to reduce the symptoms of dementia,
conceivably it can improve the quality of life for this
group of older people by fostering communication and
reducing social isolation. More research is needed into
commonly used approaches which are almost absent
in the research literature; for example interpersonal
therapy, psychodynamic, client centred, validation, goal
focused and gestalt. The potential value of all of these
approaches is underlined by the fact that when different
therapeutic approaches are tested against each
other with this population, outcomes are equivalent,
indicating an absence of superiority of any one
particular type of counselling (Scogin, F. and McElreath,
L., 1994).
Older people’s treatment preferences
The evidence available indicates that individual
counselling is highly acceptable to older people
and that, given a range of options, this would be
the psychological treatment of choice among the
community dwelling elderly (Arean, P.A. et al., 2002).
There is some evidence that group therapy may be
popular with older people in nursing homes and
residential settings (Baines, S. et al., 1987) but this
needs to be confirmed by further research.
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information sheet
The delivery of counselling services for older people
Available evidence indicates that offering group
counselling to nursing home residents (Zerhusen,
J.D. et al., 1991) and individual counselling to
community dwelling older people in their homes
(Haight, B.K., 1988) are both feasible modes of service
delivery. A proactive approach to the identification
of psychological problems among older people in all
settings is necessary to ensure problems are not left
untreated. The training of counsellors to treat this
population is also feasible, good outcomes being
associated with therapists who are well qualified and
have undergone specialised training in therapeutic work
with older people.
About the author
Andy Hill is currently Head of Research at BACP. He is
also a BACP-accredited counsellor and works part-time
as a therapist for Bolton NHS Primary Care Mental
Health Services.
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supportive approaches. Behavior Therapy. 27:565–
581.
Stanley, M.A., Beck, J.G., Novy, D.M., Averill, P.M.,
Swann, A.C., Diefenbach, G.J. and Hopko, D.R. (2003)
Cognitive-behavioral treatment of late-life generalized
anxiety disorder. Journal of Consulting and Clinical
Psychology. 71:309–319.
Thompson, L.W., Coon, D.W., Gallagher-Thompson,
D., Sommer, B.R. and Koin, D. (2001) Comparison of
desipramine and cognitive/behavioral therapy in the
treatment of elderly outpatients with mild-to-moderate
depression. American Journal of Geriatric Psychiatry.
9:225–40.
Thompson, L.W., Gallagher, D., Steinmetz and
Breckenridge, J. (1987) Comparative effectiveness
of psychotherapies for depressed elders. Journal of
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Toseland, R.W., Diehl, M., Freeman, K., Manzanares,
T., Naleppa, M. and McCallion, P. (1997) The impact of
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Watt, L.M. and Cappeliez, P. (2000) Integrative and
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Further information
This information sheet is based upon a research study
commissioned by BACP. The full report (for reference
see below) can be purchased from BACP publishing.
Hill, A. and Brettle, A. (2004) Counselling Older People:
a systematic review. Rugby: BACP.
May 2010
It should be noted that this information sheet offers broad guidance, which sets out professional good practice, but it should not be
substituted for legal and other professional advice, including supervision, applicable to your particular circumstances.
BACP is aware that law and practice are always in a process of development and change. If you have evidence that this information
sheet is now inaccurate or out of date feel free to contact us. If you know of any impending changes that affect its content we
would also be pleased to hear from you.
22
Anthology of research information sheets – 2nd edition
© BACP 2010
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information sheet
Using measures, and thinking about outcomes
by Tony Roth
This information sheet considers some
basic questions that practitioners should
ask when considering monitoring their
work, and gives advice about how to set
about this.
Practitioners of counselling and
psychotherapy are increasingly asked for
information about the effectiveness of what
they do. The request can be experienced
as benign (for example, if the intent is
genuinely to see whether clients are being
offered the best sort of service) or as more
worrying (if it is seen as a demand to justify
current practice in some way). The request
might also come from clients, who want to
know whether an intervention is likely to be
the right one for them. These demands can
make it harder to focus on the fact that
monitoring outcomes can be a part of our
reflective practice, and be of direct benefit
to supervision and to training.
Not everyone who practices as a
counsellor has a background in research
methods. The idea of this information
sheet is to give some background
information about measures and
outcomes, and to give practitioners some
confidence in thinking about how they
could set about monitoring outcomes.
Can empirical measures do justice to
counselling?
Some practitioners have profound
philosophical concerns about whether it
makes sense to talk of change in terms
of empirical outcomes. There are broadly
two versions of this stance, one radical,
the other somewhat ‘softer’. The radical
position declares that counselling is a
bi-directional process in which the work
emerges from the relationship between
the counsellor and therapist. Since
‘outcomes’ are the emergent product of
this relationship, products unique to each
encounter, it makes little sense to talk about
objectified outcomes. The content of this
information sheet will have little appeal to
proponents of this position. However, a
less radical stance is one where change
in the whole person is still seen as the
aim, but there is a recognition that change
will usually be mirrored in the domains
of symptomatic and/or ‘interpersonal’
functioning (for example, even if not the
aim of an intervention, it may well be that
counselling results in a change in specific
symptoms such as depression, or an
increase in the amount of social contact
made by a client). In this sense, even if
measuring change is an imperfect way of
detecting all that has been achieved, it is
still worth doing.
Cultural and philosophical assumptions
made by measures
Setting out to measure something
assumes that whatever is being measured
is, in some sense, a real phenomenon. For
example, the fact that a scale purports
to assess anxiety implies that we know
what we mean when we refer to ‘anxiety’,
and that there is something meaningful
about declaring that one person has a
higher anxiety score than another. Many
measures make implicit assumptions – for
example, that there is value in assessing
diagnostic categories based on clusters
of symptoms. The fact that assumptions
have been made is not necessarily a
problem; the point is that anyone using a
measure should be able to reflect on what
assumptions have been made and whether
these are congruent with their intentions in
selecting and using the measure.
A second set of assumptions is cultural.
Most measures are developed in the
context of a western empiricist tradition,
and they are usually administered to
European or American participants.
We don’t really know how measures
perform when the person completing
them is from a different culture, especially
one where the experienced sense of
BACP Information Sheets
are intended to be read in
conjunction with the BACP
Ethical Framework for Good
Practice in Counselling and
Psychotherapy.
The Information Services
ethics helpdesk team is
available to members who
wish to explore any ethical
issues concerned with their
practice.
It should be noted that this
Information Sheet offers
broad guidance, which
sets out industrial good
practice, but it should not
be substituted for legal
and for other professional
advice applicable to your
particular circumstances.
© BACP, May 2010
Previous version, January 2008
R4
information sheet
psychological self and other may be very different from a
eurocentric position. Even at a relatively straightforward
level, translating questionnaires into different European
languages can introduce subtle (and unintentional)
changes in meaning. The difficulty is compounded when
differences in perspective relate not just to language but
to the person’s cultural background.
It is important neither to overstate this problem (and
assume that cultural difference inevitably invalidates
a measure) nor to understate it (and fail to consider
whether a person’s background might influence the
usefulness of an assessment procedure). There is little
empirical evidence to guide practitioners on this point.
Ultimately good practice would be to reflect on the
issue explicitly when planning to administer a measure,
and to bear these reflections in mind when interpreting
any results.
Research ethics and research supervision
Whether practitioners plan to use this information sheet
to think about their own practice or to conduct more
formal research, it is a good idea to look at the guidance
on research ethics published by the British Association
for Counselling and Psychotherapy, Bond, T. (2004).*
As well as helping to answer questions about the
conditions for making research ethical, it also points out
that (particularly for less experienced researchers) it is
good practice to identify a suitably qualified supervisor
who can oversee and comment on any proposals. This
ensures that the research itself does not expose clients
or practitioners to unethical practice. It also guards
against the possibility that research becomes unethical
simply because the methods used cannot answer the
research question (and hence require clients to undertake
procedures of no clear benefit to them or to anyone else).
Validity, reliability and standardisation
For the reasons that follow, it is helpful for measures
to be both valid and reliable. These terms have a
number of meanings, but basically validity indicates
that a measure is detecting the phenomena it claims
to be measuring. For example, giving a depression
questionnaire to someone with chronic physical pain
could overestimate their level of depression because
pain – as opposed to depression – could underpin
their poor sleep or reports of physical discomfort.
Reliability broadly refers to the extent to which the
instrument gives a similar result if you administered
*This guidance should be read in the context of the
Ethical Framework published by the British Association
for Counselling and Psychotherapy (www.bacp.co.uk/
ethical_framework).
24
it more than once to the same person. Intuitively,
it should be obvious that a measure needs to be
reasonably stable; if it were not, it would be hard to
know whether any change observed over time reflects
your intervention, or an error introduced by the measure
itself. Achieving good validity and reliability isn’t always
easy, and instruments (such as questionnaires, for
example) usually require careful development both at a
global level (for example, by comparing their results with
other measures or indices) as well as checking that the
individual questions in the measure are appropriate (it
could be that not all the items measure the same thing).
It is also helpful if instruments have been standardised.
This is usually done by looking at the pattern of
scores obtained by samples of individuals selected
for the presence or absence of the characteristics the
instrument is asking about. For example, people with
panic disorder should score highly on an instrument that
measures panic symptoms, while people in the general
population should have low scores (technically referred
to as scores in the ‘normal’ range). These criteria may
seem fairly obvious, and in some ways they are, but can
be difficult to achieve in practice. For this reason making
up a questionnaire of your own may not be a good
idea, unless you have a very specific set of questions
that relate to your practice or approach. Partly this is
because you need some experience of the likely pitfalls
of questionnaire design, and also because the use of
standardised instruments with known characteristics
makes any reports of outcome more credible to outside
bodies. In addition, using a widely available and already
validated instrument makes it easier to compare your
results with those obtained by others.
Making sure measures are capable of detecting change
There are a lot of measures available, some more popular
than others. However, popularity isn’t always the best
guide to what is appropriate, because measures need to
be chosen on the basis that they are likely to be sensitive
to the sort of changes you anticipate happening. A good
rule of thumb is to start by thinking about what sort of
change you expect to occur, and what sort of changes
you would be interested in measuring. Then you need
to identify a measure that has been properly developed,
which in this sense means knowing that researchers
have used it, and that it performed as expected. You also
need to go one stage further because even a very robust
measure can fail to measure change if you apply it in the
wrong context.
As an example, the Beck Depression Inventory (BDI)
is widely used, and is generally acknowledged to
be reliable, valid and a good indicator of change.
However, how well it can track change depends on
how depressed people are at the start of therapy. If
they are severely depressed there is scope for them to
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make a lot of improvement. Conversely if they are only
mildly depressed, the BDI might turn out to be a blunt
instrument. This is because the shift in scores from
very mild depression to better levels of functioning is
quite small, which would make it hard to show that the
intervention makes much of an impact. The point here is
not that the BDI is a poor measure, but that the measure
should be fit for the purpose for which it is being used.
Applicability, acceptability and practicality
Even if a measure meets most of the criteria described
above (meaning it is reliable, valid and sensitive to what
it sets out to measure), it is also important to consider
whether it will be acceptable to those to whom it is
administered, and whether it is practical to implement
the measure in the context within which the work is
being carried out. For example, common sense, as well
as experience, tells us that clients and therapists are
less likely to complete lengthy measures, or to complete
multiple sets of questionnaires.
Practicality is also pertinent. Thought should be given
to the ‘mechanics’ of administering questionnaires,
especially if the aim is to have a number of therapists
and clients giving out and completing questionnaires.
Unless everyone involved is very motivated, it can
be hard to achieve a good return rate. In this sense,
issues of acceptability and practicality are paramount.
Most research supervisors can think of studies where
every attention was paid to ensure that measures
were scientifically robust but which neglected to think
about their acceptability and practicality, with the
consequence that hardly anyone completed them.
These concerns are especially relevant when it comes
to collecting data at more than one time point, as would
be the case if change from intake to outcome is being
monitored. It is important to be realistic about what
needs to happen for the system within which the work
takes place to support the monitoring you have in mind,
and to tailor expectations appropriately. An example
would be a study that assumed that a receptionist
would remember to give clients a questionnaire without
checking that the reception staff were motivated (and
therefore likely) to do this.
Detecting change without using formal measures
In some cases measures may not be the best or the
only way of detecting change. It could make just as
much sense to look at the impact of an intervention by
identifying something that you hope will change as a
consequence of your input, and looking for change in
that factor. This is an indirect way of measuring impact,
and because what you choose to measure ‘stands
in’ for a more direct assessment, it is referred to as a
© BACP 2010
information sheet
‘proxy’ measure. However, choosing the right proxy
needs some thought.
To illustrate, consider a setting where return to
employment is a major goal. Choosing ‘time taken
to return to work’ as an indicator of a successful
outcome looks fairly sensible, but in reality might be
too demanding, and lead to an underestimate of the
impact of an intervention. This is because actual return
to work depends on many factors outside the scope
of counselling (the simplest of which is whether there
are any jobs in the person’s field). A better indicator
of success could be activities which are still directly
related to the intervention, but which are more likely to
be sensitive to change (such as job-seeking behaviours,
making calls to prospective employers, or feeling more
confident about going to an interview).
Because this approach takes an explicitly indirect route
to assessing impacts, you cannot assume that it is your
intervention that is responsible for change. You would
need to be able to reflect on the plausibility of any links
between your intervention and outcome, and hopefully
maintain an open mind about any alternative explanations.
Some examples of available measures
Over the years a very large number of measures have
been developed and published. The purpose of most of
these measures is to identify and quantify the presence
and magnitude of symptoms and problems. This makes
it possible to get a sense of a client’s initial difficulties,
and identify any changes that take place over the
course of therapy.
Listing all available measures would make this a
very long information sheet but there are references
to further sources of information at the end of this
document. Many tests and measures are copyrighted,
but some are in the public domain and freely available.
There are several broad domains of questionnaires and
measures.
Measures of change in specific symptom areas
There are a large number of measures designed to
assess the degree of distress in specific symptom
areas. For example, depressive symptoms (eg Beck
Depression Inventory), panic (eg Panic Disorder Severity
Scale), obsessionality (eg Yale-Brown Rating Scale
for Obsessive Disorders), PTSD (eg Impact of Events
Scale). There is probably a validated measure available
for any area of symptom presentation. The source
books referenced at the end of this information sheet
are a good way of locating ones suited to questions you
may be interested in asking.
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information sheet
Obviously these sorts of measures are ideal if detecting
change in specific symptom domains is the aim (or at
least, part of the aim) of an intervention. However, life is
seldom so simple, and clients often come with problems
in many symptom domains. This needn’t be a problem
if you are reasonably certain that some symptoms are
more important to target than others. For example,
someone with a phobia might be rather depressed, but
your appraisal might suggest that this is secondary to
the phobia (in other words, if you treated the phobia
successfully their depressed symptoms would resolve).
In this case only monitoring phobic symptoms makes
sense. However, if you suspected that the depression
and the phobia were both important areas for
intervention, you either need to think about measuring
both, or use a global measure designed to assess a
number of symptom areas at the same time. Their great
advantage is that clients do not have to complete lots of
different questionnaires, and sometimes (because they
tap into a lot of domains simultaneously) they draw a
therapist’s attention to difficulties or problems that had
not been previously identified.
Global measures of symptoms and functioning
In most settings the range of clients will be quite broad.
For many services and therapists, a sensible (partly
because it is simple) strategy is to monitor clients
using a global measure. These assess a broad range of
symptoms, and in some cases also tap into the person’s
functioning. Although global measures can be used
alongside the more specific measures discussed above,
there is a trade-off between the additional information
from multiple questionnaires, and the risk that clients will
not find the time to complete them.
Some global measures assess a broad range of
symptoms. However, these can be quite lengthy
(reflecting their origins as tools for diagnostic screening
and assessment). A good example would be the SCL90 (Symptom Check List), which taps nine primary
symptom areas; these can be ‘summed’ to produce
a Global Severity Index (part of the SCL-90). A more
convenient form of this instrument is the Brief Symptom
Inventory, with 53 items contrasted to the 90 items of
its parent questionnaire. This reduction in the number of
items is achieved by using statistical methods to look
at the contribution of individual questions to the overall
score, and to any sub-scale scores, and seeing whether
some questions are more critical than others.
This process of reducing the number of questions to the
minimum possible makes it more likely that the measure
will be both scientifically robust and acceptable to
clients. In the UK, a widely used and free measure is the
CORE, which follows this logic by having just 34 items.
It assesses client’s subjective wellbeing, symptoms,
interpersonal functioning, and risk to self and to others,
26
and yields a global distress score. The measure has
been well researched in routine services, and there is a
lot of information about the profile of scores associated
with users of particular services (for example, primary
as opposed to secondary care settings), as well as
some benchmarking of the sort of change that is usually
observed after an intervention. The CORE battery can also
be used several times in the course of an intervention,
making it useful as a way of ‘tracking’ change.
Measures of functioning
Measures of functioning tap into patterns of behaviour
rather than patterns of symptoms; for example, how well
people are functioning in intimate relationships, socially,
or at work. Because this represents a more holistic
level of appraisal, some practitioners find this a more
acceptable or relevant way of tracking change.
There are a number of available instruments, but not all
are easy to interpret. For this reason it is a good idea to
ask how the questionnaire maps to the problems your
intervention is attempting to address. As an example, the
title of the Work and Social Adjustment Scale gives a clear
indicator of the areas of functioning it tries to assess. This
instrument is very short, at just five items, and is a rapid
and reliable way of measuring the impact of problems
on the client’s capacity for social and work functioning.
Conversely, the Inventory of Interpersonal Problems (IIP)
is a questionnaire used by many researchers. It is quite
easy to administer (it comes in short forms that take little
time to complete), is sensitive to any improvements,
and has been well standardised. However, it is quite
a complex instrument because it describes social
functioning in a number of domains and dimensions, and
interpreting results for an individual client requires some
understanding of the way in which it is constructed.
‘Qualitative’ and individualised measures of process
outcome
Some measures do not tap outcome as such but
are designed to enable clients to give structured
feedback about their experience of the process of
an intervention. This feedback can support reflective
practice and, as such, can be especially meaningful to
practitioners.
One example of these measures is the ‘personal
questionnaire’, which asks clients to identify and rate
the problems they wish to work on. A virtue of this
instrument is that it relates closely to the client’s own
goals, and can be used to review progress on a sessionby-session basis. A second example is the ‘Helpful
Aspects of Therapy’ scale, which asks clients to identify
and rate the aspects of therapy that they have found
most useful.
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A good place to look at some of these instruments is
the website of the Network for Research on Experiential
Psychotherapies: http://www.experiential-researchers.
org/instruments.html.
Measures of the therapeutic alliance
One important process variable is the ‘therapeutic
alliance’, which refers to the relationship between
therapist and client, as well as their shared sense of
common aims and purpose. There is good evidence for
a link between positive outcomes and a good alliance,
and when therapy seems not to be going as well as
had been hoped it may be worth using a standardised
measure to check that the alliance is ‘on track’.
Most measures of the alliance examine the quality of the
relationship between therapist and client, and the extent
to which therapist and client are agreed both about
goals of the intervention and the procedures being used
to achieve them. There are a number of scales available,
most of which give similar results when tested against
each other. However, the Working Alliance is probably
one of the most commonly used. It has the virtue of
being fairly short (it is often administered in a shortened
12-item version), has a version for therapists and for
clients (which helps to cross-check the congruence of
each party’s views) and is fairly widely available.
information sheet
Qualitative research usually involves looking at language
rather than numbers. This approach involves analysis
of the content of people’s talk to gain a sense of the
meanings they employ. An example would be a study by
Henry, W.P. et al (1990) which looked at the relationship
between the content of therapists’ comments and those
of the client (and which also detected differences in the
patterns of communication in good and poor outcome
cases). An important feature of the qualitative approach
is that it is usually explicitly exploratory, and makes few
assumptions about the phenomena it is considering.
Because it is a fairly intensive methodology it can be
carried out with very small numbers of participants,
making it particularly suited to individual counsellors
interested in examining some aspect of their practice.
Detailed discussion of this approach is outside the
scope of this information sheet, but there are an
increasing number of helpful references that introduce the
methodology (see Mason, J., 2000; Lepper, G. et al, 2006).
Matching methodology to the question
There are many methodologies for researching
outcomes. Evidence-based practice often focuses on
the randomised controlled trial (RCT), so it is worth
being clear what this aims to do, and then consider
other approaches.
Randomised Control Trial (RCT)
Quantitative and qualitative analysis
If you are carrying out quantitative research (which
basically means that numbers are involved) you may
need to think about doing some statistics. The helpful
thing about statistical analysis is that it indicates
whether your observations are robust (roughly, the
likelihood is that if you did the exact same thing again
you would have the same results), or whether your
findings are better accounted for by chance (if you
repeated your intervention you would probably find a
different pattern of results).
It is a good rule of thumb to match the complexity of any
statistical tests you use to your level of expertise, since
you need to understand how to apply and interpret them.
Given this, it is worth remembering that simple descriptive
statistics can often be used to ‘scope’ any data, and give
you a preliminary idea of the results you are obtaining. It
would be much better to stop at this point than to take
things further and (for the sake of seeming ‘scientific’)
end up out of your depth. If you lack confidence, getting
advice about analysis is crucial and will help you to
improve your understanding of research and statistics.
A useful introductory book is by Bell, J. (2005). For those
who want to increase their expertise, the book by Barker,
C., Pistrang, N. and Elliot, R. (2002) is an accessible and
sophisticated introduction to research methods.
© BACP 2010
This methodology is usually used to compare the
outcomes of treatments. A basic design would involve
identifying a group of individuals who meet a set of
inclusion and exclusion criteria (for example, in a trial
looking at the efficacy of treatments for depression,
participants might need to meet diagnostic criteria for
depression, and could be excluded if they are actively
suicidal or had significant substance abuse problems).
Relevant measures (for example, of depression) would
be taken before any intervention, and then participants
would be ‘randomised’ either to an active treatment or
to a ‘control’ treatment. The idea of a control group is to
act as a contrast to the ‘active’ treatment. On this basis
a control group could be an alternative psychological
treatment, or medication, or it could involve placing
participants on a waiting list.
The critical point about randomisation is that it allocates
participants to interventions in a random, as opposed to
systematic, manner. This means that the intervention they
receive is not chosen on the basis of who they are, or
how they present (and so on). Given enough participants,
this means that any variations in the characteristics
of participants become ‘evened out’. In this way any
differences that are found after treatment can be attributed
to the interventions, and not to differences among the
clients or the therapists (or any other variables).
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After the intervention period is over the measures are
repeated, and the outcomes for the active treatment
and control groups compared. An interesting example
of an RCT is one conducted recently at the Royal Free
Hospital in London which examined the relative benefits
of CBT, counselling, and treatment as usual by a GP,
finding that CBT and counselling had roughly similar
outcomes in the particular context within which they
were offered (Ward, E. et al, 2000).
If randomisation is done properly and the number of
people in the trial is big enough, RCTs can answer
questions about treatment efficacy. RCTs are rightly
seen as the most rigorous source of information about
outcomes, and it is no accident that major decisions
about treatment efficacy draw strongly on RCT
evidence. Unfortunately this leads many practitioners
to assume that the only form of outcome research that
carries any weight is the RCT. Some try to carry out
RCTs in contexts that are inappropriate, not noticing
that this is a complex and challenging trial design,
both scientifically and in terms of the resources they
require. Others simply give up on the idea of conducting
research into their practice in the erroneous belief that
there are no alternative or simpler research designs that
carry weight. There are, of course, and because they
are simpler they also often make for a better match with
the questions practitioners are asking, and can often
be implemented by individual practitioners using the
resources available to most services.
Alternatives to the RCT
Research questions which can be answered without
using an RCT, and which can give direct feedback about
the quality of practice delivered by practitioners or the
service include:
n Tracking individual outcome from a specific client,
or from a number of clients with similar difficulties.
n Comparing outcomes or client satisfaction from
different ways of delivering a service (e.g. group
vs individual treatment).
n An audit* of a service – what sort of outcomes,
how many sessions tend to be offered, how many
people take up the service (and so on).
n An audit of the type of people who use the service
– for example, what level of difficulty do clients of
the service have (this is sometimes referred to as
‘service profiling’).
All these questions could be answered using fairly
straightforward measures, and cause little interference
with the way in which a service is usually delivered.
However, a good motto is to keep the questions asked in
line with your resources. For example, a service that asks
whether it is making a measurable difference to clients
might be tempted to go further, and ask whether some
clients benefit more than others. This is a reasonable
question, but is harder to answer than it looks. Clients
differ on lots of dimensions, only some of which are likely
to be measured, but all of which could be contributing to
any observed differences in outcome. If the service found
that men seemed to be benefiting more than women,
this could be a genuine finding. Equally it could be
attributable to another factor that hasn’t been measured.
For example, if one of the referrers to the service were
very skilled, and only referred men who were suited to
therapy this would bias the overall results obtained by the
service (in this case gender is conflated with suitability).
Having access to a very large number of clients makes
the risk of this sort of error much less likely (because it
‘evens out’ the bias introduced by these unexpected
and unplanned ‘fluctuations’ in the sample under study),
but these large samples are usually the preserve of big
services or of psychotherapy researchers. This doesn’t
mean that therapists can’t use their own data to think
and reflect on any patterns of outcomes. This has been
referred to as evidence-based reflective practice (Lucock,
M. et al, 2003), and uses data as the basis for speculation
and supervision.
One further caution on service audit is that you may
need to start by thinking about how similar clients in the
service are to each other. If all the clients you monitored
had the same sort of problem, and were all equally
affected by the difficulty, looking at change across the
group would probably tell you something about how the
‘average’ client is likely to be helped. However, if some
clients presented with troubling but transient problems,
while others had intractable long-term problems, looking
at gains across the group would give you little idea of
how an individual client would benefit (this is one of the
reasons why research trials usually place restrictions on
the type of client treated). For this reason, establishing
a ‘profile’ of the clients seen in a service is a useful first
step in conducting any audit.
Evidence, persecutory practice and reflective practice
*Although research of this kind is usually described as
an audit, it still constitutes research. Helpfully the notion
of audit carries with it some sense of self-inspection and
self-reflection in relation to practice. This means that
whether or not results are intended for dissemination to
others, this is research of particular value to those who
carry it out.
28
Some audit questions have the potential to create a lot
of anxiety. Questions about outcomes from a service or
the performance of individual therapists are potentially
threatening because practitioners need to be confident that
anyone making use of data knows how to interpret it, and is
able, and willing, to make use of it in a fair-minded manner.
Anthology of research information sheets – 2nd edition
© BACP 2010
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If there is a fear that requests for evidence reflected
hidden agendas (for example, to deny funding to a
service) the spirit of evidence-based practice would
be lost. In this sense collecting evidence needs to
operate in a collegial and collaborative context. After
all, the best reason for collecting information is to tell
us whether what we do really is useful, and to enhance
the service we offer clients. Ideally evidence helps us
to reflect on what we do well, and where we realise that
we do things less well than we thought, to consider
the best response – which could include identifying
alternative approaches to the work, or offering more
supervision or training (and so on). It is not idealistic
to expect that services should be able to respond in
this way (the Luckock et al (2003) paper shows how
evidence can be used productively in an NHS setting).
information sheet
Brief Symptom Inventory: Derogatis, L.R. and
Melisaratos, N. (1983) The Brief Symptom Inventory:
an introductory report. Psychological Medicine, 13(3),
595–605.
Evidence-based Reflective Practice: Lucock, M., Leach,
C., Iveson, S., Lynch, K., Horsefield, C. and Hall, P.
(2003) A systematic approach to practic-based evidence
in a psychological therapies service. Clinical Psychology
and Psychotherapy, 10, 389–399.
Henry, W.P., Schacht, T.E. and Strupp, H.H. (1990)
Patient and therapist introject, interpersonal process
and differential psychotherapy outcome. Journal of
Consulting and Clinical Psychology, 58, 768–774.
Impact of Events Scale: Weiss, D. and Marmar, C. (1997)
The Impact of Event Scale – revised in Wilson, J. and
Keane, T. (eds), Assessing psychological trauma and
PTSD. New York: Guildford.
About the author
Tony Roth is a clinical psychologist who has worked
in the NHS for many years, but whose primary role
now lies in clinical training. He is currently joint course
director of the doctoral course in clinical psychology at
University College London.
Inventory of Interpersonal Problems (IIP): Horowitz, L.M.,
Rosenberg, S.E., Baer, B.A., Ureno, G. and Villasenor,
V.S. (1988) Inventory of interpersonal problems:
psychometric properties and clinical applications.
Journal of Consulting and Clinical Psychology, 56,
885–892.
References
Barker, C., Pistrang, N. and Elliot, R. (2002) Research
methods in clinical psychology: An introduction for students
and practitioners (2nd ed), West Sussex: John Wiley.
Lepper, G. and Riding, G. (2006) Researching the
psychotherapy process: A practical guide to transcriptbased methods. Hampshire: Palgrave Macmillan.
Mason, J. (2000) Qualitative Researching. London: Sage.
Barkham, M., Mellor-Clark, J., Connell, J. and Cahill, J.
(2006) A CORE approach to practice-based evidence:
A brief history of the origins and applications of
the CORE-OM and CORE System. Counselling &
Psychotherapy Research, 6, 3–15. See www.coreims.
co.uk for more details on the CORE System.
Beck Depression Inventory (BDI): Beck, A.T., Steer, R.A.
(1987) BDI: Beck Depression Inventory manual. San
Antonio: The Psychological Corporation.
Beck Depression Inventory (BDI): Beck, A.T., Steer, R.A.
and Brown, G.K. (1996) Beck Depression Inventory –
Second edition manual. San Antonio: The Psychological
Corporation. (There are two editions of the BDI; the
original version is still employed and more readily
available.)
Bell, J. (2005) Doing your research project: a guide for
first-time researchers in education, health and social
science. (4th ed), Maidenhead: Open University Press.
Bond, T. (2004) Ethical Guidelines for Researching
Counselling and Psychotherapy. Rugby: BACP (available
on BACP website www.bacp.co.uk/research/ethical_
guidelines.php).
© BACP 2010
Panic Disorder Severity Scale: Shear, M.K., Brown, T.A.,
Barlow, D.H., Money, R., Sholomskas, D.E., Woods,
S.W., Gorman, J.M. and Papp, L.A. (1997) Multicenter
Collaborative Panic Disorder Severity Scale. American
Journal of Psychiatry, 154, 1571–1575.
Randomised Controlled Trial: Ward, E., King, M. and
Lloyd, M. et al (2000) Randomised controlled trial of
non-directive counselling, cognitive-behaviour therapy
and usual general practitioner care for patients with
depression. I: Clinical effectiveness. British Medical
Journal, Dec 2, 321, 1383–1388.
SCL-90 (Symptom Check List): Derogatis, L.R., Rickels,
K. and Rock, A.F. (1976) The SCL-90 and the MMPI:
a step in the validation of a new self-report scale. British
Journal of Psychiatry, 128, 280–289.
Work and Social Adjustment Scale: Mundt, J.C., Marks,
I.M., Shear, K. and Greist, J.H. (2002) The work and
social adjustment scale: a simple measure of impairment
in functioning. British Journal of Psychiatry, 180,
461–464.
Working Alliance Inventory: Horvath, A.O. and
Anthology of research information sheets – 2nd edition
29
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information sheet
Greenberg, L.S. (1989) Development and validation of
the Working Alliance Inventory. Journal of Counseling
Psychology, 36, 223–233.
Ishak, W.W., Burt, T. and Sederer, L.I. (2005) Outcome
measurement in psychiatry: a critical review. London:
APA.
Yale-Brown Rating Scale for Obsessive Disorder:
Goodman, W.K., Price, L.H., Rasmussen, S.A., Mazure,
C., Fleischmann, R.L., Hill, C.L., Heninger, G.R. and
Charney, D.S. (1989) The Yale-Brown Obsessive
Compulsive Scale, 1: development, use and reliability.
Arch Gen Psychiatry, 46, 1006–1011.
Maruish, M.E. (ed) (2004) The use of psychological
testing for treatment planning an outcomes assessment.
New Jersey: Lawrence Erlbaum.
Vol 1 General considerations
Vol 2 Instruments for children and adolescents
Vol 3 Instruments for adults
Further reading
Psychotherapy research
Measures
One area where the measures are used extensively is
in psychotherapy research. A good guide and wideranging introduction to some of the issues and findings
can be found in:
There are a number of source books that give
details of measures; some good starting points are
referenced below. Although some have ‘psychiatry’ in
the title, they are broad in scope and include detailed
information about an enormous number of available
questionnaires, applicable to a very wide range of
presentations, and are a good resource. They also
include more technical discussion of questionnaire
design and interpretation than it has been possible
to include in this information sheet. Some examples
follow:
American Psychiatric Association (2005) Handbook of
psychiatric measures. Washington DC: APA.
Lambert, M. (2004) Bergin and Garfield’s Handbook
of Psychotherapy and Behavior Change, 5th Edition
Chichester: John Wiley and Sons.
Although disorder-based (which may make it inimical
to some), a review of the methodology and findings of
psychotherapy outcome research can be found in:
Roth, A.D. and Fonagy P. (2005) What works for whom?
A critical review of psychotherapy research. New York:
Guilford Press.
May 2010
It should be noted that this information sheet offers broad guidance, which sets out professional good practice, but it should not
be substituted for legal and for other professional advice applicable to your particular circumstances.
BACP is aware that law and practice are always in a process of development and change. If you have evidence that this information
sheet is now inaccurate or out of date feel free to contact us. If you know of any impending changes that affect its content we
would also be pleased to hear from you.
30
Anthology of research information sheets – 2nd edition
© BACP 2010
R5
information sheet
Research on counselling children and
young people
by Dr Sue Pattison & Belinda Harris
Introduction
This information sheet provides
practitioners with an overview of the
current research on counselling children
and young people. The information has
been derived from the BACP systematic
scoping review on this subject (Harris, B.
and Pattison, S., 2004).
The aims of this information sheet are to:
n Identify the problems and concerns
that children and young people
bring to counselling
n Provide a summary of the research
evidence in relation to the
effectiveness of counselling with a
range of therapeutic approaches
n Draw attention to issues from
the research that are of particular
relevance to practitioners
n Highlight gaps in the research
evidence
The BACP Ethical Framework for Good
Practice in Counselling and Psychotherapy
(2010) (the Ethical Framework) puts
responsibility on practitioners to keep
up to date with issues relating to their
professional practice. Contemporary
practice includes the use of research
evidence to support therapeutic
interventions. Ethical guidelines
for researching counselling and
psychotherapy (Bond, T., 2004) suggest
that this process is required to increase
the credibility and public standing of the
profession; enhance the quality, effects
and safety of counselling practice; extend,
challenge or transform existing knowledge
and demonstrate accountability. This is
particularly important when carrying out
research with vulnerable groups such as
children and young people.
Therapists working with children and
young people are increasingly likely to be
involved in multi-agency work (DfES, Every
Child Matters, 2004). This may bring up
conflicts of interest regarding issues such
as confidentiality, boundaries and sharing
of information. When a therapist is faced
with these issues, the Ethical Framework
may be used to help resolve them through
a clear, rational decision-making process.
Issues around diversity and inclusion are
also part of the landscape in relation to
children and young people, particularly
in the educational context (Pattison, S.,
2005), where the inclusion of children
with a range of abilities and needs in
mainstream schools is a priority. The
standards of practice embodied in the
Ethical Framework are clear that therapy
should be inclusive and non-discriminatory
through the therapist’s awareness of
diversity of experience and culture. The
rights of the child or young person need
to be respected, a sense of self/identity
fostered and the personal efficacy of
the child increased. This may present a
challenge to the practitioner when a child
has been ‘sent’ for therapy. For example,
in the school context a child may be
sent to see the counsellor for help with
behaviour problems. The child may not
want counselling but may feel obliged
to attend in order to prevent disciplinary
procedures. Children have the right not to
take part in counselling or psychotherapy,
though in practice it may be difficult for the
child to assert their rights.
What does research identify as the
typical presenting issues when working
with children and young people?
Contemporary research shows that work
with children and young people covers a
wide range of issues and, as such, reflects
the lived experience of children and young
people in need of support from a therapist
to help them work through feelings of
distress. Many of these issues are also
common to adults who seek counselling
and include:
BACP Information Sheets
are intended to be read in
conjunction with the BACP
Ethical Framework for Good
Practice in Counselling and
Psychotherapy.
The Information Services
ethics helpdesk team is
available to members who
wish to explore any ethical
issues concerned with their
practice.
It should be noted that this
Information Sheet offers
broad guidance, which
sets out industrial good
practice, but it should not
be substituted for legal
and for other professional
advice applicable to your
particular circumstances.
© BACP, June 2010
Previous version, June 2007
R5
information sheet
nDepression
nAnxiety
n Low self-esteem
n Sexual abuse
n Physical and emotional abuse
n Eating disorders
n Difficulties with relationships
However, the research evidence relates to the
contexts more specifically relevant to younger clients,
such as schools, and issues associated with these
environments, for example:
n School phobia
nBullying
n Behavioural problems
Children and young people suffer a variety of
psychological problems and there is some evidence
to suggest that the proportion of young people with
serious chronic difficulties has risen from 11 per cent
(Ebata, A.T. and Moos, R.H., 1990) to 20 per cent
(Sunderland, M., 2004) over the past 14 years. Such
problems tend to be more common during adolescence,
when lack of control over physical, social and
physiological changes is more likely to lead to stress,
depression, alcoholism, drug misuse, eating disorders,
self-harm and suicide (Steinberg, L., 1996).
What does research show to be the extent of the
problem?
The following statistics provide clear evidence not
only of the urgent need for well-informed, appropriate
support services for young people but also of the need
for highly skilled, attuned therapists who are capable
of making a significant impact on the young person’s
sense of self and well-being. Depression in adolescence
is widespread and therapists may be concerned to learn
of a 70 per cent increase in anxiety and depressive
disorders in adolescents since the millennium, with
40,000 children taking prescribed anti-depressants
(Sunderland, M., 2004) and suicide accounting for over
one-fifth of all deaths in young people. According to
Steinberg, L. (1996), one in three young people have
contemplated suicide with one in six actually making
a suicide attempt, these figures have risen since the
millennium (Sunderland, M., 2004). This state of affairs
prompted the government to identify the prevention of
suicide as a major healthcare target in the UK (DoH,
National Suicide Prevention Strategy, 2002). Eating
disorders are also common amongst young people,
particularly adolescent girls, and create challenges
for teachers, support staff, counsellors and medical
practitioners (Abraham, S. and Llewellyn-Jones, D.,
2001). The prevalence of bullying is increasingly of
concern to all involved in the care of children and young
people. The effects of bullying on children and young
32
people are well documented (Oliver, C. and Candappa,
M., 2003), particularly in relation to those who are
already vulnerable, such as children with learning
difficulties or disabilities (Kelly, N. and Norwich, B., 2004)
and other vulnerabilities based on gender or sexuality
(Ellis, V. and High, S., 2004).
Challenges involved in researching children and
young people
It is important for practitioners to be aware of issues
that particularly affect the research process when
children and young people are involved.
Two issues are of particular relevance to this research:
n Ethics of research with children and young
people
n Making sense of the research findings
This section introduces some of the dilemmas facing
practitioners wishing to make sense of the research
evidence in relation to their own practice.
An important challenge to practitioners is in assessing
the extent to which any measurable change in the
young person is due to the effects of counselling
or is a result of normal developmental processes.
Put simply, would the child have ‘grown out’ of their
condition without any intervention from a therapist, or
not? Practitioners and, increasingly, fund holders for
children’s services, may want to investigate ways of
evaluating psychological change in their clients.
It is common for young clients to present with
multiple problems that may need different forms of
intervention involving a range of key workers. It may
therefore be difficult to ascertain the precise impact
of any given therapeutic intervention where the key
concern is meeting the immediate needs of the young
person rather than doggedly following one particular
therapeutic approach.
Ethical considerations
Children and young people constitute a vulnerable
group. Therefore, the ethics of carrying out counselling
research may represent challenges to the research
approval, design and process, impacting on the type
of data collected. The Economic and Social Research
Council (ESRC, 2005) provides guidance on this subject.
Conducting research with children and young people
involves ‘more than a minimal risk’ (Section 1.2.2)
because they represent a ‘vulnerable group’; covering
‘sensitive topics’; permission from a ‘gatekeeper’ may
be required (ie parental/carer consent); problems with
informed consent due to developmental stage of the
Talking therapies: an essential anthology – 2nd edition
© BACP 2010
R5
child; research which may involve/induce ‘psychological
stress or anxiety’; counselling may be referred to as an
‘intrusive intervention’. Section 1.16.3.7 of the ESRC
Ethical Guidelines refers to the CRB disclosure required
when working with vulnerable groups and researcher
suitability for working in this field; the impossibility of
informed consent in some cases; and the priority that
potential risk to principal subjects of research should take.
Summary of the research evidence
A comprehensive account of the research evidence on
counselling children and young people is presented in the
BACP systematic scoping review (Harris, B. and Pattison,
S., 2004) along with the references for research studies
providing the evidence. A summary of the research and
key points are presented here in order of therapeutic
approach and in relation to specific counselling issues to
enable practitioners to make informed choices regarding
their work with children and young people.
Behavioural and conduct problems
n CBT is effective for antisocial and aggressive
behaviour, impulsivity and hyperactivity
(Robinson, T.R. et al, 1999)
n A combination of psychodynamic, humanistic and
cognitive behavioural therapies are effective with
a range of behavioural problems, such as verbal
and physical aggression in the five to thirteen age
range (Schectman, Z. and Ben-David, M., 1999)
n Psychodynamic therapy is effective for severe
behavioural problems, positive effects are
sustained at follow-up, though family therapy is
more effective overall (Szapocznik, J., 1986)
Emotional problems: anxiety
n Group CBT is effective in reducing symptoms of
anxiety in children and adolescents (Ovaert, L.B.
et al, 2003; Benazon, N.R. et al, 2002; March,
J.S. et al, 1998; Mendlowitz, S.L. et al, 1999)
n CBT is effective in relieving the symptoms of
PTSD (Ovaert, L.B. et al, 2003)
n CBT is effective for obsessive-compulsive
disorder (Benazon, N.R. et al, 2002)
n Brief psychodynamic therapy may reduce the
effects of anxiety in children (Muratori, F. et al,
2002)
n Psychoanalytic therapy has a positive effect on
agoraphobia (Blos, P., 1983)
n Humanistic therapies/play therapy can be
effective in reducing symptoms of anxiety in
children whose parents have divorced (Dearden,
C., 1998)
Emotional problems: depression
n CBT is effective in reducing the symptoms
of depression, particularly in adolescents
(Harrington, R. et al, 1998)
© BACP 2010
information sheet
n CBT is effective in reducing the rate of onset of
depressive disorder in young people ‘at risk’ of
depression (Merry, S. et al, 2004)
n Interpersonal therapy is effective in children
suffering moderate to severe depression (Mufson,
L. et al, 1999)
Medical illness
n CBT is effective in reducing the severity of
chronic headaches (Eccleston, C. et al, 2004)
n CBT may help to reduce distress during painful
medical procedures (Eliot, C.H. and Olson, R.A.,
1983)
School-related issues
n CBT can improve children’s self-control and
classroom behaviour in mainstream schools
(Squires, G., 2001)
n Eclectic problem solving models can reduce the
incidence of aggression towards other children
and encourage greater responsibility for actions
(Meredith, A., 1993)
n Group drama therapy is effective for children
at risk of developing behavioural or emotional
problems in the school context (McArdle, P. et al,
2002)
n Group activities and role play are effective in
improving levels of acting out, distractibility and
sociability with learning-disabled children (Omizo,
M.M. and Omizo, A.O., 1987)
n Play therapy can be helpful in reducing anxiety
and improving self-esteem and cognitive skills in
schoolchildren (Sherr, L. and Sterne, A., 1999)
n Person-centred art therapy can be effective in
improving self-concept (Flitton, B. and Buckroyd,
J., 2002)
Self-harming practices
n CBT is effective in reducing the level of substance
abuse in children and adolescents (Kaminer, Y.
et al, 2000)
n Group CBT is effective in lowering the risk of
repeated suicide attempts when followed up by
psychodynamic therapy (Wood, A. et al, 2001)
n Ego-oriented CBT therapy is effective for
anorexia nervosa (Robin, A.L. et al, 1999)
n A range of therapy approaches are effective in
helping psychological recovery from suicide
attempts in children and young people (Everall,
R.D. and Paulson, B.L., 2002)
Sexual abuse
n CBT is effective in reducing symptoms in
children who have been sexually abused, with
improvements lasting for at least two years
(Deblinger, E. et al, 1999)
n The depressive symptoms of sexual abuse may
benefit from a joint individual and group therapy
approach involving a combination of CBT,
Talking therapies: an essential anthology – 2nd edition
33
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n
n
n
n
n
information sheet
psychodynamic and client-centred therapies
(Nolan, M. et al, 2002)
Brief individual psychoanalytic therapy can
reduce PTSD symptoms associated with sexual
abuse (Trowell, J. et al, 2002)
Long-term group insight-oriented therapy can be
effective in relieving the psychological effects of
sexual abuse (Berman, P., 1990)
Humanistic group therapy can be effective
in enhancing self-esteem in sexually-abused
children (De Luca, R.V. et al, 1995)
Music therapy is effective in reducing a wide
range of symptoms experienced by children who
have been sexually abused (Finkelhor, D. and
Berliner, L., 1995)
Drama and play therapy are effective in improving
psychological symptoms of sexual abuse
(Reeker, J. et al, 1997)
Gaps in the research
Gaps in the research represent areas where
practitioners are likely to have difficulties in finding up to
date information relating to the effectiveness of therapy.
There are several gaps in the research, particularly in
the areas of: therapeutic relationship, therapy drop-out,
follow-up, population, issues of ‘voice’.
n The therapeutic relationship
The wider literature (Everall, R.D. and Paulson, B.L.,
2002; Hanna, F.J. et al, 1999) on child and adolescent
counselling highlights the importance of the therapeutic
relationship, yet there is little in the research that attends
directly to this aspect of therapy. Most of the research
involves short-term therapy (between three and 12
sessions), which may have implications for the kind of
relationship that is possible.
n The drop-out factor
The number of children and young people dropping
out of therapy is moderately high (Everall, R.D. and
Paulson, P.L., 2002) and yet there is little research on this.
There may be many reasons, such as the experimental
nature of the research process itself, the quality or
appropriateness of the therapeutic intervention under
investigation, or the child or young person’s willingness
or readiness to engage with therapy, and the therapeutic
relationship is the largest factor in preventing drop-out
(Everall, R.D. and Paulson, P.L., 2002). Therefore, a
deeper understanding of this complex issue derived from
the direct experiences of children and young people may
help the practitioners to understand the ways in which
particular environments, approaches or ways of working
that can hold children’s trust or attention.
n Follow-up
The majority of the research looks at follow-up periods
34
that are short, ranging from three weeks to six months
after therapy has ended. Practitioners would have
greater confidence in various approaches if the shortterm gains were proven to be sustainable over time.
n Population issues
White clients are well represented in the research.
The representation of children from ethnic minority
cultures is increasing in the general literature,
particularly relating to post-traumatic stress disorder,
but these populations are not yet prevalent in
the research into therapy outcomes. Individual
counselling is considered less suited than group
or family counselling for young people from ethnic
minority collectivist cultures (Rosello, J. and Bernal,
G., 1999). Issues of trauma and language are underresearched, yet increasingly important for practitioners
needing research evidence to inform their work
with, for example, refugee children. This may also
have implications for the training and recruitment
of counsellors and a need for a more multicultural
representation.
Certain populations of children and young people are
under represented in the literature, for example, children
with the following conditions, presenting issues or
cultural affiliations:
n Learning disabilities
n Physical disabilities
n Sensory impairments
n Eating disorders
nSelf-harm
n Substance abuse
n Homosexual, lesbian, bisexual and transgendered
young people
n Ethnic minorities
n Youth offenders
n Children of war
n Children in the care of the local authority/lookedafter children
The population regarding severity of presenting
problems and mental health issues may be represented
disproportionately in the research literature. Most of
the published research is concerned with children who
have high levels of dysfunction such as severe conduct
disorders, obsessive-compulsive disorders, clinical
depression and post-traumatic stress. There is a lack
of research on children and young people with less
severe symptoms such as those suffering from loss
or bereavement, from difficulties relating to puberty,
from bullying in school or the psychological effects of a
medical condition. A report by Youth Access (Wilson, C.,
2001) found that over three-quarters of young people
wanted to see a counsellor for help with a combination
of issues, including low self-esteem and lack of
confidence.
Talking therapies: an essential anthology – 2nd edition
© BACP 2010
R5
n Issues of ‘voice’
There is little research on the young person’s experience
of counselling and yet few practitioners working with
children and adolescents would doubt their capacity
to provide insightful feedback and potentially influence
the culture of services offered. In order to access
children’s views of therapy, practitioners could draw on
their knowledge, experience and skills in working with
children and young people to develop more creative
ways of collecting data that reflects the child’s voice.
Research methods such as photographic, collage
or drama work may offer user-friendly strategies for
children and young people to discuss their experiences
in a contained and personally meaningful way and
therefore yield potent evidence of what works and with
whom.
information sheet
References
Abraham, S. and Llewellyn-Jones, D. (2001) Eating
Disorders: The Facts. 5th Edition. New York: Oxford
University Press.
BACP (2010) Ethical Framework for Good Practice in
Counselling and Psychotherapy. Lutterworth: BACP.
Benazon, N.R., Ager, J. and Rosenberg, D.R. (2002)
Cognitive behavior therapy in treatment-naïve children
and adolescents with obsessive-compulsive disorder:
an open trial. Behaviour Research and Therapy,
40:529–39.
Berman, P. (1990) Group therapy techniques for
sexually abused pre-teen girls. Child Welfare, LXIX(3)
239–52.
Conclusion
The purpose of this information sheet has been to
offer counselling practitioners a brief overview of the
research evidence on counselling children and young
people and in this way to support and inform both
direct work with young individuals and groups as well
as decision-making about therapeutic work within
communities, schools and counselling organisations.
The evidence contained in this leaflet is explored
in more detail in the systematic scoping review by
the same authors (Harris, B. and Pattison, S., 2004).
However, this leaflet includes basic information about
the substantive areas covered by the research, and
highlights some of the key findings in relation to ‘what
works?’ ‘for whom?’ and ‘for which presenting issues?’
before noting particular areas of concerns in terms of
the research evidence available.
Blos, P. (1983) The contribution of psychoanalysis to the
psychotherapy of adolescents. Psychoanalytic Study of
the Child, 38:577–600.
Bond, T. (2004) Ethical Guidelines for Researching
Counselling and Psychotherapy. Rugby: BACP.
De Luca, R.V., Boyes, A.D. and Grayston, E.R. (1995)
Sexual abuse: effects of group therapy on preadolescent girls. Child Abuse Review, 4, 263–77.
Dearden, C. (1998) The children’s counselling service at
family care: an evaluation. www.lboro.ac.uk/research/
ccfr
Deblinger, E., Steer, R.A. and Lippman, J. (1999) Twoyear follow-up for sexually abused children suffering
post-traumatic stress symptoms. Child Abuse and
Neglect, 23(12) 1371–8.
About the authors
Belinda Harris is a UKCP registered Gestalt
psychotherapist and lecturer in the Centre for the Study
of Human Relations at the University of Nottingham,
She is a practising therapist, supervisor and trainer and
the winner of the Lord Dearing Award for excellence in
teaching.
Sue Pattison is a BACP accredited counsellor and
lectures in counselling and international education in
the School of Education, Communication and Language
Sciences at the University of Newcastle upon Tyne. She
has been involved in a variety of counselling research
projects concerning children and young people and
carries out consultancy work in the UK and overseas
with teachers, health professionals and agencies. Sue is
a practising therapist, supervisor and trainer.
© BACP 2010
DfES (2004) Every Child Matters, accessed
1 December 2005 www.everychildmatters.gov.uk
DoH (2002) National Suicide Prevention Strategy for
England. DoH Publications: London.
Ebata, A.T. and Moos, R.H. (1990) Coping and
adjustment in distressed and healthy adolescents.
Journal of Applied Developmental Psychology, 12:33–54.
Eccleston, C., Yorke, L., Morley, S., Williams, A.C. de
C. and Mastroyannopoulou, K. (2004) Psychological
therapies for the management of chronic and recurrent
pain in children and adolescents. The Cochrane Library
Issue 1.
Economic and Social Research Council, 2005.
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Elliott, C.H. and Olson, R.A. (1983) The management
of children’s distress in response to painful medical
treatment for burn injuries. Behavioural Research and
Therapy, 21:675–83.
prevention: a randomised trial of group therapy. Journal
of Child Psychology and Psychiatry, 43(6) 705–12.
Ellis, V. and High, S. (2004) “Something More to Tell You:
Gay, Lesbian or Bisexual Young People’s Experiences
of Secondary Schooling.” British Educational Research
Journal, 30(2) 213–25.
Mendlowitz, S.L., Manassis, K., Bradley, S., Scapillato,
D., Miezitis, S. and Shaw, B.F. (1999) Cognitive
behavioural group treatments childhood anxiety
disorders: the role of parental involvement. Journal of
the Academy of Child and Adolescent Psychiatry, 38(10)
1223–9.
Everall, R.D. and Paulson, B.L. (2002) The therapeutic
alliance: adolescent perspectives. Counselling and
Psychotherapy Research Journal, 20 (2) 78–87.
Meredith, A. (1993) Comprehensive counselling: one
pupil’s integration. British Journal of Guidance and
Counselling, 21(1) 95–105.
Finkelhor, D. and Berliner, L. (1995) Research on the
treatment of sexually abused children: a review and
recommendations. Journal of the American Academy of
Child and Adolescent Psychiatry, 34(11), 1408–23.
Merry, S., McDowell, H., Hetrick, S., Bir, J. and Muller,
N. (2004) Psychological and/or educational interventions
for the prevention of depression in children and
adolescents (Cochrane review). The Cochrane Library
Issue 1.
Flitton, B. and Buckroyd, J. (2002) Exploring the effects
of a 14-week person-centred counselling intervention
with learning-disabled children. Emotional and
Behavioural Difficulties, 7(3)164–77.
Hanna, F.J., Hanna, C.A. and Keys, S.G. (1999)
Fifty Strategies for Counselling defiant, aggressive
adolescents: reaching, accepting and relating. Journal
of Counselling and Development, 77, 395–404.
Mufson, L., Weissman, M.M., Moreau, D. and Garfinkel,
R. (1999) Efficacy of interpersonal psychotherapy for
depressed adolescents. Archives of General Psychiatry,
56(6) 573–9.
Muratori, F. et al. (2002) Efficacy of brief dynamic
psychotherapy for children with emotional disorders.
Psychotherapy and Psychosomatics, 71(1) 28–38.
Harrington, R., Whittaker, J., Shoebridge, P. and
Campbell, F. (1998) Systematic review of efficacy
of cognitive behaviour therapies in childhood and
adolescent depressive disorder. British Medical Journal,
316:1559–63.
Nolan, M. et al. (2002) A comparison of two
programmes for victims of child sexual abuse: a
treatment outcome study. Child Abuse Review, 11,
103–23.
Harris, B. and Pattison S. (2004) Research on
Counselling Children and Young People: A Systematic
Scoping Review. Rugby: BACP.
Oliver, C. and Candappa, M. (2003) Brothers and sisters:
a source of support for children in school? Journal of
Education, 34(1) 3–13.
Kaminer, Y., Burleson, J.A. and Goldberger, R.
(2002) Cognitive-behavioural coping skills and
psychoeducation therapies for adolescent substance
abusers. Journal of Nervous and Mental Disease,
190(11) 737–45.
Omizo, M.M. and Omizo, A.O. (1987) The effect of group
counselling on classroom behaviour and self concept
among elementary school learning disabled children.
The Exceptional Child, 34(1) 57–64.
Kelly, N. and Norwich, B. (2004) Pupils’ perceptions
of self and of labels: moderate learning difficulties
in mainstream and special school. British Journal of
Educational Psychology, 74(3) 411–437.
March, J.S., Amaya-Jackson, L., Murray, M.C. and
Schulte, A. (1998) Cognitive-behavioral psychotherapy
for children and adolescents with post-traumatic stress
disorder after a single-incident stressor. Journal of the
American Academy of Child and Adolescent Psychiatry,
37(6) 585–93.
McArdle, P. et al. (2002) School-based indicated
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Ovaert, L.B., Cashel, M.L., Sewell, K.W., McConnell,
R.A. and Sim, A.J. (2003) Structured group therapy for
post-traumatic stress disorder in incarcerated male
juveniles. Journal of Orthopsychiatry, 73(3) 294–301.
Pattison, S. (2005) Making a difference for young
people with learning disabilities: a model for inclusive
counselling practice. Counselling and Psychotherapy
Research Journal, 5(2) 120–130.
Reeker, J., Ensing, D. and Elliott, R. (1997) A metaanalytic investigation of group treatment outcomes for
sexually abused girls. Child Abuse and Neglect, 21(7)
669–80.
Talking therapies: an essential anthology – 2nd edition
© BACP 2010
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Robin, A.L., Siegel, P.T., Moye, A.W., Gilroy, M.,
Dennis, A.B. and Sikand, A. (1999) A controlled
comparison of family versus individual therapy
for adolescents with anorexia nervosa. Journal of
the American Academy of Child and Adolescent
Psychiatry, 38(12) 1482–9.
Robinson, T.R. (1999) Cognitive behaviour modification
of hyperactivity-impulsivity and aggression: a metaanalysis of school-based studies. Journal of Educational
Psychology, 91(2)195–203.
Rossello, J. and Bernal, G. (1999) The efficacy of
cognitive-behavioral and interpersonal treatments for
depression in Puerto Rican adolescents. Journal of
Consulting & Clinical Psychology, 67, 734–745.
Schechtman, Z. and Ben-David, M. (1999) Individual
and group psychotherapy of childhood aggression:
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information sheet
Journal of the American Academy of Child and
Adolescent Psychiatry, 40(11) 1246–53.
Other reading
Gabriel, L. and Casemore, R. (2008) Guidance for
Ethical Decision-Making – a suggested model for
practitioners. BACP information sheet P4. Lutterworth:
BACP.
Useful websites
American Academy of Child and Adolescent Psychiatry
Conduct Disorder – Facts for families:
www.aacap.org/publications/factsfam/conduct.htm
National Mental Health Association (US) Factsheet on
conduct disorders:
www.nmha.org/infoctr/factsheets/74.cfm
Sherr, L. and Sterne, A. (1999) Evaluation of a
counselling intervention in primary schools. Clinical
Psychology and Psychotherapy, 6: 286–96.
Internet Mental Health Pages: Conduct disorders:
www.users.globalnet.co.uk/~ebdstudy/disord1/conduct.
htm
Squires, G. (2001) Using cognitive behavioural psychology
with groups to improve self control of behaviour.
Educational Psychology in Practice, 17(4) 318–35.
Excite UK:
www.excite.co.uk/directory/Health/Mental_Health
Steinberg, L. (1996) Beyond the classroom: Why school
reform has failed and what parents need to do. New
York: Simon & Schuster.
Disorders/Child and Adolescent Obsessive Compulsive
Disorder (OCD) Resources Centre
http://ocdresource.com
Sunderland, M. (2004) Why love matters: how attention
shapes your baby’s brain. London: Brunner-Routledge.
Bullying online:
www.bullying.co.uk
Szapocznik, J. (1986) Conjoint versus one family
therapy: further evidence for the effectiveness of
conducting family therapy through one person with
drug-abusing adolescents. Journal of Consulting and
Clinical Psychology, 54(3) 395–7.
School refusal and truancy:
www.mcevoy.demon.co.uk/Medicine/Psychiatry/
ChildPsych/School
Trowell, J. et al. (2002) Psychotherapy for sexually
abused girls: psychopathological outcome findings and
patterns of change. The British Journal of Psychiatry,
180, 234–47.
Wilson, C. (2001) Breaking down the barriers: key
evaluation findings on young people’s mental health
needs. London: Youth Access.
Wood, A., Trainor, G., Rothwell, J., Moore, A. and
Harrington, R. (2001) Randomised trial of group therapy
for repeated deliberate self-harm in adolescents.
© BACP 2010
Young People and Self Harm Information Resource:
www.ncb.org.uk/projects/selfharm
Secret shame. Includes definitions, explanations of
why, etiology and demographics, diagnoses, review of
psychological literature:
www.palace.net/~llama/psych/injury
Youth Access offers information, advice and counselling
throughout the UK:
www.youthaccess.org.uk
Effective Health Care Bulletin 4(6): Deliberate Self Harm
www.york.ac.uk/inst/crd/report21.htm
Talking therapies: an essential anthology – 2nd edition
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Young People and Self Harm – an information resource
www.selfharm.org.uk
NICE (2004) Eating Disorders, Treatment Guideline
www.nice.org.uk/cat.asp?c=101239
www.acs-teens.org/substance-abuse.htm
National Children’s Bureau: www.ncb.org.uk
National Clearing House on Child Abuse and Neglect
Information http://calib.com/nccanch
National Data Archive on Child Abuse and Neglect
(NDACAN): www.ndacan.cornell.edu
Childline: www.childline.org.uk
Kidscape: www.kidscape.org.uk
National Society for the Protection of Cruelty to Children
www.nspcc.org.uk
June 2010
It should be noted that this Information Sheet offers broad guidance, which sets out professional good practice, but it should not be
substituted for legal and other professional advice, including supervision, applicable to your particular circumstances.
BACP is aware that law and practice are always in a process of development and change. If you have evidence that this Information
Sheet is now inaccurate or out of date feel free to contact us. If you know of any impending changes that affect its content we
would also be pleased to hear from you.
38
Talking therapies: an essential anthology – 2nd edition
© BACP 2010
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information sheet
Writing a practice-based case study for
publication
by John McLeod
Introduction
The aim of this information sheet is to
offer practical guidelines for counsellors
and psychotherapists who are interested
in contributing to the research literature
by publishing a case study based on their
own work with a client. The information
sheet provides an introduction to the field
of pragmatic case study research, ethical
issues involved in this kind of study and
what is involved in collecting, analysing
and writing-up case data. There are also
recommendations for further reading,
intended to enable a deeper appreciation
of the issues involved in this area of
inquiry.
There is a wide acceptance within
the counselling and psychotherapy
professions, and in the organisations
that commission and support therapy
services, that practice should be informed
by relevant research. On the whole,
this requirement has been interpreted
to mean that the findings of large-scale
randomised trials of the efficacy of
different approaches to counselling or
psychotherapy should be used as the
touchstone of whether an approach is
effective or not. While it is clear that such
studies provide an invaluable source of
evidence, it has also become apparent
that, within the field of counselling and
psychotherapy, the method of randomised
trials has significant limitations (Rowland,
2007). In response to these limitations, and
in an attempt to establish a more broadbased knowledge base for counselling and
psychotherapy, Fishman (1999) has argued
that it is necessary for the profession
to make a commitment to building a
database of ‘pragmatic case studies’. A
pragmatic case study can be defined as a
systematic, rigorous study of an individual
case, in which the available evidence is
used to achieve a plausible account of
the process and outcome of the case,
in a form that has pragmatic value in
terms of informing practice. The aim of
the pragmatic case studies movement is
to assemble a range of case reports that
is extensive and detailed enough from
which generalisations can be derived.
Two journals have been established as an
outlet for such case reports: Clinical Case
Studies and Pragmatic Case Studies in
Psychotherapy.
One of the key challenges to be faced by
those who wish to carry out case-based
research is that of constructing a case
report that will be accepted as having
scientific validity. Although it can be argued
that the psychotherapy profession is based
on knowledge generated by the early case
studies carried out by Freud and others,
the current view is that the methods used
at that time were necessarily somewhat
subjective, and open to many sources
of bias, and that the contemporary
availability of recording equipment and
measurement scales allows a higher
degree of rigour to be both expected and
achieved. Another key challenge lies in
the domain of ethics. Unlike large-scale
studies, in which information about an
individual client exists only in numerical
form embedded in a mass of other data,
a case study essentially seeks to tell the
story of an episode in the life of a person
seeking therapy (and a person offering
therapy). It is therefore important that
published case studies do everything
possible to respect the confidentiality and
well-being of the client and therapist who
are involved, and to adhere to all aspects
of the BACP Ethical Framework for Good
Practice in Counselling and Psychotherapy
(2007) (the Ethical Framework) and BACP’s
research guidelines (Bond, 2004).
Many counsellors and psychotherapists
have had an experience of writing one or
more case studies during their training.
While this information sheet is likely to be
BACP Information Sheets
are intended to be read in
conjunction with the BACP
Ethical Framework for Good
Practice in Counselling and
Psychotherapy.
The Information Services
ethics helpdesk team is
available to members who
wish to explore any ethical
issues concerned with their
practice.
It should be noted that this
Information Sheet offers
broad guidance, which
sets out professional good
practice, but it should not
be substituted for legal
and for other professional
advice applicable to your
particular circumstances.
© BACP, August 2009
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information sheet
of value to those involved in producing case reports
for training purposes, it is necessary to note that
training establishments may have requirements that
differ from the present guidelines. The goal of these
guidelines is to encourage practitioners (whether in
training or at a later stage of their career) to disseminate
practical knowledge and understanding and facilitate
constructive dialogue, by sharing examples of their
work across the professional community.
Conducting case study research in counselling and
psychotherapy: practical guidelines
This section summarises the main practical issues
associated with the process of carrying out a case
study investigation. In the preparation for case study
research it is valuable to undertake as much advance
reading as possible, to become familiar with the kinds of
challenges and pitfalls that may arise and the potential
solutions and strategies that can be applied to resolve
them. There is no single, standard, ‘correct’ way to
conduct a therapy case study. Inevitably each study
reflects the specific circumstances in which it is carried
out and involves the adaptation of methods in response
to these circumstances.
Deciding on the purpose of the case study
When planning any piece of research it is necessary to
be clear about the aims of the study and its intended
audience. Some of the research aims that may be
pursued through case study investigations include:
Exploring and demonstrating the effectiveness
of a particular approach to therapy, or specific
intervention. There are numerous examples, both in
cognitive-behavioural therapy (CBT) literature and in
studies that have used the hermeneutic single case
efficiency design (HSCED) of case studies which
have provided credible evidence of effectiveness.
(See Turpin, 2001, regarding CBT literature and Elliott,
2001 and 2002, who developed HSCED, an approach
which combines qualitative and quantitative case
data.) This kind of research is particularly influential
when large-scale studies of the approach or
intervention do not exist. When a new approach is
first developed, it would be unethical to seek to apply
it to a large sample of clients in a randomised trial.
The existence of case reports that carefully exemplify
the effectiveness of an approach or intervention
supply part of the rationale that is required in order
to plan and justify larger-scale studies. The role of
case studies in effectiveness research is therefore
mainly focused on instances where the effectiveness
of innovative approaches or interventions is being
assessed.
40
The development of theory. Theories and models
in counselling and psychotherapy are designed to
be applied to individual cases and, as a result, case
study data afford one of the best ways of testing
and refining theory. Further information on ‘theorybuilding’ case studies can be found in the journal
article written by Stiles (2007).
Exploring and demonstrating the value of counselling/
psychotherapy in relation to a specific condition.
There are many categories of problems for which
little research evidence is available concerning
the effectiveness of psychological therapy. It is
unfortunately true, for example, that there are
few studies of how counselling or psychotherapy
might help people who experience various kinds of
disability or illness. In such cases, what is of interest
is not so much whether a particular therapeutic
approach is effective, but the ways in which therapy
methods might be adapted in order to respond to the
needs of particular clients, and the case report will
focus primarily on these aspects of the work.
Allowing the voice of the client to be heard. In
the main, case study research in counselling and
psychotherapy has largely comprised stories told
by therapists and researchers. However, the case
study format can also be used to enable the client
to tell his or her story. Examples of this use of case
study inquiry can be found in Etherington (2000). In
this kind of report the therapist may be involved as
co-author, or may be involved merely at the level
of encouraging the client to write about his or her
experience.
In order to construct a readable case report, it is
necessary to decide on the primary aim of the study,
even if other secondary aims are also touched on.
For example, a case study that sought to highlight
the effectiveness of an innovative intervention may
also generate some interesting implications for theory.
However, given the complexity of the data that are
typically collected in a case investigation, there is a risk
of confusing the reader by trying to address issues of
effectiveness and theory at the same time. In addition,
the type of analysis that is carried out may be different
for each purpose.
Negotiating ethical consent
Case study research is ethically sensitive (Josselson,
1996). Reading about the intimate details of one’s own
life, particularly in the context of a formal publication,
can be an exposing and threatening experience.
Although some clients may be eager to disseminate
their story to a wider audience, the majority will feel
cautious about taking part in case study research.
Anthology of research information sheets – 2nd edition
© BACP 2009
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To address these ethical issues there are a number of
basic procedures that should be followed:
n Writing a research protocol that explains the
aims of the research, what data will be collected,
how it will be analysed and disseminated,
and the procedures that will be followed to
ensure confidentiality, avoidance of harm,
and informed consent. This protocol must be
subjected to external scrutiny, for example by
an organisational ethics committee or research
consultant.
n Providing the participant with a written
information sheet at the start of therapy
(preferably before therapy begins) and asking
him or her to sign a form that gives permission to
collect research data, which specifically mentions
that these data may be used in future for case
research, and that further permission will be
sought at the end of therapy if their material is to
be used for a case analysis. When the client is a
child, or a vulnerable adult, it is also necessary to
consult parents or advocates.
n Gaining permission, where appropriate, from the
manager or director of the clinic or agency where
the therapy was carried out.
n At the end of therapy, or at follow-up, if it is
decided that the case material is to be used
for research, it is necessary to secure further
informed consent (if the case study data is not
used for research, it should be destroyed). At
this stage, the participant should be asked to
indicate if there is specific information that he
or she would wish to be deleted from the case
study, and to indicate how he or she would
like their identity details (e.g. job, location,
ethnicity) to be changed in order to preserve
anonymity.
n The participant should be offered an opportunity
to read, comment on and edit the final draft of the
case report, in advance of publication.
n It should be made clear to the participant that he
or she can withdraw at any time (including at the
end of the process).
n Application of the above procedures to the
therapist, who is also a participant in the study.
n All case study data should be stored securely.
It is feasible to incorporate these procedures into
everyday practice. Most clients are aware of the
structure of research that supports the care that
they receive, and are well able to refuse consent,
or impose their own conditions. Some clients are
actively interested in research, eager to tell their
story, and find personal meaning in being asked
to reflect on their experience (for instance, when
completing questionnaires or responding to interview
questions).
© BACP 2009
information sheet
An underlying theme in this discussion of ethical issues
is that it is wrong to pressurise clients to participate
in research. From an ethical perspective, it is a sign of
success (of the transparency of the ethical procedures)
every time a client refuses consent. However, the
withdrawal of a client from a case study can create
a difficult situation for a practitioner-researcher who
may have invested a great deal of time and effort in
collecting a comprehensive data set on that client.
For that reason, it is valuable to try to collect data on
more than one client – if someone drops out, there are
other possible case analysis contenders remaining.
Another critical ethical issue concerns the separation
of the therapy from the research. The primary moral
responsibility of any counsellor or psychotherapist is
to provide the best possible therapy for their client. A
desire on the part of the therapist to collect a certain
type of case data can compromise this primary
responsibility. For instance, a therapist who would like
to publish a paper on a new theory of dream analysis
may subtly (or not so subtly) direct his or her clients
in the direction of dream work. To avoid this situation,
it is necessary to include the clinical supervisor in the
development of a research protocol, and to charge him
or her with the task of challenging the practitioner if the
therapy seems to be becoming ‘research-oriented’ to
the detriment of the client.
Collecting rich case data
Writing from within a psychoanalytic therapy tradition
that has relied heavily on case studies drawn solely
from the therapist’s memories of what happened during
sessions, Spence (1989) has argued that such case
studies inevitably engage in ‘narrative smoothing’
(the complexity of the therapy process is ‘smoothed’
to conform to the theoretical presuppositions of the
author). By contrast, a defining characteristic of a good
quality, systematic case study is that it is based on
a rich set of data about what happened and offers a
‘thick’ description of the process and outcome of the
therapy. There are a number of sources of data that can
be employed in counselling and psychotherapy case
study investigations. Of course, it is important to keep in
mind that specific, written consent needs to be secured
for the research use of any of the sources of case data
mentioned here:
n Outcome measures completed by the client (e.g.
the CORE questionnaire or the Outcome Rating
Scale)
n Process measures completed by the client (e.g.
the Working Alliance Inventory, a standard tool
for assessing the strength of the counsellor-client
relationship)
n Audio or video recordings of therapy sessions
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information sheet
n Therapist notes
n Recordings of supervision sessions where the
therapist discussed the case
n Diary or personal journal entries kept by the client
or therapist
n Creative works (e.g. paintings, music) arising from
the therapy
n Email or letter correspondence between therapist
and client
n End of therapy and follow-up interviews with the
client and therapist
n Reports from significant others (e.g. spouse or
work supervisor of the client)
Further information about how to access and use
these methods is provided in a section toward
the end of this information sheet. In general, to
construct a credible case report, it is valuable to
keep comprehensive notes and to ask the client
to complete one or more outcome and process
measures (preferably at each session). It is also useful
to conduct a post-therapy interview with the client in
order to collect information about the client’s overall
view of what was helpful or unhelpful in the therapy,
and the changes that he or she attributes to therapy.
This interview may be carried out by a colleague,
to allow the client more space to be critical of the
treatment experience.
Analysing case material
The analysis of case data presents a major challenge
for anyone intending to publish a counselling/
psychotherapy case study, because the process of
data collection typically generates a great deal of
information, which may be complex, contradictory and
difficult to interpret. In order to bring some structure
to the task of data analysis, it is useful to consider the
following strategies:
n Assembling the data (questionnaires, notes,
transcripts or summaries of recordings, etc) into
a bound ‘case book’ that follows the course of
the case through from pre-therapy assessment to
follow-up.
n Scoring the questionnaires and analysing
qualitative data using standardised guidelines
and inserting this information into the appropriate
sections of the case book. (So, for example,
the reader can not only see the CORE or ORS
questionnaire completed by the client at each
session, but also the score that has been
calculated.) There exist a wide range of methods
for analysing qualitative data – suggestions for
further reading are provided at the end of this
information sheet.
n Reading through the case book slowly, to
become immersed in the case, and making
42
n
n
n
n
notes. This stage of analysis is intended to
capture first impressions and emerging themes.
Writing a summary of each session, and of the
case as a whole.
Identifying the key aim of the case report (e.g.
effectiveness, further articulation of theory, etc.).
Writing a summary of the evidence and
conclusions relating to the main points, in respect
of the overall aim of the report. Looking for
evidence that would challenge or contradict these
conclusions and repeating this process until
confident about the robustness of the evidence
and conclusions. (It can be useful to think of
case analysis in terms of a judicial process – in
a courtroom, different interpretations and
explanations are offered for a set of events, and
through reasoned debate a consensus is reached
regarding which view is more supportable.)
Starting writing the report, using the headings
suggested in the following section. If certain
sections of the report are hard to write, it is
probably because the analysis is incomplete and
requires further work. An analysis that is ‘sorted’
and coherent tends to write itself.
Analysis of case material can be facilitated through
the involvement of other people – colleagues, fellow
students, clinical or research supervisors, the client.
For example, multiple copies of the case book can be
created, so that a small team of three or four people
can read and interpret the material at the same time
and meet together to engage in dialogue around
their conclusions. Guidelines for this type of team
analysis can be found in Hill et al (1997), Schielke et
al (2009), and in the extensive literature generated by
the ‘collaborative inquiry’ network (e.g. Reason, 1988).
Alternatively, a case researcher working mainly alone
can ask someone else to audit their analysis of all,
or parts, of the data. Comments and feedback can
be generated through written or oral presentations to
various audiences, including clients.
Writing the final report
Although there are a range of different structures
that can be used for case reports (see Yin, 2003),
it is sensible, in terms of meeting the requirements
of counselling and psychotherapy journal editors
and reviewers, to follow the report structure that is
specified by the journal, Pragmatic Case Studies in
Psychotherapy. The website of this journal includes
examples of case reports written within this format
and detailed instructions for authors that explain the
rationale for the structure that the journal requires. The
main headings in a pragmatic case study are:
Case context and method This section sets the scene
for the case report and includes: (a) the aim of the
Anthology of research information sheets – 2nd edition
© BACP 2009
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report, (b) the rationale for selecting this particular client
for study, (c) information about the different sources
of data that have been used and how the data have
been analysed, (d) the clinical setting in which the case
took place, (e) procedures that were used to ensure
confidentiality and to secure the consent of the client.
The client. This section provides an outline of who the
client was, the social and historical context of his/her life
(although properly disguised) and their main presenting
problems.
Guiding conception. The term ‘guiding conception’
refers to a broad understanding of the approach
adopted by the therapist. This section includes a
summary account of the theoretical model(s) used by
the therapist, the relevant research literature and the
therapist’s previous training and experience in relation
to this category of client presenting problem.
An assessment of the client’s presenting
problems, goals, strengths, and history. This section
offers a more detailed account of the background
to, and nature of, the difficulties being experienced
by the client. It is often valuable to contextualise this
information in relation to the developmental history and
cultural background of the client.
Formulation and treatment plan. A description of how
the guiding formulation is applied within this specific
case, and how the case conceptualisation is negotiated
with, or conveyed to, the client.
Course of therapy. An account of the temporal course of
therapy. It is particularly valuable if verbatim transcripts
can be used to document therapeutic process at
critical points in the therapy. The links between the
guiding conception, and ongoing therapy interventions
and process should be explored and analyzed. Any
difficulties or impasses in the therapy should be
described and discussed in relation to the guiding
conception.
Therapy monitoring and use of feedback information.
Description of the therapist process of selfreflection, supervision, client-completed quantitative
questionnaires, peer feedback, feedback from other
professionals who have worked with the client. This
section should discuss the ways in which monitoring
and feedback information were used to influence the
course of therapy.
Concluding evaluation of the process and outcome of
therapy. This is a crucial section in terms of establishing
the contribution to knowledge made by the case
study. Some of the issues that readers may want to
know about here are: a) the outcome of the therapy at
termination and ideally, if possible, at follow-up, (b) the
ways in which the guiding conception played out within
© BACP 2009
information sheet
the case (i.e. implications for theory), (c) comparisons
to previously published cases (i.e., what does this
case add to the already existing knowledge base?), (d)
implications for organisations and agencies offering
therapy services, (e) implications for practice – what is
the message of this case analysis, for therapists and
trainees?
When assembling a case report for publication, it is
essential to be mindful of the layout, referencing, and
word length requirements of the specific journal to
which the paper is be submitted. It is always helpful to
read articles already published in the target journal, to
gain a sense of its ‘house style’.
The criteria for a good case study
When an article is sent to a journal, it undergoes an
evaluation procedure that involves reports being written
by perhaps two or three reviewers. Typically, the editor
of the journal sends these commentaries directly to the
author, with a covering letter indicating the issues that
he or she considers are most significant for revision.
When preparing a case study for publication, and when
interpreting feedback from reviewers, it can be helpful to
be aware of the criteria that are used when assessing a
study of this type:
n Is the case significant? What is it that makes this
case interesting and worth reading?
n Is the evidence of sufficient quality? Does the
author supply enough descriptive material to give
a sense of what happened in the therapy?
n Is the case sufficiently contextualised? Is all
relevant information provided about the client, the
therapist, and the therapy setting?
n Have appropriate ethical procedures been
followed?
n Have the data been analysed in a systematic
and rigorous fashion? Is it possible to follow the
clear line of argument between evidence and
conclusions?
n Are multiple perspective and interpretations taken
into account? For example, have the views of the
client, or other analysts of the case material, been
taken into account?
n Does the author discuss what the present study
adds to the existing literature on the topic?
n Is the report readable? Does it follow a clear
structure?
A case study is a form of research report that depends
a great deal on what has been termed narrative
knowing – advancing understanding by telling a story,
which incorporates within it certain truths and insights.
No matter how careful case data are analysed, a case
report stands or falls on its capacity to tell a good
story.
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Conclusion
The case study or report has an important role to
play within the range of methodologies employed
in contemporary counselling and psychotherapy
research. Working on a systematic case study can
provide therapists with a unique opportunity for critical
reflection on practice, involving colleagues in that
process as co-analysts and making it possible to share
knowledge about innovative forms of practice. While
it is never possible to generalise from single cases,
the existence of journals willing to publish case study
articles means that it is possible to build up a corpus
of case evidence. Carrying out case study research
and writing a case report for publication draws on
a broad spectrum of skills and knowledge. This
information sheet has highlighted the main elements
of that body of skill and knowledge, and indicates
sources for further learning.
Hill, C.E. (1989) Therapist Techniques and Client
Outcomes: Eight Cases of Brief Psychotherapy. London:
Sage
Honos-Webb, L., Stiles, W. B., Greenberg, L. S.
and Goldman, R. (2006) An assimilation analysis of
psychotherapy: Responsibility for “being there.” In
Fischer, C. T. (Ed.), Qualitative research methods for
psychologists: Introduction through empirical studies.
New York: Academic Press
Strupp, H.H. (1980) Success and Failure in time-limited
psychotherapy. A systematic comparison of two cases:
comparison 1. Archives of General Psychiatry. 37: 595–603
Debates around methodological issues in case study
research in counselling and psychotherapy
About the author
John McLeod is Professor of Counselling at the
University of Abertay Dundee. He is author of An
Introduction to Counselling (4th edn, Open University
Press, 2009), Doing Counselling Research (2nd edn,
Sage, 2003), Qualitative Research in Counselling
and Psychotherapy (Sage, 2001) and chapters and
articles on a wide range of topics in counselling and
psychotherapy.
References and suggestions for further reading
This information sheet is best read in conjunction with
Stiles, W. B. (2007). Theory-building case study research
in counselling and psychotherapy. Counselling and
Psychotherapy Research, 7(2)
Examples of case studies
In preparing to carry out a case study investigation, it
is valuable to look at how other case study researchers
have handled the issues and challenges associated with
this kind of work. The best single source is the series of
case studies in the Archive section of Pragmatic Case
Studies in Psychotherapy (http://pcsp.libraries.rutgers.
edu). Some other interesting examples of systematic
case studies include:
Etherington, K. (2000) Narrative approaches to working
with adult male survivors of child sexual abuse: the
client’s, the counsellor’s and the researcher’s story.
London: Jessica Kingsley
44
Firth-Cozens, J. (1992) Why me? A case study of the
process of perceived occupational stress. Human
Relations, 45: 131–142
The following sources provide a sense of how the
counselling/psychotherapy profession has engaged
with the question of how best to carry out case study
research, and the role of case studies in terms of the
general evidence base for therapy policy and practice:
Edwards, D.J.A. (1998) Types of case study work:
A conceptual framework for case-based research.
Journal of Humanistic Psychology. 38(3): 36–70
Elliott, R. (2001) Hermeneutic single-case efficacy
design: an overview. In Schneider, K.J, Bugental, J.
and Pierson, J.F. (eds) The Handbook of Humanistic
Psychology: Leading Edges in Theory, Research and
Practice. Thousand Oaks, CA: Sage
Elliott, R. (2002). Hermeneutic Single Case Efficacy
Design. Psychotherapy Research. 12: 1–20
Fishman, D.B. (1999) The case for a pragmatic
psychology. New York: NYU Press.
Fishman, D.B. (2006) Finding legitimacy for case study
knowledge. Pragmatic Case Studies in Psychotherapy,
vol. 2, module 4, article 2.4.1, http://pcsp.libraries.
rutgers.edu
Hilliard, R.B. (1993) Single-case methodology in
psychotherapy process and outcome research. Journal
of Consulting and Clinical Psychology, 61(3): 373–80
Miller, R.B. (2004) Facing human suffering: psychology
and psychotherapy as moral engagement. Washington,
DC: American Psychological Association
Anthology of research information sheets – 2nd edition
© BACP 2009
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Rowland, N. (2007) BACP and NICE. Therapy Today,
18(5): 27–30
Schielke, H.J., Fishman, J.L., Osatuke, K., and Stiles, W.B.
(2009) Creative consensus on interpretations of qualitative
data: The Ward method. Psychotherapy Research.
Schneider, K.J. (1999) Multiple-case depth research.
Journal of Clinical Psychology. 55: 1531–40
Spence, D.P. (1989) Rhetoric vs. evidence as a source
of persuasion: a critique of the case study genre. In
Packer, M.J. and Addison, R.B. (eds) Entering the Circle:
Hermeneutic Investigation in Psychology. Albany, NY:
State University of New York Press.
Stiles, W. B. (2003). When is a case study scientific
research? Psychotherapy J. C. Bulletin. 38(1): 6–11
Stiles, W. B. (2005) Case studies. In Norcross J. C.,
Beutler L. E., and Levant, R. F. (Eds.) Evidence-based
practices in mental health: Debate and dialogue on the
fundamental questions. Washington, DC: American
Psychological Association
Turpin, G. (2001) Single case methodology and
psychotherapy evaluation: From research to practice.
In Mace C., Moorey S. and Roberts B. (eds) Evidence
in the psychological therapies: A critical guide for
practitioners. London: Brunner-Routledge
Case study research in psychology and social science:
the broader context
Case study inquiry is carried out by researchers in
many other fields – psychology, sociology, education,
management studies, etc. the books listed in this
section offer an introduction to some of the approaches
to case research that are used in these disciplines.
Flybjerg, B. (2006) Five misunderstandings about casestudy research. Qualitative Inquiry. 12(2): 219–245.
Runyan, W.M. (1981) Life histories and
psychobiography: explorations in theory and method.
New York: Oxford University Press
Stake, R.E. (2005) Qualitative case studies. In Denzin
N.K. and Lincoln Y.S. (eds) Handbook of qualitative
research. 3rd edn. Thousand Oaks, CA: Sage
information sheet
Ethical issues
BACP (2007) Ethical framework for good practice in
counselling and psychotherapy. Lutterworth: BACP
Bond, T. (2004) Ethical guidelines for researching
counselling and psychotherapy. Rugby: BACP
Josselson, R. (ed) (1996) Ethics and process in the
narrative study of lives. Thousand Oaks, CA: Sage
Working together as a team, to analyse case data
Hill, C.E., Thompson, B.J., Nutt-Williams, E. (1997)
A guide to conducting consensual qualitative research.
Counseling Psychologist, 25: 517–572
Hill, C.E., Knox, S., Thompson, B.J., Williams,
E.N., Hess, S.A. and Ladany, N. (2004) Consensual
Qualitative research: an update. Journal of Counselling
Psychology, 52: 196–205
Reason, P. (ed.) (1988) Human Inquiry in Action:
Developments in New Paradigm Research. London: Sage
Quality criteria the publication of case studies
Elliott, R., Fischer, T. C. and Rennie, L. D. (1999)
Evolving guideline for publication of qualitative research
studies in psychology and related fields. British Journal
of Clinical Psychology. 38: 215–229.
Sources of information about research tools and
techniques that you might consider applying in a case
study investigation
Barker, C., Pistrang, N. and Elliott, R. (2002) Research
methods in clinical psychology: An introduction for
students and practitioners. (2nd ed.). Chichester: Wiley
Cone, J.D. (2001) Evaluating Outcomes: Empirical
Tools for Effective Practice. Washington, DC: American
Psychological Association
McLeod. J. (2003) Doing counselling research. 2nd edn.
London: Sage.
Yin, R.K. (2009) Case study research: design and
methods. 4th edn. Thousand Oaks, CA: Sage.
Miller, S.D., Duncan, B.L. and Hubble, M.A. (2005)
Outcome-informed clinical work. In J.C. Norcross.
and M.R. Goldfried (eds) Handbook of Psychotherapy
Integration. New York: Oxford University Press.
Yin, R.K. (2004) The case study anthology. Thousand
Oaks, CA: Sage.
Ogles, B., Lambert, M. and Fields, S. (2002) Essentials of
outcome assessment. New York: Wiley
© BACP 2009
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45
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information sheet
Riding, N. and Lepper, G. (2005) Researching the
Psychotherapy Process: A Practical Guide to TranscriptBased Methods. London: Palgrave/Macmillan
Roth, T. (2008) Using measures and thinking about
outcomes. BACP Information sheet R4. Lutterworth:
BACP
August 2009
It should be noted that this Information Sheet offers broad guidance, which sets out professional good practice, but it should not be
substituted for legal and other professional advice, including supervision, applicable to your particular circumstances.
BACP is aware that law and practice are always in a process of development and change. If you have evidence that this Information
Sheet is now inaccurate or out of date feel free to contact us. If you know of any impending changes that affect its content we
would also be pleased to hear from you.
46
Anthology of research information sheets – 2nd edition
© BACP 2009
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information sheet
Counselling in higher and further education
by Jane Cahill
Introduction
This information sheet provides
practitioners and policy makers with a brief
summary of a recent review of counselling
in higher and further education.
(Throughout this review ‘counselling’
is used to refer to counselling and
psychotherapy services. The content
is derived from a systematic review of
research into counselling in higher and
further education which included studies
published between 1990 and 2004
(Connell, et al., 2006).
evidence has indicated that the proportion
of young people taking A-Levels has
already begun to increase (Aston, L. and
Bekhradnia, B., 2003). Age participation
index figures (DFES, 2002) also report
increases in the participation both of
females and those drawn from the highest
social class groups in higher education.
These increases contribute to the growing
gap between female and male participation
rates as well as to the varied rates between
socio-economic classifications and
variation between regions (Aston, 2003).
Student mental health: some statistics
The information sheet aims to:
n Inform counselling practice and
research
n Help shape therapeutic services
in higher and further education
using research findings as guiding
principles
These aims are in line with the
recommendations of the BACP Ethical
Framework for Good Practice in Counselling
and Psychotherapy (2007) (the Ethical
Framework) which puts responsibility on
practitioners to keep up to date with issues
relating to their professional practice.
Concerns regarding widening participation
and increased student enrolment have
heightened the focus on student mental
health. The Association for University and
College Counselling (AUCC, 1999) drew
attention to the apparent increase in levels
of psychological disorder among higher
education students. Subsequent to this
report, the Royal College of Psychiatrists
(RCP) convened a working group to
consider the evidence for and implications
of increasing morbidity, results of which are
found in their report The mental health of
students in higher education (RCP, 2003).
Some facts on student mental health are
presented below:
The world of higher and further
education
Over the past few years the government
and education systems have placed an
emphasis on expanding participation
in higher education. The government is
aiming to increase participation at initial
entry level in 2010 from the current figure
of 43% to a figure of 50% of those aged
18-30 (Department for education and skills
[DFES], 2003).
The council aims to increase the number of
higher education institutions involved over
the coming years (HEFCE, 2005/03). Recent
n 12.1% of male students and 14.8%
of female students had measurable
levels of depression ranging from
mild to severe, slightly higher than the
11.4% figure reported in the general
population. (Webb, E. et al., 1996).
n 10.5% of first years, and 13% of
second years had scores indicative
of moderate distress on the
depression subscale of the Brief
Symptom inventory and 12.5%
of first years and 14% of second
years showed moderate distress
on the obsessive compulsive scale.
(University of Leicester, 2002)
BACP Information Sheets
are intended to be read in
conjunction with the BACP
Ethical Framework for Good
Practice in Counselling and
Psychotherapy.
The Information Services
ethics helpdesk team is
available to members who
wish to explore any ethical
issues concerned with their
practice.
It should be noted that this
Information Sheet offers
broad guidance, which
sets out professional good
practice, but it should not
be substituted for legal
and for other professional
advice applicable to your
particular circumstances.
© BACP, March 2008
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information sheet
n A survey of full-time undergraduate students at
the University of Leeds showed that approximately
12% of students had raised levels of psychological
distress prior to coming to University. This figure
climbed to 20% for first and second year students
and to 25% for final year students 25% (Bewick,
B.M. et al, 2004).
n By mid-course 9% of previously symptom-free
students had become depressed and 20% had
become anxious at a clinically significant level
(Andrews, B. and Wilding, J.M., 2004).
n At Leeds University there was a rise in the
number of clients each year since 1996, from an
initial level of 524 new clients, to the recent level
of 859 (Waller, R.M. et al, 2005).
Whilst an increasing number of students are turning
to student counselling services, staff numbers are not
increasing in proportion to demand. This is exacerbated
by difficulty accessing NHS services, potentially resulting
in students with increasing levels of psychological
problems being seen within the student counselling
context (Royal College of Psychiatrists, 2003). The AUCC
survey (AUCC, 2004) indicates that although average
counselling budgets have risen over the last decade, when
changes in student numbers are factored in, the average
counselling budget per student has fallen in real terms.
Distress levels of students presenting at counselling
services
Six studies provided normative data for student
counselling services and/or compared the severity of
those attending students counselling services with a
comparative sample(s). Where studies have compared
the severity levels of students attending counselling
services with a non-clinical student population, those
attending counselling services are significantly more
distressed than those people in a non-clinical student
population. When comparing severity levels, of those
attending student counselling services with adult
mental health normative data/services there are mixed
results. The studies by Connell, J. and Barkham, M.B.
(2007) using the CORE-OM and Todd, D.M. et al. (1997)
using the SCL-90-R indicate similar severity levels
between the two populations. On the other hand, the
severity levels of student counselling attendees were
significantly lower than the normative adult out-patient
sample using the BDI-II (O’Hara, M.M. et al 1998).
Is students’ mental distress on the increase?
The evidence
The RCP report (2003) states that due to the progressive
narrowing of access to mental health services there
may have been an increased tendency for students with
48
moderate mental health problems to seek support from
university counselling services.
The majority of the evidence supporting the perception
of the worsening mental health of students attending
university counselling services has been anecdotal,
obtained by surveys of student counselling staff and
directors. The following findings were obtained from a
recent study of the US National Survey of Counseling
Centre Directors:
n 85.8% of directors believed that there had been
an increase in the number of centre clients with
severe psychological problems in recent years.
n 90.6% believed that students with significant
psychological disorders were a growing concern
on campus.
n 41.3% of directors’ clients had severe psychological
problems and 92% of directors reported an increase
in students coming to counselling who were on
prescribed psychiatric medication.
A similar perception is reported amongst UK counselling
services. The AUCC (2004) state that the increase in the
number of sessions delivered to students is indicative
of higher levels of disturbance. Their survey revealed
nearly 50% of counselling services indicated that the
amount of time devoted to clients with severe mental
health problems had increased over the past year, with
only 2.5% indicating a decrease.
To date few empirical studies have examined the issue
of the increasing severity of presentation in students
attending student counselling services. To summarise
there is little evidence to support the hypothesis
of increasing severity levels of students attending
counselling services over the last decade or so. There is
a trend for the severity of the problems to not become
worse but rather to stabilise over the time period at a
higher level of severity than in prior decades.
Some of the problems reported by students
There has been a developing body of evidence
concerning the types of problems brought by students
to counselling services. The 2004 annual report from
the AUCC indicated that the main issues presented by
student clients in 2002/3 are:
nDepression/mood
nRelationships
nAnxiety
n Academic difficulties
The report indicated that relationship problems were the
most common presenting problem at 18%, followed by
depression/mood disorder at 15%.
Anthology of research information sheets – 2nd edition
© BACP 2008
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Assessment procedures in student counselling
Six studies are summarised which relate to assessment
procedures and examination of factors impacting
on distress levels of students attending counselling
services:
n Screening measures yielded higher rates of
disclosure for sexual trauma (Freedy, J.R. et al.,
2002).
n Being asked directly (via self report measure
or therapist) yielded higher rates of disclosure
for sexual abuse by clients (Stinson, M.H. and
Hendrick, S.S., 1992).
n Clients with a reported history of abuse, as
compared to a random sample of those with no
abuse history, presented with a higher number
of presenting problems, attended more therapy
sessions, had a greater need for counselling and
had poorer outcomes post assessment (Wagner,
M.T., 1999).
n Almost half of the intake reports by therapists did
not mention clients’ use of alcohol: information
to help identify problematic drinking should be
made readily available and used by counselling
staff and that therapists routinely inquire about
patterns of student alcohol use (Matthews, C.R.
et al, 1998).
n Importance of assessing the relational quality of
students’ social support systems (Frey, L.L. et al.,
2004).
n Importance of identifying gender role conflict:
clinicians need to attend carefully to this issue by
examining and deconstructing learned gender
roles (Hayes, J.A. and Mahalik, J.R., 2000).
To summarise, three primary themes emerge as salient,
clinically useful components of assessment programs:
1) Social Support Systems 2) Trauma Screening 3)
Alcohol Use.
How effective is student counselling?
Other reviews
A review of literature on the evaluation of student
counselling was conducted in the mid 1980s (Breakwell,
1987) covering the previous twenty years. Breakwell
concluded that there had been very few attempts to
evaluate the efficacy of counselling. Where attempts
had been made, control groups had either not been
used at all, or had been used inadequately. In addition,
many studies had failed to describe the form that
counselling took.
Vonk, E.M. and Thyer, B.A. (1999) report that there
have been only four empirical evaluations of student
© BACP 2008
information sheet
counselling centres that have focused on short-term
therapy outcome in the 25 years prior to their own
study. They argued that there was a clear need for
research into the effectiveness of short term treatment
in counselling centres.
Psychodynamic therapy
Three studies examined the effectiveness of
psychodynamic therapy. Studies examining short-term
interventions found that:
n Clients showed significant improvement after
receiving short-term psychodynamic therapy
interventions (Rickinson, B., 1997; Michel, L. et al,
2003).
The effectiveness of routine psychodynamic therapy
lasting up to two years was examined by Pahkinen, T. and
Cabble, A. (1990). Data was available at six months, two
years, and five years from the start of therapy. A control
group of students attending dental services was used.
n Overall, statistically significant changes were
recorded at six months which remained stable up
to the five year follow-up.
Short term routine therapy
Six studies examined the effectiveness of ‘short term’ or
‘brief’ therapy. The following two studies used symptom
change as an outcome.
n Following ‘short-term treatment’ (4–20 sessions).
Symptom levels were significantly lower in the
treatment group than in the control group (Vonk,
E.M. and Thyer, B.A., 1999).
n Following routine counselling at a UK university,
approximately 50% of students had unfavourable
outcomes in that they were symptomatic at
14 month follow-up, or meeting Major Depressive
Disorder (MDE) or Generalised Anxiety Disorder
(GAD) criteria at 14 month follow-up (Surtees, P.J.
et al., 1998).
The following two studies examined adjustment to
college as a result of receiving counselling.
n The counselling group was found to improve
significantly in their overall adjustment to college
at six sessions whereas the control group
members did not experience significant changes.
(DeStefano, T.J. et al, 2001)
n Following 30-minute and 50-minute therapy
sessions, all students reported being better
adjusted after therapy with no difference between
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the 50-minute and 30-minute group (Turner, P.R.
et al., 1996).
The following two studies examined the effect of
student counselling interventions on retention status:
nAt two years, a higher percentage of those who
had received 1–7 sessions of counselling were
either still enrolled or had graduated as compared
with those requesting but not receiving student
counselling (Wilson, S.B. et al., 1997).
nNo group differences were found: students
receiving crisis intervention services enrolled for
the same number of semesters as the non-clinical
comparison group (Nelson, K.L., 2003).
therapist ratings of client improvement (Hatchett,
G.T. et al., 2004) and psychosocial functioning
(Cooper, S.E. et al., 2002).
nHopefulness has been associated with a greater
chance of clients resolving suicidality (Mann, R.,
2002).
nA high degree of personal agency has been
linked to less severe suicidality and a shorter stay
in therapy (Rice, R.E., 2002).
nA client’s willingness to disclose distress to the
therapist has been associated with a decrease in
client-rated stress and symptoms (Khan, J.E. et
al., 2001).
Therapy factors influencing client outcome
What influences the effectiveness of counselling in
higher and further education?
Client factors predicting drop out
nGlobal demographic client characteristics of age,
gender, ethnicity, and income did not predict
whether clients planned termination of therapy
with their therapist (Robinson, P.D., 1986).
nSelf-efficacy and outcome expectations
accounted for variance in motivation above and
beyond client gender, problem severity, and
therapist experience (Longo, D.A. et al., 1992).
nPsychopathology predicted whether a client
terminated prematurely and predicted how many
sessions clients attended. Psychopathology also
interacted with optimism in predicting premature
termination (Hatchett, G.T. et al., 2004).
nCoping styles were not useful in predicting
number of sessions or type of termination
(Stewart, D.W., 1996).
nA client’s ‘readiness to change’ was found to
influence premature termination: greater numbers
of premature terminators entered therapy at the
pre-contemplation stage, and greater numbers of
non-premature terminators entered therapy at the
preparation and action stages (Smith, J.J. et al.,
1995).
nThe greater the similarity between therapist and
client, and the lower the client’s self esteem,
then the more likely the client was to terminate
counselling prematurely (Berry, W.G. and Sipps,
G.J., 1991).
Client factors influencing symptom improvement
nEarly response in therapy has been found to lead
to less symptoms post therapy and at follow-up
(Haas, E. et al., 2002).
nPsychological and cognitive resources such as
optimism and hope have been linked to better
50
nLength of therapy (50 minutes or 30 minutes)
did not affect outcome: all students were better
adjusted after therapy with no difference between
the groups (Turner, P.R. et al., 1996).
nClients who were given test feedback within 2
weeks of their assessment reported a significant
increase in self esteem immediately following
the feedback session and a significant decrease
in symptom distress at a two-week follow-up
as compared to a control group who were given
feedback after completion of the outcome
measures (Newman, M.L. and Greenway, P.,
1997).
Therapist variables influencing client outcome
nNo therapist characteristics predicted planned
termination (Robinson, P.D., 1996).
nIn a study in which all clients who sought
counselling at the centre came from a minority
ethnic background, ratings of therapists’ general
competence were related to satisfaction rates
and attitudes towards counselling were found to
account for significant variance in the satisfaction
ratings (Constantine, M.J., 2002).
Does client-therapist similarity affect outcome?
nThere were no significant differences in change
scores on the OQ-45 or number of sessions
attended between ethnically similar and dissimilar
client/therapist dyads (Erdur, O. et al., 2003).
nComplementarity between client and therapist
was found to be associated with outcome. Those
clients with better outcomes showed a pattern
of complementarity that started at an initial high
level, then dropping, followed by a rise again
towards termination (Tracey, T.J.G. et al., 1999).
nNo relationship was found between the rating
of therapist effectiveness or satisfaction with
Anthology of research information sheets – 2nd edition
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therapy and the match between clients’ and
therapists’ beliefs on the causes of problems
or preferred and actual therapeutic orientation
(Atkinson et al., 1991).
Conclusions
Distress levels of students in Higher and Further
education
Where studies have compared the severity levels
of students attending counselling services with a
non-clinical student population, those attending
counselling services are significantly more distressed
than those people in a non-clinical student population.
When comparing severity levels of those attending
student counselling services with adult mental health
normative data/services there are mixed results. Some
research indicates similar severity levels between the
two populations while other research indicates lower
severity levels within the student counselling population.
Is student distress increasing
There is little evidence to support the hypothesis
of increasing severity levels of students attending
counselling services over the last decade or so.
Anecdotal evidence and survey research indicated an
increase in severity levels for 14 out of 19 presenting
problems. However, where clients’ perspectives are
used (e.g., via self report measures) or where the
measure is standardised and validated (e.g., as in the
case of the GAF), there is no evidence of increased
levels of student distress.
information sheet
UK student populations, some inferences may be
drawn from the research as it stands. Research on
static client variables (e.g. gender, age) in relation
to student counselling populations has not returned
positive findings. Cognitive/psychological resources
seem to be an important factor, with self-efficacy,
optimism and self-esteem being protective against
premature termination. There was little research on
therapist variables. Static variables do not appear
to be related to premature termination, whereas the
study by Constantine, M.J. (2002) found that the more
complex variable of multi-cultural competence was
predictive of symptom improvement. The evidence
regarding client-therapist matching was inconclusive,
although what the study on complementarity (Tracey,
T.J.G. et al., 1999) does suggest is that patterns of
therapist responsiveness, that is the therapist’s flexibility
in adapting to client’s needs, may be predictive of
outcome.
About the author
Jane Cahill is currently a research officer at The
Psychological Therapies Research Centre, University
of Leeds. She is an experienced project researcher
in systematic and scoping reviews in mental health
services and organisational research and also
has an interest in outcome research and measure
development.
References
Andrews, B. and Wilding, J.M. (2004) The relation of
depression and anxiety to life-stress and achievement in
students. British Journal of Psychology, 95, 509–521.
Aston, L. (2003) Higher education supply and demand to
2010. Higher Education Policy Institute.
Effectiveness of student counselling
The majority of the effectiveness research was concerned
with short-term therapy reflecting current practice and
service provision within student counselling. The research
available does indicate that short-term psychodynamic
therapy is effective within student populations and that
short-term routine therapy broadly demonstrates positive
effects. Crisis intervention was shown to be useful in one
study in that students receiving such services were no
more likely to drop out of university than students not
requesting such services.
Aston, L. and Bekhradnia, B. (2003) Demand for
Graduates: A review of the economic evidence. Higher
Education Policy Institute.
Atkinson, D.R., Worthington, R.L., Dana, D.M., Good,
G.E. (1991) Etiology beliefs, preferences for counseling
orientations, and counseling effectiveness. Journal of
Counseling Psychology, 38, 3, 258–264.
AUCC (1999) Degrees of disturbance; the new agenda.
British Association for Counselling and Psychotherapy.
Factors influencing effectiveness of student counselling
Research on the impact of variables on outcome
in student counselling is very diverse, with little
commonality between the impact factors examined.
Although the majority of the research was conducted
in the USA, limiting applicability of the findings to
© BACP 2008
AUCC (2004) Annual Survey of Counselling in UK
Colleges and Universities. British Association for
Counselling and Psychotherapy.
BACP (2007) Ethical Framework for Good Practice in
Counselling and Psychotherapy. Lutterworth: BACP.
Anthology of research information sheets – 2nd edition
51
R8
information sheet
Berry, W. G. and Sipps, G. J. (1991) Interactive
Effects of Counselor-Client Similarity and Client
Self-Esteem on Termination Type and Number of
Sessions. Journal of Counseling Psychology, 38, 2,
120–25.
Bewick, B. M., Bradley, M., Barkham, M. (2004) Student
perceptions of the University of Leeds Experience:
UNIversity Quality of Life & Learning (UNIQoLL) Project
– Report 1. University of Leeds.
Breakwell, G. (1987) The Evaluation of Student
Counselling: a review of the literature. 1962–86. British
Journal of Guidance and Therapy 15(2), 131–139.
Connell, J., Barkham, M.B., Mellor-Clark, J. (2007)
Mental health norms of students attending university
counselling services benchmarked against an agematched primary care sample. British Journal of
Guidance and Counselling, 35, 1, 41–57.
Connell, J., Barkham, M.B., Cahill. J., Gilbody, S.,
Modill, A. (2006). A systematic scoping review of
the research on counselling in Higher and Further
Education. Rugby: BACP.
Constantine, M.J. (2002) Predictors of satisfaction with
counseling: Racial and ethnic minority clients’ attitudes
toward counseling and ratings of their counselors’
general and multicultural counseling competence.
Journal of Counseling Psychology, 49, 2, 255–263.
Cooper, S.E., Rowland, D.L., Esper, J.A. (2002) The
relevance of family-of-origin and sexual assault
experience to therapeutic outcomes with college
students. Psychotherapy: Theory, Research, Practice,
Training, 39, 4, 324–343.
Department for education and skills (2002) Trends in
education and skills. http://www.dfes.gov.uk/trends/
index.cfm
Department for education and skills (2003) The future of
higher education. http://www.dfes.gov.uk/hegateway/
strategy/hestrategy/foreword.shtml
Frey, L.L., Tobin, J., Beasley, D. (2004) Relational
Predictors of Psychological Distress in Women and Men
Presenting for University Counseling Center Services.
Journal of College Counseling, 7, 129–139.
Haas, E., Hill, R.D., Lambert, M.J., Morrell, B. (2002). Do
early responders to psychotherapy maintain treatment
gains? Journal of Clinical Psychology, 58, 9, 1157–1172.
Hatchett, G.T. and Park, H.L. (2004) Relationships
among optimism, coping styles, psychopathology,
and counseling outcome. Personality and Individual
Differences, 36, 8, 1755–69.
Hayes, J.A. and Mahalik, J.R. (2000) Gender role conflict
and psychological distress in male counseling center
clients. Psychology of Men & Masculinity, 1, 2, 116–125.
HEFCE (2005/03) Young participation in higher
education. http://www.hefce.ac.uk/pubs/
hefce/2005/05_03/
Kahn, J.H., Achter, J.A., Shambaugh, E.J. (2001) Client
distress disclosure, characteristics at intake, and
outcome in brief counseling. Journal of Counseling
Psychology, 48, 2, 203–211.
Longo, D.A., Lent, R.W., Brown, S.D. (1992) Social
cognitive variables in the prediction of client motivation
and attrition. Journal of Counseling Psychology, 39, 4,
447–452.
Mann, R. (2002) Reasons for living vs. reasons for dying:
The development of suicidal typologies for predicting
treatment outcomes. PsycINFO data base (UMI No
3047148).
Matthews, C.R., Schmid, L.A., Gongalves, A.A., Bursley,
K.H. (1998) Assessing problem drinking in college
students: Are counseling centers doing enough? Journal
of College Student Psychotherapy, 12, 4, 3–19.
Michel, L., Drapeau, M. and Despland, J.N. (2003)
A Four Session Format to Work with University
Students: The Brief Psychodynamic Investigation.
Journal of College Student Psychotherapy, 18, 2, 3–14.
DeStefano, T.J., Mellott, R.M., Peterson, J.D. (2001)
A preliminary assessment of the impact of counseling
on student adjustment to college. Journal of College
Counseling, 4, 2, 113–121.
Nelson, K.L. (2003) Effects of crisis intervention on
the retention of students at a large urban university.
PsycINFO data base (UMI No 3094012).
Erdur, O., Rude, S.S., Baron, A. (2003) Symptom
improvement and length of treatment in ethnically
similar and dissimilar client-therapist pairings. Journal of
Counseling Psychology, 50, 1, 52–58.
Newman, M.L. and Greenway, P. (1997) Therapeutic
effects of providing MMPI-2 test feedback to clients at a
university counseling service: A collaborative approach.
Psychological Assessment, 9, 2, 122–131.
Freedy, J.R., Monnier, J., Shaw, D.L. (2002) Trauma
screening in students attending a medical university.
Journal of American College Health, 50, 4, 160–7.
O’Hara, M.M., Sprinkle, S.D. and Ricci, N.A. (1998)
Beck Depression Inventory--II: College population
study. Psychological Reports, 82, 3 Pt 2, 1395–401.
52
Anthology of research information sheets – 2nd edition
© BACP 2008
R8
Pahkinen, T. and Cabble, A. (1990) A 5-year follow-up
study of psychotherapy. The stability of changes in
self-concept. Psychotherapy & Psychosomatics, 54, 4,
193–200.
Rice, R.E. (2002) Assessing agentic and communal traits
in suicidal outpatients: A potential model for predicting
typologies, severity, and treatment outcomes. PsycINFO
data base (UMI No 3032207).
Rickinson, B. (1997) Evaluating the effectiveness of
counselling intervention with final year undergraduates.
Counselling Psychology Quarterly, 10, 3, 271–285.
Robinson, P.D. (1996) Premature termination in a
university counseling center: A survival analysis.
PsycINFO data base (UMI No 9700149).
Royal College of Psychiatrists (2003) The mental health
of students in higher education. Council Report.
www.rcpsych.ac.uk/publications/cr/cr112.htm
Smith, J.J., Subich, L.M., Kalodner, C. (1995) The
transtheoretical model’s stages and processes of
change and their relation to premature termination.
Journal of Counseling Psychology, 42, 1, 34–39.
Stewart, D.W. (1996) Predicting counselling service
utilization patterns with the MMPI-2 College
Maladjustment Scale. Canadian Journal of Counselling,
30, 3, 211–216.
Stinson, M.H. and Hendrick, S.S. (1992) Reported
childhood sexual abuse in university counseling center
clients. Journal of Counseling Psychology, 39, 3, 370–374.
Surtees, P.J., Wainwright, N.J. and Pharoah, P.P. (1998)
A Follow-Up Study of New Users of A University
Counselling Service. British Journal of Guidance and
Counselling, 26, 2, 255–72.
Todd, D.M., Deane, F.P. and McKenna, P.A. (1997)
Appropriateness of SCL-90-R Adolescent and Adult
information sheet
Norms for Outpatient and Nonpatient College Students.
Journal of Counselling Psychology, 44, 3, 294–301.
Tracey, T.J.G., Sherry, P., Albright, J.M. (1999) The
interpersonal process of cognitive-behavioral therapy:
An examination of complementarity over the course of
treatment. Journal of Counseling Psychology, 46, 1, 80–91.
Turner, P.R., Valtierra, M., Talken, T.R., Miller, V.I.,
Deanda, J.R. (1996) Effect of session length on
treatment outcome for college students in brief therapy.
Journal of Counseling Psychology, 43, 228–232.
University of Leicester (2002) Student Psychological
Health Project: Postgraduate student survey results.
University of Leicester (2002) Student Psychological
Health Project: Undergraduate student survey results.
Vonk, E.M. and Thyer, B.A. (1999) Evaluating the
effectiveness of short-term treatment at a university
counseling center. Journal of Clinical Psychology, 55,
1095–1106.
Wagner, M.T. (1999) Childhood abuse history correlates
and implications for adult outpatient treatment.
PsycINFO data base (UMI No 9994816).
Waller, R.M., Mahmood, T., Gandi, R., Delves, S.,
Humphrys, N., Smith, D. (2005) Student Mental Health
– how can Psychiatrists better support the work of
University Medical Centres and University Counselling
Services? British Journal of Guidance and Counselling.
33(1), 117–128.
Webb, E., Ashton, C.H.K., Kelly, P., Kamali, F. (1996)
Alcohol and drug use in UK university students. The
Lancet, 348, 922–925.
Wilson, S.B., Mason, T.W., Ewing, M.J.M. (1997)
Evaluating the impact of receiving university-based
counseling services on student retention. Journal of
Counseling Psychology, 44, 3, 316–320.
March 2008
It should be noted that this information sheet offers broad guidance, which sets out professional good practice, but it should not
be substituted for legal and for other professional advice applicable to your particular circumstances.
BACP is aware that law and practice are always in a process of development and change. If you have evidence that this information
sheet is now inaccurate or out of date feel free to contact us. If you know of any impending changes that affect its content we
would also be pleased to hear from you.
© BACP 2008
Anthology of research information sheets – 2nd edition
53
R9
information sheet
How to write a research proposal
by Sara Perren
Introduction
This information sheet has a dual purpose.
It aims to give therapists hoping to
secure funding for a research project
the information they need to produce
a realistic and successful proposal. It
also aims to help research students and
others produce a proposal which will be
acceptable to supervisors and achievable
within the timeframe and resources
available to them.
What is a research proposal?
A research proposal is a document which
concisely and lucidly outlines:
n
n
n
n
n
n
n
n
n
n
n
The planned research
Why it is important
Who will be involved
Reasons for doing it
How much of it has been done
before and by whom
The theory which will underpin it
The techniques to be used to make
it happen
Time frame
How much it will cost
Expected outcomes (if any)
Implications for practice
The proposal may be directed at intended
funders or sponsors, or it may be part of
a student project for a degree. Either way,
the aim is to convince the readers of the
proposal that the research is worth doing.
They may be reading many proposals.
Make the proposal interesting, persuasive
and well-structured. It will not be possible
to include in detail everything suggested in
this sheet. Be ruthless, sacrifice length for
the sake of clarity. The word limit should
not be exceeded – not even a little bit.
The benefit of writing a research proposal
is that it forces the researcher to consider
in detail the practicalities of making the
research really happen. Projects flounder
when they are not properly planned. Even
if badly planned research does finally get
completed it is stressful for all concerned.
If a coherent, realistic plan is in place from
the start, the research is more likely to be
successful and completed in accordance
with the proposed timetable.
Sections required in a proposal
Note: funders or universities may have a
prescribed research proposal form which
must be followed. It is important to bear
in mind therefore that the elements in
this guide are general and may not be
requested on all proposals. Equally, some
funders may ask for additional sections.
1. Title of research and title page
There will often be a guide to the maximum
number of words for the title – make it
snappy. A brief but compelling title will
make people pleased to read on. If the
research is too complex to be summarised
in half a dozen words have a brief,
attention-grabbing main title and a subtitle which elaborates.
Also include on the title page the name,
title, current position and contact details
of the lead researcher. Either here or at
another relevant point in the document give
the name, position, nature of involvement
and contact details for everyone involved.
Abstract
This will be a brief summary – usually no
more than 150 words outlining the focus
of the research, how it will be undertaken,
and anticipated findings. It can be helpful
to write this after the rest of the proposal
is completed. Attention should be paid to
the requirements set out in the application
form, e.g. number of words allowed for
each section, etc.
BACP Information Sheets
are intended to be read in
conjunction with the BACP
Ethical Framework for Good
Practice in Counselling and
Psychotherapy.
The Information Services
ethics helpdesk team is
available to members who
wish to explore any ethical
issues concerned with their
practice.
It should be noted that this
Information Sheet offers
broad guidance, which
sets out professional good
practice, but it should not
be substituted for legal
and for other professional
advice applicable to your
particular circumstances.
© BACP, November 2010
Previous version, August 2008
R9
2. Research question and rationale (including
background to the project)
The research question or hypothesis is all important.
It must be a question that can be investigated
constructively, taking into account the time and
resources available. If the question is self-generated the
temptation is to be too broad generating a project that
is impossible to complete. Limit the question to one
small area. Don’t try and look at the effect of carbon
emissions on the planet, look at the effect of them in a
tiny corner of the garden. This will be hard enough.
If you are responding to a call or tender from a particular
funder ensure that the research question fits the theme
of the ‘call for research’ and enlist collaborators if
necessary.
In the rationale include some or all of the following:
i) What circumstances/events/experiences/
reading/study/previous research have made
the investigation of this question particularly
important or interesting?
ii) What makes the question so interesting/important
that it is worth researchers’ time or sponsors’
money. An example of a hypothesis would be as
follows: ‘There is a positive correlation between
receiving adequate clinical supervision and
reducing sickness levels in counsellors working in
Primary Care’
iii) An important question, which relates to i) and ii)
above, is ‘What other research exists in this area?’
Before submitting an application it is advisable
to undertake a literature review. These days
access to the internet and an Athens password is
invaluable for doing an effective review. This gives
access to electronic databases and journals and
makes the process much more straightforward.
If possible find someone willing and organised
(e.g. a librarian) to do the routine tasks involved in
a literature review, this will save time, money and
may prevent demoralisation. (For more information
on doing a literature review, see Brettle, A., 2008.)
There may not be space to give a full review in
the proposal but it may be possible to quote
selected references to indicate the quality of the
literature review undertaken.
After describing the literature review take the
opportunity to indicate how the proposed
research may fill some gap in the current
knowledge about the subject.
iv) Give a list of research aims in bullet form –
no more than four. The list should be ordered so
© BACP 2010
information sheet
as to indicate the journey from research question
to hypothesis.
v) Speculate on what difference the research,
once completed, could make to those who are
its focus. How could it change, for example the
provision of counselling in the NHS or the type
of counselling offered to young people or our
understanding of the counselling needs of those
in same sex relationships etc?
vi) Provide a bibliography at the end of the proposal.
3. Research supervision – will there be anyone
supervising the research?
The answer to this should be yes. It is imperative to have
someone to talk to! Find a supervisor who has expertise
in the field. This could be achieved by attending a
BACP research conference or contacting the BACP
Research Department. A local university Social Science
department may well be able to help. If this is not part of
a university project but a ‘privately’ self-funded project,
it will be necessary to pay for supervision, this should be
included in the costs for the project.
4. Proposed methods (including data collection
and analysis)
It is important to describe the theoretical approach
which will underpin the work and explain how this
methodology suits the particular project. If there is
uncertainty consult with a supervisor or mentor and
read some books on different approaches to research
methods to discover which approach might best
help answer the research question (e.g. Barker, C.,
2002; Brett Davies, M., 2007; McLeod, J., 1999, 2001,
2003; Miles, J., 2005; Robson, C., 2002). As well as
considering the needs of the project, It is useful also
to consider which of the many ways of going about
research (e.g. qualitative/quantitative) best suits the
academic strengths of the researchers involved, taking
into account background experience, training and
personality. This will also help focus attention onto the all
important question of whether the research team has the
skills and resources to conduct the proposed research.
Provide references to back up the choice of research
method and to demonstrate competence and expertise.
Describe how you will go about doing the research. For
example:
n
n
n
n
n
Who are the participants?
How will the research sample be selected?
How will they be contacted?
Whose permission is required?
Whose help/co-operation must be ensured?
Anthology of research information sheets – 2nd edition
55
R9
information sheet
n Will questionnaires be used, how is the content
decided?
n What is in place for ensuring a representative
sample?
n What are the limitations?
n Will interviews be conducted?
n How will they be recorded?
n Who will do the analysis and how?
n What are the ethical issues involved? (For more
on Ethics, see section 8)
Although the above list may seem daunting (and will
vary from project to project), this is an invaluable
opportunity to think through and discuss in detail with
collaborators the stages of the research – and spot
anything that has been left out.
5. Duration of the research including dissemination
activity
State how long the research is expected to take and give
a list of important target dates (approximately half a dozen)
when significant stages of the research will be completed.
Give a month by month breakdown of what will be taking
place, when and who will be doing it. Think about research
participants; are there points in the year when they may
have other commitments and be unable to make the
time to be involved in research. Just because the project
is the priority of the researcher, it may not always be
theirs. Try and be realistic – build in holidays, e.g. don’t
plan to do the analysis in August if the researcher/s will
be on holiday in August. Forget specific months if there
are major religious or other celebrations likely to involve
either participants or researchers. Add some time for
delays. Include a timetable for dissemination activity.
(See section 9 on dissemination below.)
6. Estimated costs (including a breakdown of costs)
This is very hard. Again be realistic. Think of every
possible item of expenditure: stamps, tape recorder,
batteries, tapes, stationery, printer ink, petrol, bike
lights, transcribers, supervision. Itemise them. Include
a realistic rate for researcher time, trying not to
underestimate how long everything will take. If it is
necessary to learn a software package to help with
data analysis, include the cost of going on a course – or
quickly find the money to do that from elsewhere. Don’t
forget the cost of supervision if this is not a university
project. Include the cost of conferences (including
travel) for disseminating the research unless there is
already, for example, employer support available.
7. Where will funding come from?
If the research proposal is also a funding application
56
give all other sources of funding. If not, say whether
funding has been applied for and where from.
8. Any ethical issues identified
This is extremely important. It is vital to do everything
possible to ensure the confidentiality and well-being of
participants.
n Consider the protection and storage of any data
obtained from participants
n Think how to safeguard potentially vulnerable
people being interviewed about sensitive topics,
e.g. find out whether there are others involved in
their care, who may need to know this research
is taking place, and ascertain whether they can
provide support
n Ensure that participants are given a form to
sign which confirms their freely given, informed
consent to taking part in the research. This
form should also state that people have the
right to withdraw at any point and that their
right to receive a service will not be affected
by their willingness or refusal to take part in
research.
Universities involved in the research, or the examining
of it, will usually have guidance on ethics and research
with which the research should comply.
Those working within the NHS will be required to have
NHS ethics committee approval for the project. It is
advisable to discuss this with a supervisor. For more
information go to the Integrated Research Application
System (IRAS) website, www.myresearchproject.org.uk
Other agencies may also have guidelines or codes of
conduct for undertaking research involving their service
users – researchers should inform themselves of the
content of these guidelines.
For more information about research and ethics see
Bond, T. (2004).
9. Dissemination
There is no point in doing research if the findings
are never publicised. It will be a waste of
researcher time and funder’s money. Locally, make
presentations to those who have co-operated in
helping set up the research. Offer to send reports
to participants – and do it. Present the findings at
conferences – more than one if possible. Publish.
BACP has a research journal – Counselling and
Psychotherapy Research or find the journal best
suited to the project. Build in time and money for
this stage of the project.
Anthology of research information sheets – 2nd edition
© BACP 2010
R9
information sheet
10. Implications of research for counselling and
psychotherapy
McLeod, J. (2001) Qualitative Research in Counselling
and Psychotherapy. London: Sage.
If this hasn’t been covered already, give a summary
of the difference the research could make to the way
counselling or psychotherapy is done or provided or
thought about – don’t be timid. The research must be
important or it wouldn’t have got this far. Say so!
McLeod, J. (2003) Doing counselling research. London:
Sage.
Miles, J. (2005) A Handbook of Research Methods in
Clinical and Health Psychology. Oxford: OUP.
Robson, C. (2002) Real World Research: A resource
for Social-Scientists and Practitioner-Researchers. 2nd
Edn. Oxford: Blackwell.
About the author
Sara Perren worked as a psychodynamic counsellor
in Primary Care for nine years. Her qualitative
research has focused on people’s experience of
having (and not having) counselling in Primary Care
(Snape, C. et al, 2003; Perren, S., Godfrey, M. and
Rowland, N., 2009). She is interested in the rewards
and pitfalls of doing research as a counsellor and
in encouraging other counsellors to believe that
research is achievable and funding obtainable. She
currently works at The Tuke Centre in York.
References
Barker, C., Pistrang, N. and Elliot, R. (2002) Research
Methods in Clinical Psychology: An Introduction for
Students and Practitioners. Chichester: John Wiley.
Bond, T. (2004) Ethical Guidelines for Researching
Counselling and Psychotherapy. Rugby: British
Association for Counselling and Psychotherapy.
Web ref. http://www.bacp.co.uk/research/ethical_
guidelines.php (accessed 13 April 2010)
Brett Davies, M. (2007) Doing a Succesful Research
Project Using Qualitative or Quantitative Research
Methods. Basingstoke: Palgrave Macmillan.
Brettle, A. (2009) BACP Information sheet R1 How to do
a literature search. Lutterworth: BACP.
McLeod, J. (1999) Practitioner Research in Counselling.
London: Sage.
BACP Information sheets can be accessed, free of
charge by members, via www.bacp.co.uk. They may
also be purchased from BACP.
Other useful reading
Punch, K. (2006) Developing Effective Research
Proposals. London: Sage.
Sanders, P. and Liptrot, D. (1993) An Incomplete
Guide to Research Methods and Data Collection for
Counsellors. Manchester: PCCS Books.
Snape, C., Perren S., Jones, L. and Rowland, N. (2003)
Counselling – Why not? A qualitative study of people’s
accounts of not taking up counselling appointments.
Counselling and Psychotherapy Research 3(3): pp. 239–245.
Websites
There are many useful sites on the internet on writing
a research proposal. Type in: writing research proposal
and follow the links... A couple are:
University of Bristol, Department of Research and
Enterprise Development, Writing a winning proposal.
Web ref. http://www.bris.ac.uk/research/support/
funding/writing.html (accessed 13 April 2010)
Wong, P. How to write a research proposal. Web ref:
http://www.scholarshipnet.info/scholarship-tips/how-towrite-a-research-proposal-1 (accessed 13 April 2010)
November 2010
It should be noted that this information sheet offers broad guidance, which sets out professional good practice, but it should not be
substituted for legal and other professional advice, including supervision, applicable to your particular circumstances.
BACP is aware that law and practice are always in a process of development and change. If you have evidence that this information
sheet is now inaccurate or out of date feel free to contact us. If you know of any impending changes that affect its content we
would also be pleased to hear from you.
© BACP 2010
Anthology of research information sheets – 2nd edition
57
R10
information sheet
How to write a research paper and get
it published
by Julia Buckroyd & Sharon Rother
Introduction
This information sheet explains how
to write up research according to the
conventions of academic writing and how
to go about getting it published in a peer
reviewed academic journal. The guidelines
are based on the assumption that a piece
of research has been completed and that it
has either been written up, perhaps for an
academic dissertation, or at least that the
collected data have been analysed. Often
academic dissertations are in a form that is
quite un-publishable, usually because the
work is much too long.
After reading this information sheet it
should be possible to:
nStructure the paper according to
academic conventions
nFind a journal suitable for the paper
nShape the paper to meet the
demands of the journal
nUnderstand the peer review process
The conventional components of a
published paper
There are various elements that need to
be included in a paper published in an
academic journal. Most journals require a
conventional lay-out of the article. It makes
sense to establish what is required before
writing up, by looking at the front or back
of the publication or by checking on the
journal’s website for authors’ guidelines.
Failure to present a paper in the necessary
format is likely to ensure that it will not
even be considered.
The conventional components of an
academic paper are as follows:
nTitle
nAbstract
nKey words
nIntroduction
nMethod
nResults/Findings
nDiscussion
nConclusion
nAcknowledgements
nReferences
nAuthor details
Title
Resist the temptation to be clever or
funny in the title. The title should be an
exact description of the content of the
article. Many people decide whether to
read a paper from the title; it helps if the
title accurately describes the article. For
example, ‘The reactions of school leavers
to completing their final examinations’
should be used, rather than, ‘Free
at last; school leavers and their final
examinations’.
Abstract
The abstract is a mini version of the
paper. Often there is a prescribed word
limit; ensure that it is not exceeded. In a
journal indexed in one of the data bases,
for example PsycINFO, the abstract will
be used to describe the article, so it is
important that it contains all the necessary
information. These elements are as follows
(examples in brackets):
nBackground of the study
(Conventional weight loss
programmes have poor results in
delivering maintained weight loss
for most people. Recent research
suggests psychological approaches
to obesity are worth considering.)
nAims of the study (To evaluate
the results of a twelve week
uncontrolled psychological group
intervention for obese women.)
nMethod (Twelve obese women
recruited from an area of socio-
BACP Information Sheets
are intended to be read in
conjunction with the BACP
Ethical Framework for Good
Practice in Counselling and
Psychotherapy.
The Information Services
ethics helpdesk team is
available to members who
wish to explore any ethical
issues concerned with their
practice.
It should be noted that this
Information Sheet offers
broad guidance, which
sets out professional good
practice, but it should not
be substituted for legal
and for other professional
advice applicable to your
particular circumstances.
© BACP, April 2008
R10
economic deprivation were interviewed before
and after the intervention and at six month follow
up. Participants completed the Clinical Outcomes
in Routine Evaluation (CORE) Questionnaire, the
Binge Eating Scale and the Emotional Eating
Scale before counselling, after four weeks and at
the end of counselling. BMI and blood pressure
were also measured at these data points.)
nResults/Findings (66% of participants [n=8]
completed the intervention. 75% of completers
[n=6] lost ≥ 5% of baseline weight by the end of
the intervention and made significant reductions
in their scores on other measures. These results
were maintained or improved at follow-up.)
nConclusions (Although the number of participants
was too small to allow generalisation, the results
are promising enough to suggest that it would be
useful to replicate this research on a larger scale
and with controls.)
Key words
These are the words that will be used to index the
paper. Up to six or eight keywords are usually permitted;
consult the website or an example of an article to
find out. For example, ‘adolescents, art materials,
counselling, learning disability, special schools,’
might be the words to choose for a paper entitled
‘Counselling adolescents with learning disabilities, using
art materials, in a special school’. Note that key words
should be in alphabetical order. General words such as
‘client’ should be avoided. It is often simpler to write the
key words, abstract and title last; the rest of the paper
has been written and it is absolutely clear that these
items correspond exactly with the paper.
Introduction
This is the section of the paper which contextualises
the study, gives a brief literature overview and describes
what the paper sets out to do. Some journals (such
as BACP’s Counselling and Psychotherapy Research)
also want a reflexive section giving an indication of the
particular significance of the topic to the author.
The introduction should begin with a sentence which
locates the study within a broader context: ‘There
is widespread concern in educational circles about
truancy rates among secondary school pupils’; ‘There is
increasing evidence of mental health problems among
those seeking asylum in Britain’; ‘Men are known to
consult their GP much less often than women’. A brief
overview of the research literature on the subject is
then provided. It should usually take the following
form: ‘X has said such and such about it; Y has said
the other about it and Z has said even more about
© BACP 2008
information sheet
it. None of them have explored A’. The point is to
indicate that the existing literature has gone some way
to investigating the subject, but has not explored, or
answered satisfactorily, the aspect of the problem that
the current study researched. Then there should be a
simple description of what has been done: ‘This paper
explores’; ‘this study investigated’. Some journals like
this to be expressed in terms of aims: ‘The aim of this
study was to…’.
Method
This section of the paper is designed to give sufficient
detail to enable replication of the study; in theory the
reader should be able to go away and repeat the study
using only the information provided in the paper. It has
several sub-sections; the order of them may vary:
Methodology
It needs to be indicated here whether the study
is quantitative, qualitative or both. The choice of
methodology needs to be justified; the subject and
the question will dictate what is most appropriate.
If for example the question seeks to elicit opinions,
perceptions or memories, a qualitative methodology
is clearly best. Projects that seek to quantify or
present statistical analysis will demand quantitative
methodologies.
Qualitative and quantitative methods
If it is qualitative the method needs to be described
– focus group, interview, etc and if quantitative how
the study was designed – before and after, single arm,
uncontrolled etc.
Recruitment and description of participants
Here there needs to be a description of how the
participants were recruited: advertisement, referral,
self-referral etc; and who they were: women/men;
counsellors/clients/health centre patients etc; how
many; what age; ethnicity etc. Where relevant for
quantitative papers, details of selection and sampling
should be provided. Inclusion and exclusion factors can
also be listed.
Procedure
This section should include a description of exactly
what was done: ‘Participants were invited to attend
focus groups of not more than six members taking
place in the local community centre for one and a half
hours’; ‘Participants were interviewed by telephone
for between 30 and 45 minutes’; ‘Questionnaires
were sent by post to all participants with a stamped
addressed envelope enclosed’. It is common to include
some indication of the content of semi-structured
interviews; validated questionnaires should be
referenced.
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Ethics
Many journals will only publish papers that include
details of how ethical approval was obtained, for
example from a university or an NHS ethics committee.
The steps taken to obtain informed consent should also
be described.
references are not submitted in accordance with their
requirements without even reading the paper; most
journals will require the references to conform before the
paper is published.
Author details
Results/Findings
It is common for quantitative papers to describe
this section as ‘results’ and for qualitative papers to
describe it as ‘findings’. The convention is that results/
findings should not be confused with comment upon
those findings. Qualitative papers often amalgamate the
two which makes it hard for the reader to distinguish
between data and interpretation, but some qualitative
journals allow this.
All journals will require the author’s contact details and
many like to have a brief biography, usually of around
50 words. The journal website should be consulted for
details.
First choose the journal
All the information so far needs to be read in
conjunction with what follows.
How is the decision made about the choice of journal?
Discussion
This section comments on the findings. Conventionally
the limitations of the study and the need for further
research are included. Care should be taken not to
introduce any new material at this point. However, this
section also allows for reflection on the implications of
the study, especially for practice or training.
Conclusion
Some journals like the discussion to be limited to
thoughts on the paper and the research that has
generated it and keep the Conclusion for thoughts
about the wider implications. Other journals
amalgamate these two under Discussion. Look at the
journal that you have selected to see what style it uses.
Acknowledgements
Funders should be acknowledged here. This is also
the place where credit can be given to people who
have helped with the study but are not co-authors,
for example course tutors, participants, statisticians,
colleagues who have read and commented on drafts.
References
The reference list should cite material that has been
used in the body of the article. This will need to be
presented according to one of a number of styles
e.g. Harvard, American Psychological Association,
Vancouver. The Notes to the Author on the journal
website will explain exactly how they are to be
presented. Some journals now reject papers where the
60
nWhy was the research done in the first place?
nIs the paper for researchers or professionals?
If the paper is largely concerned with a particular way
of doing research (e.g. qualitative health research,
innovative research methods) then clearly it is for other
researchers. If the work is trying to influence practice, it
might be more suitable for practitioners. One student,
for example, published some work on groups for
mothers with eating disorders. The first thought was
that the research might influence practice, so it was
published in a journal for counsellors; however, because
the work was innovative, it was noticed by the editor
of a research journal, who then asked the student to
write something for his publication. His calculation
was probably that his readership might be interested in
replicating and extending the student’s research.
The second decision that needs to be made is who
might be influenced by the work. The research may be
on carers of terminally ill people who have discovered
that the patients long for a listening ear. Should a
counsellor be made aware of this? Probably counsellors
don’t need persuading. Maybe it is health care
professionals within the palliative care services who
need to hear it. Perhaps influence needs to be directed
towards those who allocate money within the NHS for
palliative care. If the paper is published in a counselling
journal, it is probably preaching to the converted. If it
is published in a palliative care journal the research is
being directed more precisely to those who need to act
on it and to those who can use it to fight their corner
with the policy makers and commissioners of services.
The next step is to find a journal, which publishes
articles which use a similar approach to the one that
has been used in the research. The research may be on
Anthology of research information sheets – 2nd edition
© BACP 2008
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information sheet
a particular approach to counselling people who have
problems with alcohol. Alcohol counsellors need to hear
it, but a journal on alcohol counselling which publishes
papers written in the style of the paper needs to be
found. Journals that focus on CBT will be unlikely to
publish psychodynamically informed papers; journals
which publish papers with lots of statistics will be
unlikely to publish qualitative work.
will be full of phrases such as, ‘We decided that it was
better; our initial impetus to do the work was; we had
originally planned to; we were surprised to see that’.
The editorial policy described on the website should be
consulted and recently published papers read. Either
the journal must publish papers written in the style that
is most personally comfortable, or the paper has to
conform to the journal’s style.
The next question is whether the journal that is being
considered publishes articles using the kind of research
methodology that has been employed in the study.
There is a broad distinction between qualitative and
quantitative work; some journals publish both; many
publish only one or the other. Beyond that, journals
sometimes specialise in the particular kinds of research
methodologies that interest them. Feminist journals, for
example, will want submissions that show evidence of
a methodology that takes account of feminist principles
and ideas. Make sure that the paper falls within their
remit as submitting to journals that are inappropriate will
waste a lot of time.
Another issue that needs to be considered is the length
of paper that the journal will publish. Journals that
publish qualitative papers will allow many more words
than journals publishing quantitative papers, but all will
expect guidelines to be followed. Editors like papers to
be shorter rather than longer and the length of the paper
should match the importance of the research. If four
people have been interviewed for an MA dissertation on
some aspect of counsellor training, a seven thousand
word paper should not be submitted; it should be about
fifteen hundred to two thousand words.
A further question is whether to submit to a journal that
has a national or an international list of contributors.
International journals are more prestigious so many
journals claim to be international. Membership of
the editorial and advisory boards and contributors’
affiliations can substantiate this claim. International
journals have more prestige and are often more difficult
for beginners to get published in, so journals that
have ‘British’ or ‘UK’ in the title, or which cater for a
specifically British group such as ‘primary care’ can be
more accessible.
Career researchers (usually those in universities) are
often under pressure to publish in the most prestigious
journals; there is a system of rating journals called the
Social Science Citation Index. It rates journals according
to the number of times that their articles are referenced
(‘cited’) by authors writing in other journals; the higher
the score, the more important the journal. This scale can
be found on the Internet. Very few counselling journals
are rated at all; that is because counselling research
is relatively new. However, there are a good number of
psychology journals that are rated. Counselling research
could also be published in journals for more established
disciplines, for example mental health psychology or
qualitative research journals.
In selecting the journal there are other factors to
consider. What style of writing does the journal use?
Some journals require the use of the passive voice. The
papers will be full of expressions such as, ‘Participants
were selected; results indicate; subjects were informed
that’. Other journals want exactly the reverse; they
want to know who the researcher is, how they came
to be doing the research, what was going on for the
researcher during the research process, so the papers
© BACP 2008
There will be instructions on exactly how the work is
to be submitted; some journals now use electronic
submission over the Internet, others want submissions
as attachments to emails. Some still want hard copies.
Note carefully whether a cover sheet or a covering letter
is required which identifies the author and a copy of the
article which is anonymous; journals usually send out
articles for review anonymously.
The convention is that authors should submit to only
one journal at a time. Editors get very upset if they go
to the trouble of having a paper reviewed, only to be
informed that it has been accepted elsewhere. Many
journals ask for confirmation that the work has not
been submitted elsewhere. Publication in the field of
social sciences and health is often a very slow process.
Expect consideration of the paper to take months
rather than weeks – all the more reason for choosing
the journal carefully. If there is uncertainty the abstract
can be sent to the editor to ask whether it is a suitable
submission.
The peer review process
When a paper is submitted it will be acknowledged,
usually within a week or two. If nothing has been heard
within this time frame, enquiries should be made in
case the paper never arrived. Next, the paper will be
screened. This initial screening determines whether
the paper meets the journal’s basic requirements. If it
doesn’t pass this first test, a rejection letter or email will
be received, sometimes with a recommendation that the
paper be submitted to another journal.
The paper is then sent out to reviewers, usually experts
in the subject matter and/or the methodology that
has been used. Many journals use two reviewers,
Anthology of research information sheets – 2nd edition
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some three, some one. The reviewers will be asked to
comment on every aspect of the paper and will send
those comments back to the editor. This can take
some time. When the reviews come back to the editor,
they are usually sent out with some kind of judgement
about what should happen next. If the paper has been
rejected the reviews will be useful in improving the
paper to send somewhere else. Major revisions or minor
amendments may be required before resubmission. It is
very rare indeed to have a paper accepted without the
need for any revisions. Some journals now track this
whole process via a website.
About the authors
What happens after your paper is accepted
Sharon Rother came to academic life via an MA in
Counselling Inquiry at the University of Hertfordshire
in 2002. In the same year she was appointed as a
Research Assistant and is now Research Coordinator
for the Obesity and Eating Disorders Research Unit.
She has published a number of articles and is co-author
with Julia Buckroyd of Therapeutic Groups for Obese
Women (2007) and Psychological Responses to Eating
Disorders and Obesity (2008) both published by Wiley.
When the submission has been turned into a Portable
Document Format (pdf) it will be returned for proof
reading. Often additional details for the references will
be requested. However, substantial changes cannot be
made at this stage of the proceedings.
After the proofs are returned the next step is the actual
publication of the work! It is usual to receive a copy of
the journal that has the paper in it. A certain number
of off-prints can also be ordered in hard copy or,
more usually these days, copies can be downloaded
electronically from the journal’s website.
Conclusion
Julia Buckroyd is Professor of Counselling at the
University of Hertfordshire and Director of the Obesity
and Eating Disorders Research Unit. She has spent her
entire working life in the academic world and has written
and published widely. Her publications in counselling
include: Eating your Heart Out, The Student Dancer
and, with Sharon Rother, Therapeutic Groups for
Obese Women and Psychological Responses to Eating
Disorders and Obesity. From January 2004 to December
2007 she was Editor of Counselling and Psychotherapy
Research.
Further reading
French, S. and Sim, J. (1993) Writing: A Guide for
Therapists. Oxford: Butterworth Heinemann.
Hall, G.M. (1998) How to Write a Paper. 2nd Edition.
London: BMJ Books.
The process described above is common to all
academic writing. Once it has been mastered it can be
applied to any paper or project. Counselling urgently
needs to create a larger evidence base for its treatments
and procedures. Publishing in the style that has been
described above will not only make the results of a
particular project available to others, but will also help
develop a critical mass of counselling research.
Pamir, M.N. (2002) How to write an experimental
research paper. Acta Neurochirurgica. Supplement. 93:
109–113.
Entering “How to write an academic paper” in Google
will come up with a long list of sets of instructions for
various academic institutions. These may be useful.
April 2008
It should be noted that this information sheet offers broad guidance, which sets out professional good practice, but it should not
be substituted for legal and for other professional advice applicable to your particular circumstances.
BACP is aware that law and practice are always in a process of development and change. If you have evidence that this information
sheet is now inaccurate or out of date feel free to contact us. If you know of any impending changes that affect its content we
would also be pleased to hear from you.
62
Anthology of research information sheets – 2nd edition
© BACP 2008
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information sheet
Undertaking systematic reviews in counselling
and psychotherapy
by Peter Bower
Introduction
The aims of this information sheet are:
n To describe systematic reviews,
and the methods used to undertake
such reviews
n To describe how systematic reviews
are used in evidence-based practice
n To consider the strengths and
weaknesses of systematic reviews
n To consider future developments in
systematic reviews
Deciding on the best counselling or
psychological therapy for a client is a
complex task. It is good practice for the
helping professions (including counsellors
and psychological therapists) to use an
evidence based approach to make these
decisions, which means taking account of
the best scientific evidence available about
the effectiveness of treatments.
At present, ‘best scientific evidence’
is often interpreted to mean evidence
from research studies called randomised
controlled trials. For further discussions
about evidence based practice and
randomised controlled trials, see Bower,
2010.
Although a well conducted randomised
controlled trial provides the best scientific
evidence about the effectiveness of a
treatment, each trial provides only a
single test. Researchers like to repeat
(or ‘replicate’) their studies to make sure
they can have confidence in the results.
However, making sense of many studies
and testing the effectiveness of a particular
treatment is a challenge.
An important type of scientific publication
is the literature review, which brings
together available research on a particular
topic. There have been concerns raised
in the past that reviews are sometimes
reported in a biased way, with authors
only tending to review studies that they
know about, and preferentially reporting
studies that confirm their existing
hypotheses (Mulrow, 1987). Furthermore,
reviewing a topic means summarising
many individual studies, which often use
different methods and differ in quality
and rigour. In these cases, it is not clear
whether all studies can be relied upon,
or whether the findings of some studies
should be de emphasised or discounted.
Reviews should highlight the weaknesses
and discrepancies in the research as well
as its strengths.
Systematic reviews are literature
reviews that are designed to overcome
these potential problems and provide
comprehensive, unbiased and
transparent reviews of evidence about
the effectiveness of treatments, including
counselling and psychological therapy.
Although systematic reviews are often
identified with medical interventions, it
is important to note that many of the
techniques used in systematic reviews
have a history in counselling and
psychological therapy. For example, many
of the techniques used in a systematic
review (i.e. comprehensive searches,
meta analysis) were first used by Mary
Smith, Gene Glass and Thomas Miller
in their classic review of the ‘Benefits of
Psychotherapy’ which brought together
many hundreds of studies of counselling
and psychotherapy (Smith, Glass, & Miller,
1980). This was an attempt to bring some
clarity to the early debates about the
value of counselling and psychological
therapy, and the relative effectiveness of
psychodynamic, behavioural, cognitive
and other approaches.
Systematic reviews are also generally
associated with quantitative methods, but
many of the principles are relevant to many
BACP Information Sheets
are intended to be read in
conjunction with the BACP
Ethical Framework for Good
Practice in Counselling and
Psychotherapy.
The Information Services
ethics helpdesk team is
available to members who
wish to explore any ethical
issues concerned with their
practice.
It should be noted that this
Information Sheet offers
broad guidance, which
sets out professional good
practice, but it should not
be substituted for legal
and for other professional
advice applicable to your
particular circumstances.
© BACP, January 2010
R11
information sheet
different types of research, and have been adapted for
use with qualitative methods (Khan, Bower & Rogers,
2007).
Where can I find information about systematic
reviews?
A doctor called Archie Cochrane is often considered
the architect of the systematic review. In 1979, he
suggested that the medical profession produce
‘a critical summary, adapted periodically, of all …
relevant randomized controlled trials’. In 1993 the
Cochrane Collaboration was set up with the task of
‘preparing, maintaining and promoting the accessibility
of systematic reviews of the effects of health care
interventions’ (Bero & Rennie, 1995; Starr & Chalmers,
2008). The Cochrane Library is advertised as ‘the best
single source of reliable evidence about the effects
of health care’ and part of the library is the Cochrane
Database of Systematic Reviews, which contains
many thousands of systematic reviews on aspects of
health care, including counselling and psychological
therapy.
Also part of the Cochrane Library is the Database
of Abstracts of Reviews of Effects (DARE), which
contains details of systematic reviews which meet strict
quality criteria but have been published outside of the
Cochrane Collaboration. Individual systematic reviews
are also published regularly in peer reviewed journals.
The Campbell Collaboration has a similar role in relation
to systematic reviews in crime and justice, education
and social welfare, and the Evidence for Policy and
Practice Information and Co-ordinating Centre (EPPICentre) is another organisation that conducts systematic
reviews in areas such as education, health promotion,
employment, social care, crime and justice.
BACP has also commissioned a range of systematic
reviews on topics of relevance to its members. These
include reviews of the impact of clinical supervision
(Wheeler & Richards, 2007), counselling in the
workplace (McLeod, 2001; McLeod, 2008), in higher
and further education (Connell et al., 2006), in lesbian,
gay, bisexual & transgender people (King et al., 2007),
older people (Hill & Brettle, 2004), and children and
young people (Harris & Pattison, 2004).
What is a systematic review?
The Cochrane Collaboration (http://www.cochrane.org/)
defines a systematic review as follows:
A systematic review identifies an intervention
for a specific disease or other problem in
64
health care, and determines whether or not this
intervention works. To do this authors locate,
appraise and synthesize evidence from as many
relevant scientific studies as possible. They
summarize conclusions about effectiveness, and
provide a unique collation of the known evidence
on a given topic, so that others can easily
review the primary studies for any intervention.
(http://www3.interscience.wiley.com/cgi-bin/
mrwhome/106568753/ProductDescriptions.
html#creviews, accessed 19 July 2009)
The Campbell Collaboration (http://camp.ostfold.net/)
defines a systematic review as follows:
The purpose of a systematic review is to sum up
the best available research on a specific question.
This is done by synthesizing the results of several
studies. A systematic review uses transparent
procedures to find, evaluate and synthesize
the results of relevant research. Procedures
are explicitly defined in advance, in order to
ensure that the exercise is transparent and can
be replicated. This practice is also designed to
minimise bias. Studies included in a review are
screened for quality, so that the findings of a large
number of studies can be combined. Peer review
is a key part of the process; qualified independent
researchers control the review author’s methods
and results. (http://camp.ostfold.net/what_is_a_
systematic_review/index.shtml, accessed 19 July
2009)
Systematic reviews seek to draw together individual
pieces of research to provide an overview that is more
comprehensive and rigorous. This increased rigour
derives from the statistical advantages of multiple
studies (so called ‘power’) which allows more precise
estimates of how well a treatment works. A review
also allows the consistency of results to be assessed.
The key features of systematic reviews are described
below.
Explicit research question
First, a systematic review starts with an explicit
research question. When the focus of the review is
on the effectiveness of a treatment or intervention,
these questions are often formulated according to
the PICO formula (Higgins & Green, 2009), where the
research question is defined in terms of four elements:
Population, Intervention, Comparison, Outcome. For
example, a research question might be, ’in patients
with major depression (Population), is experiential
psychotherapy (Intervention) more effective than
behaviour therapy (Comparison) in reducing depressive
symptoms (Outcome)?’
Anthology of research information sheets – 2nd edition
© BACP 2010
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Systematic reviews also make explicit the types of
evidence that are needed in order to answer the
question. For example, many systematic reviews of
the effectiveness of treatments or interventions are
restricted to randomised controlled trials.
Although many reviews are concerned with the
effectiveness of treatments and are restricted to
randomised controlled trials, this is not necessary for a
systematic review, because the general methods can in
theory be applied to almost any research question and
can include almost any type of study (for example, nonrandomised quantitative studies, or qualitative research,
with some adaptation).
Being explicit about the research question, and the
types of studies that are to be included in a systematic
review helps to avoid bias. For example, if a systematic
review is clear about the sorts of studies that are to
be included at the outset, then it is more difficult for
reviewers to bias the review process by excluding
studies where the results are unexpected or do not
fit their preconceptions. Many systematic reviewers
publish the details of research questions and inclusion
criteria before the review begins.
Comprehensive searches for studies
To be effective, systematic reviews need to have
a comprehensive overview of the evidence, rather
than reviewing a selected part which just happens
to be immediately available to the reviewers, which
was one of the criticisms of a traditional literature
review. The development of systematic reviews has
led to major advances in the science of searching
for studies, and systematic reviews harness
powerful electronic bibliographic databases such as
MEDLINE and PSYCINFO, in an attempt to provide
a truly exhaustive search of all potential locations of
relevant research. Electronic database searches are
often complemented by other forms of searching,
including hand searching (physically checking
the content of journals), searching for citations of
particular authors, seeking the help of experts,
and searches of the ‘grey’ literature (e.g. literature
outside conventional journals, such as reports and
conference abstracts). A systematic reviewer will
wade through many thousands of references looking
for relevant studies and decisions about inclusion or
exclusion are often made by more than one reviewer
to make sure their judgements are reliable. The
whole search process will be documented so the
reader can see what sources were searched, when,
and how decisions were made to include or exclude
the studies that were found. In principle, enough
detail should be provided to allow someone else to
repeat the search.
© BACP 2010
information sheet
Data extraction
When decisions about the inclusion and exclusion of
studies have been made, reviewers extract relevant data
from these studies. This may include data about the
context of the study (e.g. when and where the research
was done), the patient populations included and details
of the treatments under test. Data will also be extracted
on the quality of the studies and the main results. Data
are extracted onto standardised forms, so that the same
data are extracted from each study in a consistent
and reliable way. See the Cochrane Handbook for
Systematic Reviews for examples (Higgins & Green,
2009).
Quality appraisal
As noted above, one of the main difficulties faced by
reviews is that studies on a particular subject will differ
widely in their quality and rigour. Systematic reviews
seek to sort good quality evidence from biased and
misleading evidence by introducing the idea of quality
appraisal. This involves the systematic application of
quality criteria to all studies. For example, there are a
number of ways of judging the quality of randomised
controlled trials (Schulz & Grimes, 2002a; Schulz
& Grimes, 2002b). Reviewers may look at how the
randomisation was done, how many patients dropped
out of the study and how the analysis was conducted.
The key issue is that the same criteria are applied to
all studies. This is to avoid the bias which can occur
when reviewers make judgements about quality based
on their knowledge of the results. For example, flaws
in studies may be ignored when the results support
the views of the reviewers and weaknesses may be
highlighted in studies which report challenging results.
Synthesis
The ultimate aim of many systematic reviews is to
synthesise the available literature to make judgements
about the overall effectiveness of a treatment or
intervention. Sometimes this synthesis is narrative
in form, where the reviewers describe the individual
studies, identify patterns in the results and attempt to
summarise the overall meaning of the data. Narrative
syntheses are sometimes appropriate, but can be
difficult to make sense of when there are many studies
on a subject and the results are inconsistent.
Sometimes, the synthesis is quantitative, using a
technique called meta analysis (Smith, Glass, &
Miller, 1980; Sutton et al., 1998). Although the terms
systematic review and meta analysis are sometimes
used interchangeably, they are not identical, as meta
analysis is not necessary for a systematic review,
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nor is it sufficient to make a review systematic. In
meta analysis, the results of similar studies (e.g. all
studies of individual experiential psychotherapy for
depression) are pooled statistically in order to get an
overall estimate of the effectiveness of a treatment
in a particular population. For example, one of the
first meta analyses ever conducted summarised the
results of hundreds of studies of counselling and
psychological therapy and suggested that, overall,
people who received psychotherapy were better off
than most of those who did not receive treatment
(Smith, Glass, & Miller, 1980). Meta analysis can
provide a quantitative summary of all the evidence,
as well as providing an estimate of how confident we
should be in the results and how much the results of
individual studies differ from one another.
Updating reviews
Research evidence is not static and new studies are
constantly being completed and published. These new
studies may confirm previous knowledge, or challenge
it. Some systematic reviews are regularly updated in
order to keep abreast of the latest knowledge and
ensure that the evidence in the review reflects current
knowledge as closely as possible.
An example of a systematic review
An example of the use of systematic review techniques
in relation to counselling and psychological therapy
is the review ‘Effectiveness and cost effectiveness
of counselling in primary care’ by the author of this
information sheet and Nancy Rowland (Bower &
Rowland, 2006; Bower, Rowland, & Hardy, 2003).
This review was first published in 2001 and was
recently updated with the latest studies in 2006.
Studies included in the review were randomised trials
of counselling by practitioners working in primary
care and meeting the BACP accreditation criteria.
Searches were conducted on a number of databases
(including MEDLINE, EMBASE, PsycINFO, CINAHL,
the Cochrane CENTRAL register of controlled trials
and a specialist register of trials in depression and
anxiety held by the Cochrane Collaboration). Eight
trials were included, and rated for quality, and the data
were subjected to meta analysis. The main result of the
review was that six trials, with a total of 772 patients,
reported short term psychological health of patients
in counselling compared with those receiving routine
care from the general practitioner. The review found
that patients receiving counselling had significantly
lower (i.e. better) psychological symptom scores than
patients who did not. The effect size of counselling (i.e.
a quantitative measure of its superiority to routine care
in improving psychological outcomes derived from
66
the meta analysis) was 0.28. This can be interpreted
to mean that the average patient in counselling has a
better outcome than approximately 60% of patients
receiving routine care from the general practitioner.
In the analysis of long term outcomes (with four trials
and 475 patients), patients in counselling did not differ
in outcome from patients treated by their general
practitioner.
How can I judge the quality of a systematic review?
As the technology of systematic reviews has been
developed, these reviews have become popular, and
many reviews in the literature have been labelled
‘systematic’. However, as with any research method,
systematic reviews can be done well or badly. There
are checklists and guides available which can help a
reader judge whether a review is of high quality (Oxman
& Guyatt, 1988). Example questions that must be
asked are:
n Has the review asked a clear and focused
question?
n Are inclusion and exclusion criteria stated
clearly?
n Is the search for studies transparent and
thorough? For example, have the reviewers
provided details of their search terms, the
databases searched and the years covered by
the searches? Have they searched the grey
literature, contacted experts, and followed up
references in bibliographies?
n Is the validity of studies assessed?
How are systematic reviews used in evidence based
practice?
Evidence based practice has been defined as ‘the
conscientious, explicit, and judicious use of current
best evidence in making decisions about the care of
individual patients.’ Currently, a rigorous systematic
review of randomised controlled trials is considered
‘best evidence’ for the effectiveness of treatment.
In settings such as the NHS, searching for and
interpreting ‘current best evidence’ through systematic
reviews is generally done centrally by organisations
such as the National Institute for Health and Clinical
Excellence (NICE). Specialist teams of researchers,
clinicians and other stakeholders are involved in
the review process, and the resulting reviews are
then used to create clinical guidelines, which are
‘systematically developed statements to assist
practitioner and patient decisions about appropriate
health care for specific clinical circumstances’ (Field &
Lohr, 1990). See Bower (2010) for further discussion of
clinical guidelines.
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What are the strengths and weaknesses of
systematic reviews?
When conducted well, a systematic review should
provide a comprehensive summary of all available
evidence relating to the effectiveness of a treatment,
with the quality of studies assessed in a reliable manner
and the whole review process done in a way that is
transparent and open to criticism. Cochrane reviews
have the additional advantage in that they are regularly
updated, so that new evidence is quickly entered
into the review and the results can keep pace with
developments in the literature.
As noted above, systematic reviews are not always
done well and need to be assessed, like any piece of
research, so that the reader can be confident in the
method and conclusions. Systematic reviews can also
be quite complex in terms of their methods, which can
make it difficult to disseminate the findings in ways that
are useful for professionals and patients.
Many of the criticisms of systematic reviews reflect the
fact that such reviews are often restricted to randomised
controlled trials. Some critics do not feel that such
studies are appropriate in counselling and psychological
therapy, as they are better suited to the evaluation of
drug treatments which are not so influenced by context,
meaning and the complexities of human relationships.
Further discussions about criticisms of evidence based
practice and randomised controlled trials can be found
in Bower (2010).
Systematic reviews sometimes provide no specific
guidance, because the evidence is so limited in scope
or so poor in quality that no strong conclusions can
be made. No matter how sophisticated the review
methodology, it can never overcome limitations
in the primary studies on which it is based. The
conclusion ‘more research is needed’ is often found
in systematic reviews. However, many reviews do at
least provide details of the key research priorities for
the future.
How will systematic reviews change in the future?
Although systematic reviews do not have to be
restricted to randomised controlled trials, the majority
of those examining the effectiveness of treatments
do not include other study types. Researchers in
health and social care are increasingly recognising
that randomised controlled trials cannot always
provide answers to the questions that policy makers,
professionals and patients want to answer. There
is increasing interest in the contribution of other
study designs, including qualitative research. One of
© BACP 2010
information sheet
the most interesting areas in the development of
systematic reviews is the adoption of some aspects
of systematic review techniques in the synthesis of
qualitative research (Campbell et al., 2003), and the
use of systematic reviews to synthesise the results of
qualitative and quantitative research about the same
topic (Dixon-Woods & Fitzpatrick, 2001).
Conclusion
The impact of evidence based practice has led to a
significant focus on the use of systematic reviews to
support decision making about treatments, including
counselling and psychological therapy. Systematic
reviews can potentially provide a transparent and
reliable method for summarising the literature on the
effectiveness of treatments and the systematic review
technology has provided evidence of the effectiveness
of a number of counselling and psychological therapy
treatments (Bower & Rowland, 2006; Churchill et al.,
2002). Understanding the strengths and limitations of
systematic reviews can help ensure that they play an
appropriate role in decision making about how best to
help clients.
About the author
Peter Bower is a psychologist and health services
researcher working at the University of Manchester.
He conducts research work into the effectiveness
of psychological therapy and other mental health
interventions in primary care, and has a special
interest in the use of randomised controlled trials
and systematic reviews in this area. He works as a
consultant on systematic review work conducted
by the British Association for Counselling and
Psychotherapy and is a member of the BACP
Research Committee.
References
Bero, L. & Rennie, D. (1995). “The Cochrane
Collaboration: preparing, maintaining and disseminating
systematic reviews of the effects of health care”,
Journal of the American Medical Association, vol. 274,
pp. 1935–1938.
Bower, P. (2010). Evidence based practice in counselling
and psychotherapy. BACP Information sheet R2.
Lutterworth: BACP.
Bower, P. & Rowland, N. (2006). se of Systematic
Reviews no. Issue 3, p. Art. No.: CD001025. DOI:
10.1002/14651858.CD001025.pub2.
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Bower, P., Rowland, N., & Hardy, R. (2003). “The
clinical effectiveness of counselling in primary care:
a systematic review and meta-analysis”, Psychological
Medicine, vol. 33, pp. 203–215.
Campbell, R., Pound, P., Pope, C., Britten, N., Pill, R.,
Morgan, M., & Donovan, J. (2003). “Evaluating metaethnography: a synthesis of qualitative research on
lay experiences of diabetes and diabetes care”, Social
Science and Medicine, vol. 56, pp. 671–684.
Churchill, R., Hunot, V., Corney, R., Knapp, M., McGuire,
H., Tylee, A., & Wessely, S. (2002). “A systematic
review of controlled trials of the effectiveness and
cost-effectiveness of brief psychological treatments for
depression”, Health Technology Assessment, vol. 5,
no. 35.
Connell, J., Barkham, M., Cahill, J., Gilbody, S., &
Madill, A. (2006). A systematic scoping review of the
research in higher and further education, Lutterworth:
BACP.
Dixon-Woods, M. & Fitzpatrick, R. (2001). “Qualitative
research in systematic reviews”, British Medical Journal,
vol. 323, no. 765, p. 766.
Field, M. & Lohr, K. (1990). Clinical practice guidelines:
directions for a new program, Washington: National
Academy Press.
Harris, B. & Pattison, S. (2004). Research on counselling
children and young people: a systematic scoping
review, Rugby: British Association for Counselling and
Psychotherapy.
Higgins, J. & Green, S. (2009). “Cochrane Handbook
for Systematic Reviews of Interventions Version 5.0.1,”
The Cochrane Collaboration, http://www.cochranehandbook.org/.
Hill, A. & Brettle, A.. (2004). Counselling older people:
a systematic scoping review, Rugby: BACP.
Khan, N., Bower, P., & Rogers, A. (2007). “Guided selfhelp in primary care mental health: a meta synthesis of
qualitative studies of patient experience”, British Journal
of Psychiatry, vol. 191, pp. 206–211.
King, M., Semlyn, J., Killaspy, H., Nazareth, I., &
Osborn, D. (2007). A systematic review of research on
counselling and psychotherapy for lesbian, gay, bisexual
& transgender people, Lutterworth: BACP.
McLeod, J. (2001). Counselling in the workplace: the
facts, Rugby: BACP.
McLeod, J. (2008), Counselling in the workplace:
68
a comprehensive review of the research evidence (2nd
edition), Rugby: BACP.
Mulrow, C. (1987). “The medical review article: state of
the science”, Annals of Internal Medicine, vol. 106, pp.
485–488.
Oxman, A. & Guyatt, G. (1988). “Guidelines for reading
review articles”, Canadian Medical Association Journal,
vol. 138, pp. 697–703.
Schulz, K. & Grimes, D. (2002)a. “Allocation
concealment in randomised trials: defending against
deciphering”, Lancet, vol. 359, pp. 614–618.
Schulz, K. & Grimes, D. (2002)b. “Sample size slippages
in randomised trials: exclusions and the lost and
wayward”, Lancet, vol. 359, pp. 781–785.
Smith, M., Glass, G., & Miller, T. (1980). The Benefits of
Psychotherapy. Baltimore: Johns Hopkins University
Press.
Starr, M. & Chalmers, I. (2008). The evolution of The
Cochrane Library, 1988–2003 (http://www.updatesoftware.com/history/clibhist.htm, last accessed 29 April
2008), Oxford: Update Software.
Sutton, A., Abrams, K., Jones, D., Sheldon, T., &
Song, F. (1998). “Systematic reviews of trials and other
studies”, Health Technology Assessment, vol. 2, no. 19.
Wheeler, S. & Richards, K. (2007). The impact of clinical
supervision on counsellors and therapists, their practice
and their clients: a systematic review of the literature,
Lutterworth: BACP.
Further information
Information about reviews commissioned by BACP
can be found at http://www.bacp.co.uk/research/
Systematic_Reviews_and_Publications/index.php
Information about the Cochrane Collaboration can be
found at http://www.cochrane.org/
Information about the Campbell Collaboration can be
found at http://www.campbellcollaboration.org/
Information about the EPPI-Centre can be found at
http://eppi.ioe.ac.uk/cms/
The Cochrane Library is freely available at
http://www.library.nhs.uk
A short history of meta analysis can be found at
http://glass.ed.asu.edu/gene/papers/meta25.html
Anthology of research information sheets – 2nd edition
© BACP 2010
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information sheet
January 2010
It should be noted that this Information Sheet offers broad guidance, which sets out professional good practice, but it should not be
substituted for legal and other professional advice, including supervision, applicable to your particular circumstances.
BACP is aware that law and practice are always in a process of development and change. If you have evidence that this Information
Sheet is now inaccurate or out of date feel free to contact us. If you know of any impending changes that affect its content we
would also be pleased to hear from you.
© BACP 2010
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information sheet
Finding research funding
by Kaye Richards
Introduction
Many research ideas may not get off the
ground because of a lack of research
funding. Nonetheless, whether the
research project is costed at £500,000 or
£5,000, the same good practice principles
apply when writing funding applications,
whatever the scope of the project. This
information sheet will offer guidance on
how best to approach finding research
funding. It will take you through the key
steps, both in terms of searching for
funders and writing applications, which
will help to increase the likelihood of
submitting a successful research bid. It will
cover the following areas:
n
n
n
n
Searching for funders
Finding a good funding fit
Developing your research bid
Writing a funding application
Searching for research funding is time
consuming, complex and often tedious.
A one in five success rate is realistic for
applications, so those who want to get
research funding must be prepared for
some hard work. Ten applications may
be submitted before success but do not
get disheartened. Once relevant trusts/
organisations have been identified and
thorough written applications made, the
applications may be targeted to a variety
of funders. However, the research question
must first be clearly identified. This will
provide the best chance of knowing
whether the research meets the objectives
of funding bodies, which will increase the
likelihood of a successful bid.
Step One: Searching for funders
There is not one main funder that
funds research into the psychological
therapies – out of thousands of funding
trusts there are only half a dozen or so
of these trusts which explicitly state that
they fund counselling and psychotherapy.
Therefore finding research funding for
counselling and psychotherapy will
take time and require a detailed search,
along with a trawl through information on
funding bodies to find those that match
your research topic. Such searching
is necessary because many funders
have targeted population groups and
priorities for funding, so for example if
you are developing a research project for
counselling children and young people in
schools, the potential funders for such a
project will be different from those that,
for example, might fund a research project
about counselling for asylum seekers.
Funders are large and small, offer varying
amounts of money and have a wide
range of objectives. While the process of
finding funders will take time, there are
some sources that can make that process
quicker. Some of these provide access
to details of a range of research funding
information (e.g. The UK Research Office
(UKRO), Community of Science (COS)
and RDInfo). Others provide searchable
databases of trusts for a wider range of
purposes, both practice and research
(the most useful being the Directory of
Social Change’s Trustfunding Directory
as it aims to list all publicly registered
funding charities). There are also
specific funding bodies that are worth
considering. For example, for university
research funding The Economic and
Social Research Council (ESRC) is
the UK’s leading research funding and
training agency addressing economic
and social concerns. Also, BACP has
set up a Research Foundation to further
research in the psychological therapies,
so over time research funding will be
available specifically for the psychological
therapies. Other BACP funding initiatives
do currently exist e.g. BACP’s seedcorn research grant available to BACP
members. More detailed information on all
these resources is listed in the appendix.
These should provide a basis for locating
relevant funders.
BACP Information Sheets
are intended to be read in
conjunction with the BACP
Ethical Framework for Good
Practice in Counselling and
Psychotherapy.
The Information Services
ethics helpdesk team is
available to members who
wish to explore any ethical
issues concerned with their
practice.
It should be noted that this
Information Sheet offers
broad guidance, which
sets out professional good
practice, but it should not
be substituted for legal
and for other professional
advice applicable to your
particular circumstances.
© BACP, November 2010
© BACP, September
2008
Previous
version, September
2008
R12
Funding a PhD study
Those looking for funding for a PhD research project will
find that many charitable trusts won’t fund individuals
or students. The best option for funding a PhD is to
discuss the project with a university department and
a leading expert in the field (as they have access to
university funds for funding/supervising PhD research).
Another idea is to apply for studentships that are already
being funded and these can be identified by looking
at job advertisements in weekly higher education
newspaper supplements, eg. The Times Higher
Education Supplement and the Guardian Education
Supplement. Alternatively, a PhD project could be part
of an organisation’s research bid, and thus applications
would then be able to be made to some charities.
Step Two: Finding a funding fit
information sheet
broaden the search and approach it from different
perspectives, as not all funders have specifically
defined research priorities. It is useful here to look for
key phrases/buzz words in the information provided by
funders. If they fit with the project there may be scope
for submitting an application, remembering to use these
key phrases/buzz words in the final application. Be
creative about matching the research and the funding
source. Be flexible.
Consider the geographical area
Be mindful that some funders like to give to specific
geographical areas, so it is likely that applications made
to funders favouring the areas where the project is being
undertaken may have a greater chance of success.
Applications to local charities/trusts can sometimes be
more successful than approaches to national charities/
trusts.
Match research criteria to that of funders
The key to being successful in finding funding is not
only identifying a range of funders but also identifying
those funders that have criteria clearly matching the
research topic – it is essential to find a funder with a
‘good fit’. Often research proposals are well designed,
but they fail to match the priorities of a funding body, so
do not waste time sending applications to inappropriate
funders – be realistic not idealistic.
More than one application can be made
The entries in the Directory of Social Change’s
Trustfunding Directory give an indication of the
information you can access about all grant making
trusts in the UK.
If the project looks like an initial good fit it is useful
to contact the funding body office/programme officer
to clarify the funding priorities with simple questions
such as:
Name of trust:
Address of trust:
Financial information: lists grant total
Areas of work: lists areas that the trust will fund
Exclusions: will state what trustees do make
grants to: e.g. unsolicited applications, students,
individuals etc.
Applications: will identify how to submit an
application
General information/summary: provides more
information about what has been previously
funded, current aims and priorities, along with any
current restrictions
Research funders use keywords to identify their funding
criteria, so refer to databases using keywords as the
main search strategy (e.g. Directory of Social Change
Trustfunding Directory) and compare them with the
research project. Although key words are useful,
© BACP 2010
Many charitable trusts offering funding have grants for
small amounts (e.g. £500–£5,000). It may be possible
to approach several of these and thus achieve success
with a number of these small grant applications. Having
attained the offer of funding it is often easier to write to
the second or third agency asking them to match it.
n Does this sound like the sort of project you will
fund?
n Do you have any thematic priorities?
n Are matched/partnership funds acceptable?
n What information is required of the researcher?
These questions are worth asking to make sure the
project fits the funding requirements. A quick phone
call can save much wasted work. Do not try to force a
project to fit a funder’s criteria. Accept the situation if
it does not fit and move on to finding a funder that is a
better match.
Making sure you find the right funder
n Do both you and your proposed project meet the
eligibility criteria?
n Is the sponsor likely to offer funding at a sufficient
level and for long enough?
n If the sponsor will only provide partial funding,
can the balance of funding and facilities you
require be made available from other sources?
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n Can you meet the application deadlines and are
you certain of the application procedures?
n What is the likelihood of success – is it worth the
effort of making an application?
n Will you have freedom to publish or are there
likely to be confidentiality restrictions?
n Who will have ownership of the results?
n How far are you prepared to tailor your research
to a sponsor’s requirements?
n Is the sponsor compatible with your own
conscience and the mission of your department/
institution?
n Are the sponsor’s interests likely to conflict
with any other work that you or your immediate
colleagues are undertaking?
(Final, S., 2008).
Step Three: Developing the research bid
Deciding on your research team
When beginning to seek research funding for the
first time it may feel as though only the experienced
researchers get the cash. This is true for those
funders who want to ensure that the researchers
they are funding have a proven track record and
will deliver good quality research. However, do not
be disheartened – all experienced researchers have
had to have been awarded their first research grant
at some point. It may be wise to submit bids for
small funding grants to strengthen your research
credibility rather than a bid for a large amount,
or think carefully about who might partner/work
collaboratively with the researcher to strengthen the
application.
In deciding the scope of the project, be realistic in a
number of ways, including financially. Be aware of the
skills and time available to the research team. It may be
necessary to build a research team that will strengthen
the bid. Include more experienced researchers to
support the bid, perhaps go into partnership with
a university or a practice organisation, or get an
experienced researcher on board as a supervisor for
the project. This will give a message to funders that the
researcher has access to a range of skills and relevant
ongoing research supervision/guidance throughout the
project. Often a collaborative project brings together the
full range of skills that are needed for any good research
project, so ensure that all the skills and competencies
have been recognised and that these are reflected in the
research proposal.
In addition, evidence of a spread of support from your
department/organisation of work, community bodies
and other relevant organisations strengthens any
proposal. Evidence of inter-professional working is often
advantageous and funders may want to know if users
72
(e.g. clients, practitioners, policy makers etc.) can be
and are being actively involved in the project, not just
being used as research subjects.
Other issues
A clear and thorough grant application may include:
n Seeking (or knowing how to seek) ethical
approval
n Identifying the full costs (bearing in mind all costs
and ‘value for money’)
n Contacting people to use as referees
n Reconsidering the project (are all those good
ideas really necessary now?)
It is also a good idea to discuss the research ideas
with other people and be clear about how this research
builds on earlier research. It is useful to get samples of
previous successful applications to help to structure an
application and cover all the key issues.
In preparing the project, make a decision about what is
unique about it – i.e. how will it contribute to knowledge
and also how will it benefit society? Often funders want
benefits for targeted population groups, so demonstrate
how these benefits will be achieved. Effective
dissemination is also a strong feature of how research
benefits others, so any good research proposal will have
a clear dissemination strategy.
Further issues:
n What are the ethical issues/dilemmas - sensitive
issues or potential problems?
n Does the researcher/team have the skills and
competencies needed?
n Are potential problems foreseen and how are they
to be solved?
n Should users be involved and how?
n Are co-funding or collaborative studies an
option?
n Should a research partner(s) be found?
Step Four: Writing a funding application
There are many points to consider when writing an
application. Try to ensure that the proposal is well
developed, that the financial and project management
places are fine-tuned and respond to the requirements
of the priority themes. Overall, the application must offer
three key things:
1) Quality and ability: demonstrate originality and
expertise in the relevant field of research
2) Relevance to users: think about the groups of
Anthology of research information sheets – 2nd edition
© BACP 2010
R12
users who would potentially benefit from the
research
3) Value for money: ensure that the costs reflect the
benefits of the work to be undertaken. information sheet
Perren, S. (2008) will help guide you through the
process of writing a good research proposal.
Project management
(Bradford University, 2008)
An important point is to read the application rules and
guidance notes very carefully. It may sound simple,
but it is necessary to prove to funders an ability to
fill in the application properly. Also, a copy of the
assessors’ marking criteria for applications is a useful
tool/checklist in writing an application, to assess the
criteria against which it is being marked. Try to fulfil all
the criteria.
When writing a funding application clearly formulate the
problem to be researched and the context, along with
a strong rationale and detail of what will happen with
the research when it is completed. As pointed out in
ESRC (2008) application guidelines the chosen research
design must be defended against critical appraisal and
thus must, for example:
n Establish appropriate aims and objectives
n Demonstrate a well-thought-out research design,
explaining why the research is being carried out
and why now? Also, be clear about what led to
this research, who should conduct it, and offer
realistic comments on the limitations and barriers
to undertaking this research
n Give details of research methodology and the
specific methods to be used
n Demonstrate clear, systematic data collection
and method of analysis
n Outline realistic and justified time scales and
costings (with detailed breakdown of specific
expenditure, e.g. postage, computing, travel,
office overheads)
n Anticipate likely interpretation of results, what
might they be used for and what will the benefits
be?
n Outline the dissemination strategy and check that
it will be effective
n Identify potential users of the research
n Provide any appendices – what tools will be used?
n Outline a thorough and brief bibliography
n Outline the gap in knowledge that the research
will fill
n Anticipate ethical approvals that may be required,
prior to commencement of project and explain
how these will be addressed
Other considerations are:
n What will happen after the research finishes?
n What is the long term potential of the research?
n How will the information be used in the next
five years?
© BACP 2010
In terms of project management the application
needs to be well thought out and structured, with
appropriate resources for all stages of the research
identified. Whether it is postage stamps to send
out questionnaires, office overheads or travel
expenses, funding bodies need to know all the
costs for the project. Don’t hide costs, assessors
will pick these up and question the budget. Ensure
that all costs are fully justified, including costs for
staff, and be clear about what percentage of the
full costs are being sought. Be realistic within the
time constraints of the research. Don’t offer to do
too much as assessors will question whether the
project will be completed on time, they will want
reassurance that the team will deliver as scheduled.
Allow plenty of time for finding funding. A rushed
application can easily be detected and any
application that fails to follow the procedure might
not reach the assessors.
Conclusion
Any general guide to writing a research application
will inevitably miss the unique requirements of specific
funders. However, to give an application the best
chance of success, ensure the application is thorough
and that it captures the funders’ attention, along with
communicating passion and enthusiasm for the project.
Don’t be intimidated by big funding organisations
or be deterred by the prospect of writing a detailed
application. Detailed applications are as much for the
researchers’ benefit as for the funders, covering every
eventuality and ensuring the capacity to undertake the
best possible research.
Should any application fail, make the most of feedback
from the funding body and use this to inform future
applications. Try and try again.
About the author
Kaye Richards is BACP’s Research Facilitator and
her role is to undertake research, promote research
awareness and facilitate research into counselling
and psychotherapy. A key part of her role at BACP
is to encourage and support BACP members in
understanding and doing research in counselling
and psychotherapy. She also works with BACP’s
Counselling Children and Young People (CCYP) Division
and is interested in research developments in this arena.
She has written and edited numerous publications
Anthology of research information sheets – 2nd edition
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including being co-author of the recently published
BACP systematic review titled ‘The impact of clinical
supervision on counsellors and therapists, their practice
and their clients’ (2007).
References
Bradford University (2008). Research applications:
some informal guidelines. http://www.brad.ac.uk/rkts/
researchsupp.php?content=writingfundingappITTING
RESEARCH APPLICATIONS. Accessed 13 June, 2008.
ESRC (2008) General guidance notes on constructing a
good application: Part II. http://www.esrcsocietytoday.
ac.uk/ESRCInfoCentre/Support/research_award_
holders/FAQs2/index2.aspx?ComponentId=5079&Sourc
ePageId=5441. Accessed 13 June, 2008.
Final, S. (2008). Making sure you find the right funder.
http://www.researchresearch.com/news.cfm?pagename
=FundingArticle&ElementID=2878&lang=EN&type=defa
ult. Accessed 13 June 2008.
Perren, S. (2008). How to write a research proposal.
BACP Information sheet P9. Lutterworth: BACP.
Further information
Sources for finding research funding
Overview
The following information provides relevant
information on finding funders and key funding
bodies. Further relevant information and funding alerts
are available on BACP dedicated research funding
web pages (see http://www.bacp.co.uk/research/
Finding_Research_Funding/index.php). The information
provided is not exhaustive, but these sources should
reveal potential funders and get the process of finding
funding started.
Some of the information pointed to is available
on-line and through libraries. It is also worth
doing an internet search with keywords/phrases
such as ‘how to find research funding’, ‘research
funding bodies’, funding councils etc. And finally
organisations exist that will offer training in finding
funding if you want further professional development
in this area.
1) R & D Info (www.rdinfo.org.uk)
The RDInfo unit is funded by the Department of Health
and provides access to details of research funding,
training and advice. It provides information on healthrelated research funding opportunities. Registration
for the profiling service (including ongoing email alerts)
enables researchers to keep updated with the latest
74
funding opportunities, targeted to their research areas
such as psychology and psychiatry.
2) UKRO (www.ukro.ac.uk)
The UK Research Office (UKRO) is the UK’s leading
information and advice service on European Union
funding for research and higher education. UKRO
provides up-to-date information on all funding
opportunities, through the Framework Programmes for
Research and Technological Development, and other
sources of funding for research and higher education
offered by the EU and other European-level funding
organisations. Any UK university, charity or public
sector research organisation can subscribe to UKRO.
Associate membership is available to companies and
non-UK research organisations.
3) Community of Science (COS) (www.cos.com)
COS is the leading global resource for hard-to-find
information critical to scientific research and other
projects across all disciplines. It is the largest, most
comprehensive database of available funding. COS
offers different types of membership that provide a wide
range of benefits. These include: Individual membership
as well as Universities and Research Institutions
membership.
4) ResearchResearch.Com
(www.ResearchResearch.com)
This is branded as a ‘newspaper for the research
world’. It provides information of funding opportunities
and news on research policy and politics. It also
offers a complete funding opportunities alert service
for researchers. It provides daily news from over
30 countries around the world. In the UK you can
subscribe to /purchase; 1) Funding opportunities, 2)
News monitoring in Research Day, UK and 3) News in
depth, comment and analysis in Research Fortnight. For
subscription details contact the head office (London)
020 7216 6500 or email [email protected]
5) Directory of Social Change’s Trustfunding Directory
(DSC) (www.trustfunding.org.uk)
The Trustfunding directory details all trusts included
within DSC and CAF publications and is updated
regularly throughout the year. It includes information
on over 4,200 grant-making trusts. Details of all the
information published online are available in a variety of
text book versions, many of which should be available
from main libraries and also can be purchased. DSC has
three different websites:
n Grants for individuals (www.grantsforindividuals.
org.uk)
n Companies giving funding (www.companygiving.
org.uk)
n Government Funding (www.governmentfunding.
org.uk)
Anthology of research information sheets – 2nd edition
© BACP 2010
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6) ESRC
(www.esrc.ac.uk/ESRCInfoCentre/index.aspx)
The Economic and Social Research Council (ESRC) is
the UK’s leading research funding and training agency
addressing economic and social concerns. The aim
of the ESRC is to provide high quality research on
issues of importance to business, the public sector and
government. The research funding schemes enable
individuals and groups to pursue world-class research in
academic institutions and independent research centres
throughout the UK. This can be through research
centres and groups, fellowships, research grants,
programmes and networks or research resources. The
website contains all the current information required for
those wishing to make an application for ESRC research
funding or training.
7) FunderFinder (www.funderfinder.org.uk/index.php)
FunderFinder develops and distributes software to help
individuals and not-for-profit organisations in the UK to
identify charitable trusts that might give them money.
They also produce general information on aspects of
funding and fund-raising, which you can access online.
8) Times Higher Education Supplement (THES)
(www.thes.co.uk)
You can sign up for a free weekly THES newsletter
information sheet
alert that has details of the latest research funding
opportunities. Visit: www.thes.co.uk/newsletter
9) British Association for Counselling and
Psychotherapy (BACP)
BACP has set up a Research Foundation to further
research in the psychological therapies. The
Foundation aims to facilitate high quality, high priority
and independently peer reviewed research in the
psychological therapies, based on robust methodology,
for the benefit of the community and those who are the
recipients of psychological therapy services. Over time
research funding opportunities should become available
under the remit of the Foundation. For further details
email: [email protected].
BACP currently offers a £5,000 seed corn research
funding grant for BACP members on a yearly basis to
encourage a new piece of counselling and psychotherapy
research. For further details visit www.bacp.co.uk/
research or email: [email protected].
Please note: the information/web addresses listed
above were correct at time of printing. It is possible
that these may quickly become outdated. Also, the lists
are not necessarily provided on the basis that they will
actually fund counselling and psychotherapy research.
November 2010
It should be noted that this information sheet offers broad guidance, which sets out professional good practice, but it should not be
substituted for legal and other professional advice, including supervision, applicable to your particular circumstances.
BACP is aware that law and practice are always in a process of development and change. If you have evidence that this information
sheet is now inaccurate or out of date feel free to contact us. If you know of any impending changes that affect its content we
would also be pleased to hear from you.
© BACP 2010
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information sheet
Statistics in counselling and psychotherapy
by Stephen Joseph, Colin Dyer & Hugh Coolican
Introduction
The aim of this information sheet is to
explore the research contexts in which
different statistical tests are appropriate
and the rationale for their use and
explain some of the basic concepts and
procedures in gathering statistics.
This may help readers to gain more from
their reading of research reports containing
statistical analysis of quantitative data and
help them to conduct their own research
studies.
In statistics, we have to turn the concepts
we use into numbers. Therapists use many
concepts, including unconditional positive
self-regard, self-esteem, authenticity,
and depression. To conduct research,
the first step is to operationally define the
concept. What this means is finding a way
to actually measure it. Often this is by a
standardised interview or by self-report
questionnaire. For example, if we were
interested in depression, we might use the
Beck Depression Inventory (Beck et al,
1961) to assign people a numerical score
reflecting their level of depression. In a
data set, each of the things measured is
called a variable.
Once we are dealing with numbers it is
possible to test if people’s scores change
over the course of therapy, to compare
their score with other peoples’ or to see
how their scores relate to other variables.
Descriptive statistics
‘Descriptive’ statistics form the starting
point for analyses. For example, if we
were to say that the average age of
people attending a therapy centre was
42 years, this would be an example of a
descriptive statistic. The usefulness of
descriptive statistics is that they reduce a
dataset to a single easily comprehended
value that summarises a key property of
the entire set There are two basic ways of
doing this:
n use a measure of ‘central tendency’
to capture the idea of an average
(i.e., mean, median and the mode)
n use a measure of ‘dispersion’ (i.e.,
range, and the standard deviation)
to capture the differences between
individual scores
Terms used in statistics associated with a
numerical value
Mean. The mean is the arithmetic average
of a set of data, found by dividing the
sum of all the scores by the count of their
number. For example, imagine we ask 10
people to rate how happy they are on a
seven point scale, where 1 = not happy
and 7 = very happy. The ten people rate
themselves as: 5, 6, 4, 3, 6, 4, 6, 3, 6, 7,
respectively. If we add those ten scores up
we get a total of 50. Divide 50 (the total)
by 10 (the number of people) and we get
5. The mean is 5 and describes the whole
group of 10 people in terms of a typical
score value to which each individual score
in the set contributes. It can, therefore,
offer a guide to the typical value in the
set as long as there are no unusually
large or small values present. For this
reason, it is best used when score values
are reasonably closely grouped together.
Should there be extreme values another
statistic, called the median, should be
used.
Median. The median is the middle value of
a set of scores. If we take the 10 example
scores above, and put them in order, we
get: 3, 3, 4, 4, 5, 6, 6, 6, 6, 7. With any row
of 10 numbers, the middle point is where
there are five numbers on each side, so
the median would in this case be exactly
halfway between 5 and 6 at 5.5.
Mode. Finally, a less common, but
still occasionally useful indicator of
BACP Information Sheets
are intended to be read in
conjunction with the BACP
Ethical Framework for Good
Practice in Counselling and
Psychotherapy.
The Information Services
ethics helpdesk team is
available to members who
wish to explore any ethical
issues concerned with their
practice.
It should be noted that this
Information Sheet offers
broad guidance, which
sets out professional good
practice, but it should not
be substituted for legal
and for other professional
advice applicable to your
particular circumstances.
© BACP, November 2010
Previous version, August 2009
R13
central tendency is the mode. This is simply the most
commonly occurring value found in a set of data. In our
example, therefore, the mode would be 6 since that
value occurs four times. The mode is not as commonly
used as the mean or the median as it provides
less information, but sometimes it can be useful.
For example, say we set up a new therapy service
we might be interested at the end of the first year in
knowing what the most common presenting problem
was in our clients.
Measure of dispersion
The mean, median and the mode are all useful as a way
of describing the central or most representative value of
a dataset. However, it is also useful to have a figure that
indicates the degree of variability within a dataset – that
is, how closely scores are bunched together.
Range. The easiest measure of dispersion to calculate
is the range. This simply indicates the size of the
difference between highest and lowest scores in the
set. In the above data set of ten people the scores run
from 3 to 7, so we would say that the range is 4 with a
minimum score of 3 and a maximum score of 7.
Standard deviation. The most widely used measure
of dispersion is the standard deviation (SD) which
characterises a dataset in terms of its distribution
around a central value (usually the mean).
If we look at the steps showing how the SD is calculated
we can see exactly what this means:
n The first step is to calculate the mean of the
dataset.
n Then subtract each item of data from the mean to
find the difference scores.
n Next, square each difference score (multiply it by
itself).
n Find the mean of the squared difference scores –
this is called the variance.
n Then calculate the square root of the variance.
For example, in the above example dataset of ten
people who rated their happiness;
n We know the mean is 5.
n So the difference scores would be: 0, -1, +1, +2,
-1, +1, -1, +2, -1, -2, respectively.
n The squared difference scores would be: 0, 1, 1,
4, 1, 1, 1, 4, 1, 4, respectively.
n The mean of the squared difference scores is 1.8
(this is the variance).
n The square root of the variance = 1.34. This is the
SD.
© BACP 2010
information sheet
This is useful because the larger the SD, the higher the
variability among the scores. What constitutes “high”
or “low” variability, and each case, must be assessed
in the light of what is known about such factors as the
measurement method employed, the sampling method
and the characteristics of the sample.
A real life example that illustrates the use of descriptive
statistics is the study by Kirsten et al (2008) who
administered the Beck Depression Inventory at intake
and termination of therapy. At intake, the mean was
23.64 and the SD was 10.17. At termination, the mean
score was 14.78 and the SD was 8.30. So we can see
that the mean has fallen (indicating that the average
level of depression has fallen) and so has the amount of
dispersion (i.e. the scores are now more bunched up).
‘Correlation’ in a research report
It is common to want to know the relationship between
two or more variables (Correlation). For example,
does longer time in therapy lead to a better outcome?
To answer such a question empirically a researcher
would typically conduct a survey of a number of
people, asking questions about how long they were in
psychotherapy for and their well-being. When a number
of people are sampled in this way the results might look
like the data in Table 1.
Table 1
Time in therapy and psychological adjustment
(self-assessed) of 12 cases
Time (weeks)
Adjustment Questionnaire
Score/100
19
57
25
49
28
73
15
40
13
40
17
55
26
73
23
49
25
56
29
57
17
50
15
47
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It is possible to look across all these scores and ask
how they vary in relation to each other. Does it look
like people who were in therapy longer are also better
adjusted? Note that we are not interested in whether
it is true for everyone, just whether, on average, the
variables co-vary in this way.
A scatterplot can give us two very important pieces
of information about the variables in question since it
indicates both the ‘direction’ and the ‘strength’ of their
relationship.
To make it easier to see, it is usual to present such data
as a scatterplot.
A scatterplot is a type of graph in which each axis (i.e.
the horizontal and vertical lines that frame the graph)
is scaled for one of the variables. To draw a scatterplot
you locate each member of each pair of values in
the data on the appropriate axis and mark the point
of intersection on the graph. Figure 1 represents the
scatterplot for the data in Table 1.
In constructing a scatterplot it is often possible to
differentiate between the variables that are to be
plotted. If one takes precedence logically over the
other, this is called the predictor (or independent)
variable and it normally appears on the X (horizontal)
axis of a scatterplot. The other variable, called the
outcome (or dependent) variable is scaled on the Y
(vertical) axis and represents the particular focus of the
research (i.e. the variable about which one wishes to
make a statement). In Figure 1 the predictor variable
is thus time in therapy and the outcome variable the
measure of psychological adjustment. As you can
see, a scatterplot makes it much easier to visualise
the relationship between the two variables. As time
in therapy increases, psychological adjustment
increases.
The ‘direction’ of the relationship between two
variables can be considered by comparing the relation
between height and weight, for example. On average,
taller people tend to weigh more. Thus we can say
that the direction of the relationship between these
two variables is positive because, in general, weight
increases with height and vice versa. Or, consider
the data in the example above about whether time in
therapy is related to psychological adjustment. Here the
trend is positive, suggesting the generalisation that the
longer the time in therapy the better the outcome.
However, not all variables are positively related. We
might actually find that the longer people are in therapy,
the lower they score on a psychological disturbance
scale. The direction of the relationship in this case would
be negative because as one variable increases, so the
other decreases. On the scatterplot, these relationships
(whether positive or negative) show themselves in the
way the intersection points are distributed. A positive
relationship is shown when the general trend runs from
the bottom left towards the top right-hand corner of the
graph. A negative relationship shows itself when the
trend is from top left towards bottom right.
The ‘strength’ of the relationship between two
variables can be explained as the extent to which the
value of one variable can be predicted from any value of
the other. Think again about height and weight. We can
Figure 1
Time in therapy and self-assessed adjustment
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say that on average there is a positive relationship
between the two, but it is also true that not all taller
people weigh more than people less tall. It’s only a
moderately strong relationship. To put it another way,
if we know someone’s height we might try to predict
their weight but, because the relationship between
these variable is only moderately strong, we would not
necessarily get the answer exactly right.
How can we use a scatterplot to obtain this
information?
A good impression of the direction of relationship can
be obtained simply by looking carefully at the way the
intersection points are distributed on the field of the
graph. The strength of the relationship can similarly be
gauged by looking at the distribution of intersection
points. If the relationship is very strong indeed then
the points will almost form a straight line, and if the
relationship is very weak, they will be distributed almost
at random, with no discernible trend.
Testing for correlation statistically
The relationship of two sets of scores has two
dimensions: (1) direction ­– that is, whether the scores
vary positively or negatively – and (2) strength in relation
to the closeness of the relationship. Both of these
qualities are captured in summary form in a statistic
called the correlation coefficient.
A coefficient of zero indicates a nil (random) relationship
between the two sets of scores. A coefficient of +1
indicates a perfect (i.e. consistently proportional),
positive relationship (i.e. as one increases in magnitude,
the other increases in magnitude of a consistent
ratio). A coefficient of -1 indicates a perfect (i.e.
consistently proportional), negative relationship (i.e.
as one increases in magnitude the other decreases in
magnitude, of a consistent ratio). The signed values
of the correlation co-efficient thus contain, essentially,
the same information as a scatterplot, but in concise
numerical form. The sign (i.e., +ve or –ve) of the
coefficient indicates the direction of co-variation and the
strength of the relationship is indicated by a value of the
coefficient, which ranges between 0 and 1.
Thus, if the points on the scatterplot run clearly from
the lower left-hand towards the top right hand corner,
you have a strongly positive correlation and will find
that the value of the correlation co-efficient will be
positive and will approach 1 (having a value of, say,
0.70 upwards). On the other hand if the points run from
the top left hand to the bottom right hand corner you
have a strongly negative correlation and the value of the
correlation co-efficient in this case will again approach
1 but will be negatively signed (e.g. -0.70). If there is
© BACP 2010
information sheet
no very consistent pattern visible in the scatterplot you
have a weaker correlation and the coefficient is likely
to be below 0.30 (and close to 0 if the pattern appears
more or less random).
It is beyond the scope of this information sheet to
go into detail on how to calculate the correlation
co-efficient. But it is worth noting that the commonly
used formulas for calculation are either the Spearman’s
Rank Order Co-efficient or Pearson’s Product Moment
Coefficient. Both generate a signed value between
-1 and +1 to express the relationship between the
variables. The data in Table 1 generate a Spearman
coefficient of +0.81. (The details of which correlation
statistic to choose and how they are calculated can be
found in any introductory statistics text, for example,
Coolican, 2004, Dyer, 2006, Greer & Mulhern, 2002.)
Correlation and causality
Correlation does not imply causality! There are two
essential points to remember about the correlation
coefficient. First, even though two sets of scores
may be related in some way (and possibly generate
a high coefficient), this does not mean that their
relationship is a causal one. For example, if it is shown
that greater amounts of time in therapy are related to
better adjustment, it doesn’t necessarily mean that
the therapy has led to the adjustment. It might be that
more adjusted people tend to stay in therapy longer.
Alternatively, maybe over a period of time, people tend
to recover anyway regardless of therapy. It might even
be that both are caused by some third variable. For
example, in this case, both could be caused by winning
some money leading to the person being more cheerful
and being able to afford to stay in therapy longer!
Curvilinear relationships The second essential point
when thinking about correlation is that the relationship
between variables must be a linear one. This means
that the scores must be related in the same direction
(positive or negative), across the whole range of the
variables in the population, not just in the sampled
scores. If the underlying relationship should be nonlinear, a correlation coefficient will mislead because its
value and sign will depend entirely on which part of its
population range has been sampled. For example, it
might be that longer duration of therapy is beneficial,
but only up to a point. It might also be that very long
periods of time in therapy can be harmful in some
way. Thus the relationship, between time in therapy
and outcome, is more complex than hypothesised
and requires more sophisticated analysis than simply
looking for a linear association. For example, Figure
2 illustrates a curvilinear relationship. If we sample
only those scores from region A we obtain a negative
relationship, but if we sample scores from region B we
obtain a positive relationship.
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Figure 2
The effect of sampling from different regions of a curvilinear range of paired datasets
Drawing reliable inferences from data
Whereas descriptive statistics summarise data,
inferential statistics are concerned with drawing
conclusions. For example, imagine that a researcher
is interested in whether a new therapy is able to help
people who are depressed. The researcher then designs
an experiment in which 100 depressed people are
randomly allocated to one of two groups, the ‘therapy
as usual’ group or the ‘new therapy’ group. Random
allocation is used to rule out the effects of other
variables. The idea is that if we have a large group of
people and we randomly allocate them into two groups,
all of the differences in things like age, personality and
social status should average themselves out so that the
two groups will be equivalent, on average, with respect
to these variables.
Another way to create two equivalent groups is to
carefully match the two groups. So, if it is important
that the two groups are equivalent in age, we make sure
that, for each person of a certain age in group 1, there is
also a person of that age in group 2.
All participants in the experiment have eight weeks of
therapy at the end of which the research team conducts
interviews and uses standard questionnaires such as
the Beck Depression Inventory with all participants to
see how many are now depressed. The purpose of
this research is not simply to describe but to draw a
conclusion about the effectiveness of the therapy.
as usual’ group, 15 of the 50 are no longer depressed
and, in the ‘new therapy’ group, 17out of 50 are no
longer depressed. Does the ‘new therapy’ represent
an improvement over ‘therapy as usual’? Comparing
15 to 17 you’d probably say ‘no’. It’s not a big enough
difference to be able to say that it’s probably due to the
new therapy. But what if 23 people in the new therapy
group were no longer depressed? Comparing 15 to
23 you might now say ‘yes’. It would seem to be a
substantial difference and, if there are no other obvious
reasons for why this is, you might conclude that this is
evidence that the ‘new therapy’ is an improvement. But
can we be sure?
If as many as 37 people in the ‘new therapy’ group were
no longer depressed, most people would say that this
difference was now sufficiently big to be certain that the
difference was due to the new therapy. But again, can
we be sure? The answer is that we can never be sure.
All we can ever say is that the difference is so big that it
is unlikely that it is due to chance. Intuitively we have a
good sense of when the difference in numbers between
the two groups is big enough to infer some meaningful
difference between the therapies. But doing it intuitively
means that there will always be some disagreement
between people. Scientists have therefore, developed
formal statistical tests that use probability to express
the likelihood of obtaining a given set of data. Once a
probability has been computed the information value of
the data can more easily be assessed.
Expressing probability
The use of probability
To understand inferential statistics, it is necessary to
understand the use of probability. Staying with the
above example, imagine it is found that in the ‘therapy
80
Imagine tossing a coin eight times. It would be unlikely
that you would get eight heads in a row. If a coin is
balanced equally on each side, then each toss of the
coin has a 1 in 2 chance of being heads. (This would
Anthology of research information sheets – 2nd edition
© BACP 2010
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be expressed as a probability of 0.5, p=0.5.) So, on the
first toss, there is a 1/2 chance of heads. The chance
of two heads in a row is 1/4 (p=0.25). The chance of
three heads in a row is 1/8 (p=0.125). Four in a row is
1/16 (p=0.0625). Five in a row is 1/32 (p=0.03125). Six
in a row is 1/64 (p=0.015625). Seven in a row is 1/128
(p=0.0078125). Eight in a row is 1/256 (p=0.00390625).
See Table 2.
As you can see, the probability of getting eight heads in
a row is very unlikely. So if you did get eight heads in a
row you would be justified in thinking that the coin must
surely be weighted on one side more than the other.
This is the logic that we apply to the experiment testing
the ‘new therapy’. The experiment is designed with
the statistical assumption that each group is ‘equally
weighted’,and therefore, if there is a big difference, we
would conclude that the ‘new therapy’, like the coin that
turns up several heads in a row, has an added weight.
Null hypothesis In science, this assumption (that each
group is equally weighted) is called the null hypothesis.
In general terms, the null hypothesis asserts that,
despite differences in scores between two samples,
e.g. ‘new therapy’ group and ‘old therapy’ group, they
are nevertheless drawn from the same population
(and therefore do not reflect the effect of different
treatments). ‘Population’ refers to the specific wider
pool from which the sample is drawn. For example, if we
were interested in a new therapy for older men suffering
from depression, our ‘population’ would be older men
suffering from depression. Obviously we could not do
research with the whole population of older men as it
would be too large, so we obtain a sample. The idea is
that we obtain a sample which is representative of the
population in question. In that way we can generalise
our findings from the sample to the population.
Table 2
Probability of throwing eight heads in a row
Number of
tosses
Probability of
heads in a row
Probability as a
decimal
1
1/2
.50
2
1/4
.25
3
1/8
.125
4
1/16
.063
5
1/32
.031
6
1/64
.016
7
1/128
.008
8
1/256
.004
Note: probablity as decimal can range from 0 (never occur)
to 1 (must occur).
© BACP 2010
information sheet
It is the null hypothesis that is being put to the test
by experiment. There has to be persuasive evidence
that the null hypothesis is unlikely to be true before
we consider accepting any alternative hypothesis.
Interestingly this is also how we reason in everyday
life. For example, we say, ‘if there isn’t something
wrong with X’s memory, then how come they have
forgotten their keys so many times?’ We assume
the null hypothesis is true, work out the odds of the
outcome occurring IF the null hypothesis ­IS true, but
then reject it in favour of the alternative if those odds
are sufficiently low.
But how low does the probability have to be (how
many heads have to turn up in a row), before we
reject a null hypothesis? There is no single answer to
this, but there is a common convention in the health
and social sciences to use p=0.05 (or 1/20) for the
probability that a given result would occur when
the null hypothesis is true. This is referred to in the
literature as a significance level of p<0.05. Assuming
the coin is evenly weighted, Table 2 tells us that a
probability of lower than p=0.05 is roughly equivalent
to throwing five or more heads in row.
So, we would decide that a new therapy represents an
improvement over therapy as usual via the significance
level. A significance level of p<0.05 sets a (small)
probability that the observed difference between the
two sets of scores could have been obtained even
though the null hypothesis is true. The scientific
method is to remain open minded about the source
of the observed difference unless it is large enough to
trigger the rejection of the null hypothesis. We try to
design research studies so that when we reject the null
hypothesis we can assume any difference is due to a
particular alternative hypothesis (which are the different
treatments in the above case).
Testing for difference between groups
Often researchers are interested in differences between
groups of people. There are two main research designs
in which such testing for difference can be achieved.
These are called the Independent Groups, and Related
Groups designs.
Independent Groups Design
The independent groups research design involves
forming two distinct groups of individuals that are
compared. As an example of this design, consider
a hypothetical research project in which two groups
of people who have either been treated using
psychodynamic or cognitive-behaviour therapy are
interviewed about their psychological health. Table 3
shows the results of a small hypothetical data set,
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with seven people in each group each of whom has
been scored on the number of symptoms mentioned
by each person. Looking at these data, does it look as
though there is a difference between groups?
The first step in analysis would be to calculate the
mean scores for each group. Remember, the mean
score is the arithmetic average of a set of data.
The mean number of symptoms of both groups in
Table 3 is identical. Both groups have a mean number of
symptoms = 8; so by that measure there is no evidence
of difference. Going back to the discussion about
probability, when the numbers are identical there is no
need for further statistical tests, but when the numbers
are different we would apply statistical tests. The two
tests that are appropriate for an independent groups
design are:
therapy is finished, they all complete the same measure
again. It’s possible now to test whether these same
people score lower on the number of symptoms than
they did previously. Table 4 gives the results of a small
hypothetical data set, with seven people who rated their
number of symptoms before and after therapy.
Can we say that the therapy was successful? From the
calculation of the mean scores for each group in Table 4
it appears that the therapy might have been successful,
as the mean score at time 2 (mean = 1.57) is lower than
at time 1 (mean = 3.57). However, we can’t really say
anything more than this unless we apply an appropriate
statistical test to assess the probability of having
obtained these results when the null hypothesis is true.
The appropriate statistical tests for the related groups
design are:
n Independent t-test
n Mann-Whitney U test
n The paired t-test
n Wilcoxon Matched Pairs Signed Rank Test
These statistical calculations are used to provide the
statistical probability that a difference as large as this or
larger would occur if the null hypothesis were true.
The details of which statistical tests to choose and
how to calculate them can be found in any introductory
statistics text (e.g. Coolican, 2004, Dyer, 2006, Greer &
Mulhern, 2002).
Related groups design
Clinical significance
The related groups design is created when the members
of one group of individuals each provide two sets of
scores, so that the scores are related to each other
by having been generated by the same individuals on
different occasions. An example of this design in the
clinical setting might be when a group of people first
attend for therapy, at which time they all completed
a measure of psychological health. Then, after the
In the study by Kirsten et al (2008), mentioned above,
the difference on the Beck Depression inventory, at
intake and termination, was tested using the paired
t-test and the difference found to be statistically
significant.
Statistical significance must not be confused with
clinical significance which refers to what we usually
mean when we say an intervention was successful.
Table 3
Comparing two independent groups in number
of symptoms
CBT Group
Table 4
Repeated group measures design
Psychodynamic Group
Number of symptoms
Person
Number of
symptoms
Person
Number of
symptoms
Person
Time 1
Time 2
1
4
1
2
1
4
2
2
3
2
1
2
3
1
3
4
3
6
3
4
2
4
4
4
4
4
4
2
5
6
5
3
5
6
3
6
2
6
4
6
2
1
7
1
7
4
7
2
0
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Clinical significance can be defined in a variety of ways,
but commonly it is used to mean when a client has
moved from being in the ‘abnormal’ range to within the
‘normal’ range. For example, on the Beck Depression
Inventory a score of above 17 is taken to indicate
significant levels of depression. Thus, in the Kirsten
et al (2008) study, levels of depression were above this
cut off at intake and below at termination. As well as
being a statistically significant difference, this was also
therefore a clinically significant difference.
The researcher’s hope is always that the main influence
on the difference between the sets of scores is the
variable that differentiates the groups, such as the effect
of the treatment, with the other factors contributing
very little. However, other factors can also intervene to
cause a difference. It is for this reason that experimental
methods are used in order to try and rule out the
influence of confounding factors (Bower, in press, Dyer
& Joseph, 2006).
information sheet
About the authors
Stephen Joseph is Professor of Psychology, Health and
Social Care at the University of Nottingham.
Colin Dyer is now retired and was formally a lecturer at
North Warwickshire and Hinckley College.
Hugh Coolican is a principal lecturer at Coventry
University where he teaches on the undergraduate and
postgraduate psychology programmes.
References and further reading
Coolican, H. (2004). Research methods and statistics
in psychology (4th edition). (Chapter 11 and 10 on
descriptives and 14 on correlation) London: Hodder &
Stoughton.
Dyer, C. (2006). Research in Psychology: A practical
guide to research methods and statistics. Oxford:
Blackwell.
Conclusion
All empirical research in the social and behavioural
sciences essentially boils down to either testing
for covariation in individual differences, or testing
for differences between groups. No matter how
complicated research may look, researchers are always,
in essence, doing one or other of these two things.
Understanding this can help to make it easier to make
sense of research. Statistics are useful for helping
us to ask questions. But, no matter how statistically
significant a finding is, it must always be evaluated in
light of the quality of the design of the study.
Dyer, C., & Joseph, S. (2006). What is an RCT?
Counselling and Psychotherapy Research, 6, 264–265.
Greer, B., & Mulhern, G. (2002). Making sense of data
and statistics in psychology. Houndmills: Palgrave.
Kirsten, L.T., Grenyer, B.F.S., Wagner, R., &
Manicavasagar, V. (2008). Impact of separation anxiety
on psychotherapy outxcomes for adults with anxiety
disorders. Counselling and Psychotherapy Research, 8,
36–42.
November 2010
It should be noted that this Information Sheet offers broad guidance, which sets out professional good practice, but it should not be
substituted for legal and other professional advice, including supervision, applicable to your particular circumstances.
BACP is aware that law and practice are always in a process of development and change. If you have evidence that this Information
Sheet is now inaccurate or out of date feel free to contact us. If you know of any impending changes that affect its content we
would also be pleased to hear from you.
© BACP 2010
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information sheet
Introduction to conducting qualitative research
by Dr Rita Mintz
Aims and introduction
This information sheet provides a basic
introduction to qualitative research. It
is aimed at practitioners considering
undertaking qualitative research for
the first time and counselling students
conducting research as part of their degree
studies.
counsellor’s experience. It has been
particularly prominent in practitioner
research where the goal is to make a direct
difference to counselling practice or to
inform policy in significant ways. Examples
include Rennie’s (1990) research on client’s
representations of the therapeutic hour
and Knox, Hess, Peterson and Hill’s (1997)
work on the impact of therapists’ selfdisclosure.
The information sheet aims to:
n introduce the basic philosophical
premise and key defining features of
qualitative research
n present an overview of the main
genres in qualitative research that
are particularly relevant to therapists
n introduce readers to factors to
consider in the design of qualitative
research
n provide examples of qualitative
research and guide readers toward
further resources.
It is common for practitioners to feel
they lack the expertise, resources or
time to conduct research, and it is widely
recognised that there is a considerable
gap between counselling research
and practice. In recent years however
therapists have become increasingly
involved in research and this will inevitably
expand in the light of the forthcoming
regulation of the counselling profession.
While quantitative research has tended
to be seen as the ‘gold standard’ and is
highly valued in providing ‘hard’ scientific
evidence, there has been a steady
growth in qualitative studies in Health
and Social Sciences and an increasing
awareness of the direct contribution this
approach can make to our understanding
of human experience in many situations,
including the therapeutic encounter.
Qualitative inquiry has directly enhanced
our appreciation of the more complex
processes in therapy and has shed
valuable light on both the client’s and
Philosophical roots
Qualitative inquiry is built upon a deep
concern with understanding human
experience. Its philosophical roots can
be largely traced to reactions against
the dominant philosophy of positivism
in the late 19th and early 20th centuries.
Positivism, which has dominated the
natural sciences, maintains that the
purpose of any science is to offer causal
explanations of social, behavioural and
physical phenomena. It is characterised
by a belief in objective observation,
quantifiable data and verifiable truths and
uses a wide range of statistical methods to
achieve its aims (Maykut and Morehouse,
1994).
In contrast is the perspective that the
human sciences are fundamentally different
in nature and purpose from the natural
sciences and that their aim is to achieve
in-depth understanding of human action
and experience. Leading exponents (eg
Lincoln and Guba, 1985) have maintained
that an alternative paradigm, based on
a different set of postulates from the
positivist perspective, is needed to do
full justice to the complexity of human
experience. Qualitative research therefore
has emerged from a range of philosophical
positions such as phenomenology and
social constructionism that have been in
opposition to the positivist movement and
have challenged traditional and accepted
views of understanding the nature of ‘truth’.
BACP Information Sheets
are intended to be read in
conjunction with the BACP
Ethical Framework for Good
Practice in Counselling and
Psychotherapy.
The Information Services
ethics helpdesk team is
available to members who
wish to explore any ethical
issues concerned with their
practice.
It should be noted that this
Information Sheet offers
broad guidance, which
sets out professional good
practice, but it should not
be substituted for legal
and for other professional
advice applicable to your
particular circumstances.
© BACP, First published April 2010
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Differing philosophical positions have a direct impact
on the framing of research questions, the choice of
research methods and the criteria utilised to evaluate
the credibility of the research. Matters are further
complicated by the wide range of genres of qualitative
research, all generally falling under the umbrella of the
human science approach. Their complex philosophical
roots, along with the growing diversity and ongoing
debates within qualitative research, can be confusing to
the novice researcher. A ‘health warning’ might therefore
be in order! The reader is directed to sources such as
MayKut and Morehouse (1994), McLeod (2001), Dallos
and Vetere (2005), Creswell (2003), Lowenthal (2007),
and Willig (2007) which are accessible introductions to
this diverse and complex field.
n
n
n
n
Key defining features
Qualitative research is often defined in terms of what
it is not, ie research that does not involve statistics or
other numerical data. This does not do full justice to
the ethos of qualitative inquiry. While there are varying
traditions within this ‘broad church’, it is generally
agreed that a range of key features characterises most
(but not all) qualitative research (Dallos and Vetere,
2005; Lincoln and Guba, 1985; Maykut and Morehouse,
1994; McLeod, 2001).
n Naturalistic enquiry – Studies real world
phenomena in as unobtrusive way as possible,
maintaining a sense of openness to what may
emerge.
n An exploratory and descriptive focus – The
fundamental aim is to illuminate what things
mean to people. Researchers are interested
in investigating exploratory and descriptive
questions. The focus is not on obtaining
‘universal truths’ but on achieving a deeper
understanding of the meaning of experience from
the perspective of the participants selected for
the study.
n Contextual emphasis – Maintains that human
experience and behaviour are to be viewed in
its context and full complexity. Such contextual
understanding needs to include social, cultural,
environmental and historical factors.
n An acknowledged interpretive stance – Assumes
that understanding participants’ experience
necessarily involves a process of interpretation
on the part of the researcher. Researchers
therefore can never totally remove their values
from the research process.
n Emergent design – Design flexibility is built
into the process, allowing for methods and
procedures to be adapted in response to new
circumstances and experiences.
n Flexible sampling – The choice of participants
is guided by a range of theoretical and practical
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considerations. It is not necessary to seek a
representative sample which would normally be
required in quantitative research.
Inductive method of data analysis – Conclusions
arise from a process of immersion in the data
rather than imposing theories or categories
formulated in advance.
Reflexive stance – Recognises the self of the
researcher as an integral part of the research
process; the researcher is called upon to
disclose, within appropriate limits, his or her
perspective on the phenomenon being studied.
Gives a voice to participants – Focuses on
enabling participants’ voices to be heard.
This entails providing rich descriptions of the
phenomenon being investigated.
Empowerment as a research goal –
Acknowledges that research is not a neutral
activity and has social and political implications.
Many branches of qualitative research entail a
commitment for the research process to benefit
and empower participants as far as possible
Within the context of key defining features there is
an enormous diversity and richness in the qualitative
research tradition. While different writers characterise
this terrain in various ways, the main genres, which
seem most relevant to counselling research, are
summarised below.
Psychological phenomenology – Phenomenology
is one of the underlying philosophical traditions
underpinning qualitative research. As a research genre
it aims to achieve a comprehensive and authentic
description of the way a phenomenon is experienced
by an individual or group. The task of the researcher
is to immerse himself or herself in the material until
his or her sense of the essence of the phenomenon
being investigated becomes clear. In this process the
researcher does as much as possible to ‘bracket off’,
that is, put aside, his or her own experiences in order to
understand those of the informants. Many small scale
counselling research studies utilise phenomenological
methods (see, for example Bachelor, 1995; Worthen
and McNeill, 1996), and many approaches to qualitative
research draw heavily on the phenomenological
tradition. For further discussion see Spinelli (2005).
Grounded theory – This was developed by sociologists
Glaser and Strauss (1967) who aimed to develop a form
of research that would enable theoretical statements
to be firmly ‘grounded’ in the experience and conduct
of research informants. It aims to ‘discover’ new ways
of making sense of the social world. In contrast to
pure phenomenological research, which is generally
restricted to description rather than model building,
this approach aims to generate theory, that is, a formal
framework for understanding the phenomenon being
investigated. This is an inductive approach which
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begins with descriptive data and then subjects that
material to increasing levels of conceptualisation. There
are explicit guidelines to follow and there are many
published articles which can serve as clear examples
of its application. in counselling research (eg, Rennie,
1994; 2000). An accessible overview of grounded theory
is presented in McLeod (2003).
Heuristic inquiry – This tradition, derived from
phenomenology, was developed by Moustakas and
Douglass (1985). As with other genres of qualitative
research it involves the “search for discovery of
meaning and essence in significant human experience”
(Moustakas, 1990:11). More so than other forms of
qualitative inquiry however, the self of the researcher is
present throughout the process.
Heuristic investigation involves self search,
self dialogue and self discovery. The research
question and methodology flow out of inner
awareness, meaning and inspiration. It involves a
subjective process of reflecting, exploring, sifting
and elucidating the nature of the phenomenon
under investigation… (Moustakas, 1990: 9)
While the process can seem amorphous, Moustakas
(1990) describes six stages to guide the researcher.
Work by Etherington (2000, 2004) draws heavily on
heuristic methods and provides clear examples of this
research approach.
Discourse analysis – Discourse analysis is part of a
wider range of discursive or narrative approaches which
involve close attention to stories and conversations.
Placed within the social constructionist movement
(Dallos and Vetere, 2005) this approach is based on
the assumption that reality is largely constructed
through language and context. While various forms
of discourse analysis have been applied to therapy,
they all aim to make sense of the use of language in
therapeutic settings by providing detailed analysis
of selected segments of texts. Researchers work
mainly with transcripts of sessions, generally rely on
interpretive analysis and tend to generate research
reports structured around passages of discourse quoted
from informants. It is common to present findings
through an in-depth analysis of a single case (McLeod,
2003). Useful examples include research by Madil
and Barkham (1997) focusing on the discourse in one
successful case of brief psychodynamic-interpersonal
psychotherapy and Taylor and Loewenthal’s study
(2001) of a client’s experience of preconceptions of
therapy. Further discussion on this approach can be
found in McLeod (2001) and Potter (1997).
Case studies – This involves a focus on a single
case (person, group, setting, etc) or a series of
cases to provide an in-depth and holistic analysis of
a phenomenon characterised by the participant(s)
86
concerned. Case studies normally entail a range of
data collection methods which might include recording
therapy sessions, simulated recall of sessions,
interviews, diaries, journals and questionnaires. This
form of research is highly relevant to counselling
practitioners and builds upon the intensive case
study that is normally a part of counsellor training. An
example of a systematic case study is the investigation
by Etherington (2000) into the experiences of two
male clients who were sexually abused. For further
discussion see Yin (2009).
Designing a qualitative study
All research involves making a series of decisions
regarding the research methods to be used. It is
important to recognise that there is no perfect research
design – each has its strengths and limitations.
It is beyond the scope of this document to examine
specifically the methods derived from the various genres
highlighted above. Instead, a broad generic process
relevant to qualitative research is summarised below.
Deciding on a focus of inquiry: What is the research
question?
This is a key challenge in any form of research.
Qualitative research tends to be based around openended discovery oriented questions (eg What are
young peoples’ perceptions of counselling?). There is
a delicate balance between keeping the question open
enough to allow for the discovery that is inherent in
qualitative research and being specific enough to ensure
a manageable focus. Many questions can emerge
directly from the practice of therapy or the counsellor’s
curiosity about “burning issues”.
Sampling: How will participants be selected?
There are two broad kinds of sampling techniques that
are used by social researchers: probability sampling
and non-probability sampling. In probability sampling
people or events are chosen on the basis of being
representative of a cross section of people or events in
the whole population being studied. This is used in the
positivist paradigm where there are large samples and
the aim is to generalise from the sample to the wider
population.
Non-probability sampling, which is generally used in
qualitative inquiry, does not aim to achieve a random
selection of participants from which generalisations
can be made. Instead the goal is to acquire deep
understanding of some phenomenon experienced by a
carefully selected group of people. A widely used form
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of non-probability sampling is purposive sampling.
As the term suggests the sample is selected with
a particular purpose in mind – selecting persons or
settings who represent the range of experience on the
phenomenon being investigated. Specific criteria for
the sample are established and made transparent in the
research report.
Another main form of sampling, used in grounded
theory studies, is theoretical sampling. Individuals or
groups are selected according to their potential to
lend new insights to the developing theory. The main
question for ongoing sample selection is: “What groups
or sub-groups does one turn to next in data collection?
And for what theoretical purpose?” (Glaser and Strauss,
1967). Sampling stops when the point of ‘theoretical
saturation’ has been reached. In other words nothing
new emerges any more.
Sample sizes are relatively small in qualitative research
and generally range from approximately eight to thirty,
depending upon the nature and scope of the study.
Some qualitative studies, particularly when using
questionnaires, involve larger samples.
Data collection: What is the most appropriate way to
collect data?
Another key decision involves what means of data
collection to utilise. This needs to be consistent with the
aims and nature of the investigation. Main means of data
collection in qualitative research are highlighted below.
nInterviews – The most widely used method of
collecting qualitative data and can be seen on a
continuum ranging from an unstructured format
to a relatively structured one.
n Unstructured interview – This generally begins
with one main question or theme and relies on
a spontaneous generation of questions and
conversation in which participants engage in a
natural unfolding dialogue with the investigator.
This provides the greatest scope to explore the
informant’s unique perception of their experience.
It may however result in data that is difficult to
organise, and the relative lack of structure can
be particularly challenging for the inexperienced
researcher.
n Semi-structured interview – This consists of
a series of topics or broad interview questions
which the researcher is free to explore and probe
within the interview. The order of covering the
topics or asking the questions is likely to vary
with different interviews, but common information
is sought from all participants. The semistructured interview provides a broad framework
for the researcher, while being sufficiently flexible
to follow up particular areas.
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n Structured interview – This includes a detailed
set of questions and probes which are normally
followed in a specified order. This allows for
more standardised data but provides less scope
for exploring the unique perspectives of the
participants. Very highly structured interviews are
not commonly used qualitative research.
Therapists inevitably bring valuable counselling skills
to interviewing. Dallos and Vetere (2005) remind
us however that applying clinical skills to research
interviewing is paradoxically both helpful and
problematic, and practitioners need to be very mindful
of the boundaries between counselling and research.
In most studies interviews are recorded and transcribed
verbatim in preparation for the analysis of the data.
n Focus groups – This involves a small number
of people who are brought together on one or
more occasions to explore attitudes, perceptions,
feelings and ideas about a specific topic.
Emphasis is placed on group interaction as a
means of eliciting perspectives. Decisions need
to be made regarding the composition of the
group. Discussions usually last for approximately
two hours, and groups of about six to ten
participants are manageable.
Facilitating focus groups is a skilled task drawing
heavily on one’s experience of understanding
and managing group processes. The researcher
needs to facilitate the group, observe the process
and possibly take notes. The group interaction
can result in a richness of data but the material
can be more difficult to organise than that
collected from interviews. Focus groups are
normally recorded for subsequent transcription.
n Open–ended questionnaires – This provides
the opportunity for participants to respond
anonymously to a series of open questions in a
written questionnaire. The questionnaires can
also include vignettes or various dilemmas to
respond to. Because of their anonymity they
can be particularly useful for sensitive areas of
inquiry. A larger number of participants can be
covered than in interviews and the method is
relatively unobtrusive. Questionnaires however do
not provide scope for probing as in face to face
methods and therefore important areas could be
missed.
n Documentary data – In addition to methods
which entail responding to questions posed by
the researcher, another form of data collection
involves material which has been created
previously by research participants. Examples
of personal documents include letters, diaries,
personal journals, poetry or other creative
material. These might be used as the main
source of data or to supplement other forms of
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data collection such as interviews. In addition
to spontaneously produced material research
participants may also be asked to keep a journal
or diary or some other form of reflective account
related to the research topic. Some forms of
research include the use of official documents.
n
Data analysis: How can I make sense of the data?
The qualitative researcher often amasses a large amount
of data and is confronted with the task of making
sense of that data and putting them into a meaningful
format that captures the meaning, as interpreted, of
the phenomenon being investigated. The self of the
researcher is integrally involved in the process. Unlike
quantitative research, most qualitative approaches
do not lend themselves to step by step procedures to
be exactly followed. There are however a wide range
of rigorous data analysis methods to draw upon, eg
consensual qualitative analysis (Hill, Thompson and
Nutt – Williams, 1997), interpretative phenomenological
analysis (Smith, Jarman and Osborne, 1999) and the
constant comparative method (Maykut and Morehouse,
1994). To a certain extent, as suggested by Denzin and
Lincoln (2000), the method emerges in response to the
nature and focus of the particular research question,
and they highlight the need for flexibility and creativity.
It is beyond the scope of this information sheet to
examine the wide range of data analysis methods
available to the qualitative researcher. What is presented
is a broad generic description of fundamental processes
that are involved, to a greater or lesser degree, in the
analysis of most qualitative data. For further discussion
see McLeod (2001, 2003), Maykut and Morehouse
(1994), Lincoln and Guba (1985), Moustakas (1990), and
Polkinghorne (1991).
Qualitative data analysis is cyclical in nature and entails
a process of initially deconstructing the data and then
reconstituting them into some meaningful whole. Key
processes, which are not intended to be discrete, can
be summarised as follows:
nImmersion – “The first step in any qualitative
data analysis is to become immersed in
the information collected. As suggested by
McLeod, J. (2003:.85) “the main instrument
that researchers possesses is their capacity to
enter in an empathic way the lived experience
of the person or group being studied.” The
researcher intensively reads or listens to material,
assimilating as much of the explicit and implicit
meaning as possible. This gives a feel for the
data as a whole
n Segmenting the text into discrete meaning
units – While it is vital to develop a sense of
meaning of the text as a whole, one of the key
tasks in qualitative research is to find ways of
88
n
n
n
breaking down the flow of text (the descriptions,
accounts or stories that participants share) into
its component meanings. The aim is to apply
a systematic method of segmenting the text,
of dividing it into workable bits, to enable the
properties and meanings to be closely examined.
Labelling, coding and categorising meanings –
Once the researcher has segmented the text into
some kind of ‘meaning units, he or she needs to
make sense of what these units might actually
mean, as all qualitative research involves one form
or another of attributing meaning to segments of
text. This is a rigorous and painstaking process,
but the researcher also needs to be as “playful,
imaginative, creative and sensitive as they can in
generating all the possible meanings implicit in
segments of text.” (McLeod, 2001:144).
Sifting and ordering: conceptualising themes
and patterns – This involves beginning to bring
some order to the mass of meaning units.
Different research traditions utilise different
means to accomplish this. Whatever approach
is used the aim is to inductively derive the main
themes and patterns that emerge from the data.
This is likely to involve an initial categorisation
followed by a refinement of themes and patterns.
Exploration of relationships across themes and
patterns – The focus of this stage is to examine
the various themes that have emerged and to
explore relationships that may exist between
them. It is about ordering them in a way that
most accurately reflects the richness of the data
obtained.
Writing up the research – Writing up qualitative
research usually involves a rich narrative by the
researcher as well as including as much verbal
material as appropriate from the participants. How
the findings are written up will revolve around the
way the analysis has been conducted and may
entail constructing a model or using an established
theory to explicate the findings. As suggested
by McLeod (2001: 146) qualitative researchers
struggle with what has been called the “crisis of
representation – the challenge of conveying on
paper both the richness of understanding what the
researcher has developed and the various ‘voices’
of informants.”
A number of software packages have been developed to
assist in the analysis of qualitative data. See, for example,
Lewis and Silver (2007) for an accessible guide to
Computer Assisted Qualitative Data Analysis (CAQDAS).
Trustworthiness: How will the quality of the research
be judged?
With any research there is always the question of how
one can judge its credibility, and there are many factors
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that span both quantitative and qualitative approaches.
Validity however is the concept traditionally employed in
the positivist approach, while the term trustworthiness
generally refers to criteria to evaluate the soundness
of qualitative research. Trustworthiness is a complex
concept which is used somewhat differently by various
writers, but examples of some of the key issues that
need to be addressed include:
n
n Describing the context of the study – This
should include the researcher’s initial perspective
on the research topic and also the social and
institutional environment in which the research
took place.
n Providing a clear and comprehensive
description of research procedures – All
methods used in the research should be clearly
documented to provide a basis for others to
judge how well the study was conducted.
n Building an audit trail – Readers need to be
shown how the researcher moved from the raw
data through the various phases of data analysis
to arrive at findings and conclusions.
n Using member checks – This refers to the
process of asking interview participants to
provide feedback on whether the researcher has
accurately represented their experience.
n Researcher reflexivity – As the main tool in
qualitative research is the self of the researcher,
a reflexive account of key aspects of the
researcher’s process can contribute to the
credibility of the study.
n
n
n
n
For further discussion on the trustworthiness of
qualitative research see Elliott, Fischer and Rennie
(1999), Morrow (2005) and Stiles (1993).
n
Ethical considerations: How can ethical standards be
ensured?
Ethical considerations permeate all aspects of the
research process, from the formulation of the research
question through to the dissemination of the findings.
The complexities surrounding the ethical conduct of
counselling research have been well documented (eg
Bond, 2004; McLeod, 2001) and inevitably involve
the sensitive balancing of potential tensions. The
principles that underpin the BACP Ethical Framework
are directly applicable to the research process, and
the BACP document Researching in Counselling and
Psychotherapy (Bond, 2004) further encapsulates
ethical research principles. The principles apply to all
research traditions, but certain aspects are brought into
particular focus in qualitative inquiries.
n Relationship with research participants
– Qualitative research inevitably involves
developing a trusting relationship with the
© BACP 2010
information sheet
informants and providing a climate that will
enable the individual to openly share meaningful
aspects of their experience. The investigator
needs to be mindful however of potential
tensions between counselling and research.
Attention to boundary issues is particularly
imperative when conducting research involving
previous clients
Informed consent – Participants need to be fully
informed about research procedures, including
any possible risks involved
The safety of participants – By the very nature of
qualitative research painful material may emerge,
and it is the responsibility of the researcher to do
everything possible to ensure participant safety.
This not only entails the fundamental principle
of informed consent but also involves care and
attention to the ethical dimensions of the design
of the study. These principles are well illustrated
in a study by Ashton (2006) on the experiences
of bereaved mothers. For further relevant
considerations see Bond (2004) & BACP Ethical
Framework (2010).
Right to withdraw – The researcher should
ensure that participants feel free to cease their
participation at any time without fear of reprisals.
Anonymity of research participants – In
qualitative research which relies on detailed
descriptive accounts provided by participants,
particular care needs to be taken to avoid
unwittingly revealing the identity of the informant.
The researcher’s responsibility to self – As
qualitative research directly involves the self
of the researcher careful consideration needs
to be given to the personal challenges and
vulnerabilities involved in conducting the research
Appropriate consultation/supervision – It
is evident that researchers need access to
appropriate consultation/supervision during the
research process. They will need opportunities
to explore the many intricacies of the research
process, to grapple with the many decisions that
will need to be made and to make sense of the
way the research may be impacting upon their
participants and themselves.
Concluding note
Approaching any kind of research can seem formidable
to those new to this endeavour. It admittedly involves a
range of challenges along with many potential personal
and professional rewards. For many individuals the first
tentative step involves building up the confidence to
engage in a process that might initially seem daunting
to them. A number of writers remind us however that
many facets of the therapist’s skills and ways of being
are directly transferable to the qualitative research
tradition. It is hoped that this information sheet (which
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has only ‘scratched the surface’ of a huge topic) has
provided some initial guidance to those who might be
considering taking that first step.
Researcher: Using Ourselves in Research. London:
Jessica Kingsley.
Glaser, B.J. & Strauss, A. (1967). The Discovery of
Grounded Theory. Chicago: Aldine.
About the author
Rita Mintz is a Senior Lecturer in Counselling at the
University of Chester and a BACP Senior Accredited
Practitioner. She is the Programme Leader for the M.A.
in Counselling Studies and has devised and currently
delivers the Research Methods Module for M.A.
students. She has supervised numerous dissertations,
including many innovative qualitative studies. Research
for her Ph.D. utilised qualitative methodology.
Guba, E.G. & Lincoln, Y.S. (1981). Effective Evaluation:
Improving the Usefulness of Evaluation Results
Through Responsive and Naturalistic Approaches.
San Francisco: Jossey-Bass.
Hill, C.E., Thompson, B.J. & Nutt-Williams, E. (1997).
A guide to conducting consensual qualitative research.
Counselling Psychologist, 25, 517–72.
Lewis, A. & Silver, C. (2007). Using Software in
Qualitative Research. London: Sage.
References
Ashton, G. (2006). A Child’s Death: A Heuristic
Exploration of a Mother’s Grief. Unpublished
Dissertation. University of Chester.
BACP (2010). Ethical Framework for Good Practice in
Counselling and Psychotherapy. Lutterworth: BACP.
Lincoln, Y.S. & Guba, E.G. (1985). Naturalistic Enquiry.
London: Sage.
*Lowenthal, D. (2007).Case Studies in Relational
Research: Qualitative Research Methods in Counselling
and Psychotherapy. Basingstoke: Palgrave.
Bachelor, A. (1995). Clients’ perceptions of the
therapeutic alliance: a qualitative analysis. Journal of
Counselling Psychology, 42, 323–37.
Madil, A, & Barkham, M. (1997). Discourse analysis of a
theme in one successful case of brief psychodynamicinterpersonal psychodynamic psychotherapy. Journal of
Counselling Psychology, 44, 232–44.
*Bond, T. (2004). Ethical Guidelines for Researching
Counselling and Psychotherapy. Rugby: BACP.
*Maykut, P. & Morehouse, R. (1994). Beginning
Qualitative Research. London: Falmer Press.
Creswell, J. (2003). Research Design: Qualitative and
Quantitative Approaches. London: Sage.
*McLeod, J. (2003). Doing Counselling Research.
Second Edition. London: Sage.
*Dallos, R. & Vetere, R. (2005). Researching
Psychotherapy and Counselling. Maidenhead: Open
University Press.
*McLeod, J. (2001). Qualitative Research in Counselling
and Psychotherapy. London: Sage.
*Denscombe, M. (2007). The Good Research Guide
for Small Scale Research Projects (3rd edition).
Maidenhead: Open University Press.
*McLeod, J. (2003). Qualitative Research Methods in
Counselling Psychology. In Handbook of Counselling
Psychology. Wolfe, R., Dryden, W. & Strawbridge, S.
(Eds). (pp.74–92). London: Sage.
Denzin, N.K. & Lincoln, Y.S. (Eds.). (2000). Handbook of
Qualitative Research (2nd edition). Thousand Oaks, CA:
Sage.
Morrow, S.L. (2005). Quality and trustworthiness in
qualitative research in counselling psychology. Journal
of Counselling Psychology, 52, 250–260.
Elliot, R, Fischer, C.T. and Rennie, D.L. (1999). Evolving
guidelines for the publication of qualitative research
studies in psychology and related fields. British Journal
of Clinical Psychology, 38, 215–229.
Moustakas, C. (1990). Heuristic Research: Design,
Methodology and Applications. London: Sage.
Etherington, K. (2000). Narrative Approaches to Working
with Adult Male Survivors of Child Sexual Abuse: The
Client’s, the Counsellor’s and the Researcher’s Story.
London: Jessica Kingsley.
*Etherington, K. (2004). Becoming a Reflexive
90
Moustakas, C. & Douglass, B.G. (1985). Heuristic
enquiry: the internal search to know. Journal of
Humanistic Psychology, 25 (3), 39–55.
Knox, S., Hess, S., Pederson, D. & Hill, C. (1997). A
qualitative analysis of client perceptions of the effects
of helpful therapist self-disclosure in long term therapy.
Journal of Counseling Psychology, 44 (3), 274–383.
Anthology of research information sheets – 2nd edition
© BACP 2010
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Polkinghorne, D.E. (1991). Qualitative procedures for
counselling research, In C. Watkins and L Schneider
(Eds). Research in Counselling. Hillsdale, N.J.: Lawrence
Erlbaum, 163–204.
Potter, J. (1997). Discourse Analysis as a Way of
Analyzing Naturally Occuring Talk. In D. Silverman (Ed).
Qualitative Research: Theory, Method and Practice.
London: Sage.
Rennie, D.L. (1994). Storytelling in psychotherapy:
the client’s subjective experience. Psychotherapy, 41,
234–43
Rennie, D. (1990). Towards a Representation of the
Client’s Experience of the Psychotherapy Hour. In
G. Lietaer, J. Rombauts & R. Van Balen (ed). Client
Centred and Experiential Psychotherapy in the Nineties
(p.155–172). Leuven: Leuven University Press.
Rennie, D.L. (2000). Experiencing Psychotherapy:
Grounded Theory Studies. in D. Cain and J.
Seeman (Eds.) Handbook of Research in Humanistic
Psychotherapies. Washington: American Psychological
Association.
Silverman, D. (1997). Discourses of Counselling. HIV
Counselling as Social Interaction. London: Sage.
Smith, J., Jarman, M. & Osborne, M. (1999). Doing
Interpretative Phenomenological Analysis. in Murray
M. and Chamberlain, K. (Eds) Qualitative Health
Psychology. London: Sage.
Spinelli, E. (2005). The Interpreted World. London: Sage.
Stiles, W.B. (1993). Quality control in qualitative
research. Clinical Psychology Review, 13, 593–618.
information sheet
Taylor, M. & Lowenthal, D. (2001). Researching a
client’s experience of preconceptions of therapy.
Psychodynamic Counselling, 7 (1), 63–82.
Willig, C. (2008). Introducing Qualitative Research
in Psychology: Adventures in Theory and Method.
Maidenhead: Open University Press.
Worthen, V. & McNeill, B.W. (1996). A phenomenological
investigation of ‘good’ supervision events. Journal of
Counselling Psychology, 43, 25–34.
Yin, R. (2009). Case Study Research: Design and
Methods (4th ed). London: Sage
The above starred references (*) provide a helpful broad
introduction to qualitative research.
Useful journals
British Journal of Guidance and Counselling
Counselling and Psychotherapy Research
Journal of Counselling Psychology
Journal of Humanistic Psychology
Psychology and Psychotherapy: Theory, Research
and Practice
Psychotherapy Research
Qualitative Health Research
Qualitative Inquiry
Qualitative Research Journal
Useful databases
Assia
PsycINFO
PubMed
SocINDEX
Web of Science
First published April 2010
It should be noted that this Information Sheet offers broad guidance, which sets out professional good practice, but it should not be
substituted for legal and other professional advice, including supervision, applicable to your particular circumstances.
BACP is aware that law and practice are always in a process of development and change. If you have evidence that this Information
Sheet is now inaccurate or out of date feel free to contact us. If you know of any impending changes that affect its content we
would also be pleased to hear from you.
© BACP 2010
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information sheet
How to design and conduct research interviews
by Sheila Spong
Introduction
The aim of this Information Sheet is to
help counselling and psychotherapy1
practitioners and students to develop
sound research interviewing skills. The
sheet:
n introduces the uses of research
interviewing
n explains different styles of research
interview
n identifies relevant ethical issues
Interviewing is a research method which
can be used within different broad
research approaches. This Information
Sheet focuses primarily on using interviews
to collect qualitative (non-numerical) data.
Designing an interview-based project
Choosing to use interviews
Before making a decision about which
research method to use, be clear what the
research is intended to find out. Develop
a precise research question that the
particular study is meant to answer, and
then decide whether interviewing is the
best way of collecting the data needed to
answer it before planning the interviews.
Interviews are particularly useful for
exploring new topic areas and for
collecting in-depth information from
individuals or groups. They may also
facilitate participants in exploring their
own experiences and stories, and may be
effective in exploring difficult or sensitive
topics through the building of a trusting,
empathic relationship in one or more
meetings.
In this Information Sheet the terms
“therapy” and “counselling and
psychotherapy” are used interchangeably.
1
Interviews are less suitable for collecting
data from large samples of participants or
for collecting answers to simple, factual,
or closed questions: in these situations
a survey may be more appropriate and
less time consuming. Interview data is not
usually suitable for providing evidence
that one thing causes another: a trial or
other form of quantitative study may be
more appropriate (Joseph, Dyer et al.
2009).
Advantages of using interviews to
collect data:
n Interviews can collect a variety of
data, including very rich in-depth
material
n There is an opportunity to develop a
real rapport with the participants
n Interviews can be enjoyable,
rewarding and empowering for
interviewer and participants
n In unstructured and semi-structured
interviews (see below) the interview
can follow the participants’ interests
rather than staying with the
researcher’s preconceived ideas
about the topic
n The researcher can gradually
develop an understanding of the
research topic
n The researcher can use prompts
and explanations to clarify and
extend the questions
n Participants often find it satisfying
and even therapeutic to discuss
their views and experiences in depth
Disadvantages of using interviews to
collect data:
n Interviews are time consuming at all
stages – making the arrangements,
interviewing, transcribing the
interviews, analysing and reporting
the data. Generally only a limited
number of interviews can be carried
out because of the time needed
BACP Information Sheets
are intended to be read in
conjunction with the BACP
Ethical Framework for Good
Practice in Counselling and
Psychotherapy.
The Information Services
ethics helpdesk team is
available to members who
wish to explore any ethical
issues concerned with their
practice.
It should be noted that this
Information Sheet offers
broad guidance, which
sets out professional good
practice, but it should not
be substituted for legal
and for other professional
advice applicable to your
particular circumstances.
© BACP, First published February 2011
R16
n Interviewing demands a substantial commitment
from interviewer and participants
n Participants may become upset during or after
discussing emotionally significant material.
The researcher has an ethical responsibility to
minimise the risk of any such distress and to
provide a recourse to alleviate it if required (Bond,
2004 p8).This could involve giving information on,
or referral to, an appropriate source of help
n In unstructured and semi-structured interviews
(see below) the direction of the discussion is
unpredictable so it may be harder to collect prespecified information. Where different questions
are asked of different participants, it is more
difficult to make comparisons between interviews
n Participants may lack the language skills to
describe subtle experiences
n Participants and interviewers risk confusion about
appropriate boundaries for the research project. In
particular, the boundaries between research and
therapy could become unclear for participants
who are in therapy. It is the responsibility of the
researcher to maintain these boundaries in the
interests of the client (Bond 2004).
Checklist: questions to consider when choosing
interviews to collect data for a project
n Has the aim of the research been clearly
defined, with a research question or precise
topic specified?
n How will appropriate respondents be identified?
Will they be willing and able to participate?
n Will the participants have the knowledge to help
answer the research question?
n Are the resources available for interviewing,
recording, transcribing and analysis?
n What ethical issues are involved? How can any
adverse impact on participants be minimised?
n Can the information be collected better in some
other way?
Different types of interview
The decisions about the type of interview to undertake
will depend on the data needed, the potential participants
and the context in which the interviews take place.
information sheet
questions in the same way, so the answers can readily
be compared. It has some of the characteristics of a
questionnaire in that the researcher determines the
precise questions in advance.
Semi-structured interviews consist of a series of broad
open questions, each of which can be followed-up
with a number of prompts or additional questions.
This format ensures that the interview covers all the
topics that are important to the research, but also
permits unanticipated information to emerge and allows
participants to expand on issues that are of particular
significance to them.
Unstructured interviews are more like a conversation
about a broad area of interest. The researcher may have
no pre-planned questions or just one or two, and will
follow the lead of the participant about the development
of the interview. Taking part in an unstructured interview
may leave the participant feeling empowered, as it
allows his or her own story to be heard. Narrative
interviewing is one type of research which often uses
this type of format as it focuses on the participant telling
her or his own story (Speedy 2008).
On the whole, highly structured interviews are more
suited to obtaining data which can be easily converted
into numerical form, whilst semi-structured and
unstructured interviews provide the opportunity to
obtain in-depth qualitative (non-numerical) data. An
interview may include some highly structured questions
and other questions which are less structured.
Individual and group interviews
In group interviews or focus groups participants interact
with each other and develop their ideas in discussion.
They are particularly suitable for seeing the arguments
and counter-arguments that are raised in a conversation
or for observing the impact of group dynamics.
Interviewing groups of participants saves time in one
way but is more complex to organise and more difficult
to transcribe than individual interviews. For more
detailed information on managing group interviews
see, for example, Bloor et al (2001), Litosselti (2003) or
Puchta (2003).
Mode of interview
Structured, semi-structured and unstructured
interviews
Structured, or survey-type interviews have a clear series
of questions, often closed, which the interviewer keeps
to without deviating. Many market research interviews
are like this. The advantage of this type of interview
is that it ensures each participant is asked the same
© BACP 2011
Interviews can be carried out face-to-face, by
telephone, video link, email or using internet chat
room facilities (Mann and Stewart 2000). The use of
newer technologies allows researchers to access
people who are otherwise difficult to reach, but
also may exclude some potential participants.
The researcher may have less information about
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who is responding (Bond 2004) and some types
of technologically assisted interviews may involve
the loss of non-verbal information. The researcher
will need to be confident that the technology
used is reliable and is sufficiently secure to
ensure confidentiality. Researchers considering
technologically assisted interviews should refer to the
specialist literature for more information (for example
Mann and Stewart 2000; O’Connor, Madge et al.
2008)
The type of research approach
An interview is a research method which can be used
within different broad research approaches (Sarantakos
2005). Some types of interviews are intended to
objectively gather knowledge from participants. In this
case the interviewer aims to be a neutral presence
taking part in a broadly scientific activity. Other, more
recently-developed approaches to research interviewing
acknowledge the impact the researcher has on what
the participant says, by focussing on the ways in
which the interviewer and interviewee work together to
co-construct the story that is told (Fontana and Frey
2008).
See Information Sheet R (Mintz, date) for information on
sampling in qualitative research.
There are particular difficulties involved with interviewing
clients as research undertaken during therapy may
impact on the work with the client in ways that
cannot be fully anticipated. For example, clients may
become anxious knowing that what they say may be
published, even though their anonymity is assured.
Interviewing clients should always be considered
carefully with reference to the BACP Ethical Guidelines
for Researching Counselling and Psychotherapy (Bond
2004) and the BACP Ethical Framework for Good
Practice in Counselling and Psychotherapy (BACP 2010)
and discussed with an experienced research supervisor
or mentor.
Interviewing one’s own clients should always be
approached with very considerable caution as there is
risk that both the research and the therapy could be
compromised by the dual relationship. This is discussed
below in the section on Ethical issues in therapy
research interviews. For more information see Bond
(2004).
How to find participants
Whatever research approach is adopted, it is important
that the researcher is respectful of the experience and
knowledge shared by the participant, without judging its
truth status.
Checklist: choosing the type of interview to use
n Structured/ semi-structured/ unstructured
n Individual/ group
nMode
n Type of research approach
People are most likely to agree to take part in interviews
if they are particularly interested in the topic, if it is
easy for them or if they have personal contact with the
researcher. It may be acceptable to offer expenses or a
small fee.
Recruiting through personal contacts can be
problematic as the personal relationship may influence
the participant’s responses in unexpected ways. It
is particularly important to be cautious not to overgeneralise from a personal contact sample.
Deciding who to interview
The number of interviews
In deciding who to interview, the researcher needs to
consider the following:
There are no simple guidelines for deciding how many
interviews to undertake, or how long each should last.
Some narrative research or case study research may
involve only one or a very small number of participants
who may be interviewed once or several times. A more
traditional qualitative research study would usually
include at least six participants but the actual number
is determined by the needs of the project and by the
constraints of time and availability.
n Who are the most appropriate people to
interview?
n How can they be contacted?
n How many interviews will be needed?
Choosing who to interview
Typical interviewees for research into therapy are clients,
therapists, other professionals and the general public.
All researchers need to state how they chose their
participants and to provide a rationale for this decision.
94
The researcher must be careful not to claim more for
the research findings than is warranted whatever the
number of interviews undertaken, and should be very
cautious about generalising from a small number of
interviews to a wider population.
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Planning an interview
Step 4: finish the interview schedule
Once a clear research question has been defined, and
the type of interview chosen, it is necessary to plan
an interview schedule or interview guide. This involves
writing a series of interview questions. The interview
questions need to be carefully worded to avoid any
ambiguity or bias and it is good practice for the draft
questions to be checked by a third party to ensure that
this is achieved.
The amount of detail needed in the interview schedule
will depend on the degree of structure chosen. The
example below shows one approach to developing
a schedule for a semi-structured interview, but this
can be adapted according to the degree of structure
required.
Example: creating a schedule for a semi-structured
interview
Step 1: create the interview questions
i. Choose the broad topic area.
ii. Narrow this down to a particular research
question that this project is intended to answer,
or a specific topic to be explored.
iii. Create a number of interview questions (usually
open questions) which will encourage the
participants to talk about different aspects of
the research question.
iv. Develop a number of follow-up questions and/
or prompts for each interview question, to
encourage the participant to say more, explore
ideas further or give examples. These can be
used as and when they are needed.
Step 2: put the questions in order
i. Usually start with more general questions and
move on to more specific questions.
ii. Usually start with less personal or controversial
questions to help build a research alliance.
iii. Make sure that the questions are in an order
that will make sense to the research participant.
Step 3: check each question
i. Is it open or closed?
ii. Is it leading (i.e. does it suggest one answer is
more desirable/likely than another)?
iii. Is it ambiguous?
iv. Is it too complex?
v. Is it likely that the participant will be able to give
a meaningful answer?
vi. Is it intrusive?
vii. Is it respectful?
viii.Will the response help to answer the research
question/ illuminate the research topic?
© BACP 2011
information sheet
i. Ask a third party to check the questions and the
way they fit together into the interview schedule
ii. At the beginning add a reminder to ensure that
participants have adequate information about
the interview process and the research project,
including ethical information such as the right
not to answer any of the questions (see the
section on research ethics, below).
iii. Add any questions about relevant demographic
data (usually at the end). This might include, for
example, gender, age, therapy orientation.
iv. Add a reminder to debrief and thank the
participant at the end.
v. Add a reminder to give any additional information
participants should know at the outset: the right
to withdraw, who to contact if the interview has
caused them any distress, whether there will be
any further contact from the researcher, how to
access the findings if they wish
vi. Add a reminder to offer to answer any questions
about the research.
vii. Prepare an easy-to-read copy of the schedule
to use in the interview.
viii.Pilot (try out) the schedule.
Piloting the interview schedule
It is advisable to pilot an interview schedule before using
it with the actual research participants. This means
trying it out with one or more people who are not going
to be participants in the research project but who are as
similar as possible to those who will be taking part in the
project. Piloting the schedule enables the researcher to
check how well the format works to address the research
question, whether the questions are unambiguous,
and approximately how long it takes. It also gives the
interviewer practice in the interview process, including
managing any technology. It is useful to record and
transcribe pilot interviews (with the pilot participants’
written consent) because this may help identify any
problems.
After one or more pilot interviews, improvements to
the schedule can be made, which may include adding,
deleting or changing some of the questions. If these
changes are major, another round of pilot interviews will
be useful to check out the revised schedule.
It may be possible to include data from any pilot
interviews in the study if they are relevant and if full
consent for this has been obtained (Holloway 1997).
Before the interview
Before any interviewing is carried out or potential
participants are approached, it is essential to get ethical
approval from any organisations involved, See Bond
(2004) for more detail on this topic.
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Ethical research requires informed consent from
participants (Bond 2004). To ensure consent is properly
informed, the researcher should provide concise written
information about the study when approaching potential
participants. Before the interview takes place the
participant will normally be asked to complete a consent
form as evidence of their consent to take part in the
study. Participants need to be informed that they can
withdraw their consent at any time up to publication,
and that if they do so, their data will not be used in
the study. See Bond (2004) for further guidance on
participant information and consent.
In arranging the interviews the researcher may have to
be flexible about times and venues as he or she will need
to fit in with the availability of the participants. The need
for a quiet and private environment should be taken into
account, particularly if the interview is to be recorded.
The interviewer also needs to pay attention to their
personal safety when making interview arrangements.
In selecting an interview venue the researcher should
bear in mind the meaning that participants may attach
to particular places. For example, a counselling client
may find it convenient to be interviewed in the premises
where they receive therapy but in this location he or she
may find it more difficult to be critical of their therapist.
Conducting the interview
It is reassuring to the participants if the researcher is
organised and ready. If the interview is being recorded
(audio and/or video) the equipment needs to be simple
and reliable. Participants should be reminded that they
will be recorded and the equipment indicated. A brief
technical check is advisable to ensure that the sound and/
or light levels are adequate, if this is not too disruptive.
Recording and transcribing
It is usual to record and transcribe (make a word-forword written record of) research interviews to ensure
that participants’ words and meanings are gathered
as precisely and accurately as possible. There are,
however, situations where this is not feasible, particularly
with participants who are reluctant to be recorded. A
decision to use a research method where interviews are
not recorded needs to be discussed carefully with an
experienced research mentor or critical friend who has
relevant experience, as relying on note taking or memory
will lead to a substantial loss or distortion of data.
There are a wide variety of recording devices available
including digital recorders which usually provide a good
sound quality. Sound files from these can be downloaded
on a computer and played back using various software
packages, some of which are available cost-free from the
96
internet (see, for example, Express Scribe (NCH 2010). It
is important to consider how the data is to be stored and
ensure interviewees are aware of this.
Checklist: choosing how to record the interviews
Is recording feasible?
n If not, how can the interview be accurately
captured?
Audio recording only?
n Simple, cheap and unobtrusive
Video recording required?
n Useful in a group interview to identify who is
speaking
n Essential if intending to analyse non-verbal
communication
n May be more inhibiting for participants
n Requires additional caution to ensure
confidentiality is maintained
Sound quality
n Check the sound quality is adequate for the
environment
n Group interviews usually require higher
quality recording equipment and/or extension
microphones
Playback of recording
n Digital devices are conveniently compatible
with computers for down-loading sound files for
storage and playback
Checklist: choosing how to transcribe the
interviews
What level of detail is needed for the type of
analysis intended?
n For most purposes it will be sufficient to create
an accurate transcript of the words spoken,
with an indication of pauses and of other
significant sounds
n For some types of analysis either more or less
detail may be needed. For example discourse
analysis and conversation analysis require more
precise transcription (McLeod 2001)
n It is often useful to make notes during
transcription as a reminder of nuances or
interpretations which present themselves during
this extensive period of immersion the data
Transcription symbols
n For projects requiring detailed transcripts, the
use of a recognised set of transcript symbols
such as the Jefferson system (Jefferson 1984) is
recommended
Who should transcribe?
n For small-scale projects, it is an advantage for
the researcher to transcribe his or her own data
as it ensures a real familiarity with the material.
Making notes or keeping a research diary during
transcription can help generate the first stages
of analysis.
n Transcribing can be very time-consuming so
employing an audio-typist may save a great
deal of time
Anthology of research information sheets – 2nd edition
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information sheet
Working with the interview material
Dual roles
Analysis
Any situation where the interviewer is in another
relationship with the participant – whether this is a
professional or personal relationship – is likely to impact
on the findings of the study. Dual relationships may
result in:
Once the interview material has been transcribed, it
needs to be analysed. There are many well-developed
approaches to analysing interview data. It is essential to
use some coherent and rigorous system of analysis and
to ensure that the type of analysis chosen is consistent
with the overall research approach. See Information
Sheet R14 (Mintz, 2010) for further information on
qualitative analysis, and Information Sheet R13 (Joseph
et al 2009) for information on statistical analysis.
Validity or trustworthiness
Although the process of analysis varies between types
of research it is always essential to pay attention to
issues of validity (Elliott, Fischer et al. 1999; McLeod
2001 pp181–189; Dallos and Vetere 2005 ch 10).
Essentially, interview research is valid if the findings
reported by the researcher are meaningfully related
to what the interviewees have said. Two important
approaches to ensuring the validity of interview research
are transparency and member checking.
Transparency in this context involves the researcher
explaining clearly what she or he has done and
the reasons for the decisions made. In addition,
transparency involves ensuring that the participants’
voices are truly represented in the presentation of the
findings, for example by using extensive quotations.
n participants feeling an obligation to join/ remain in
the study
n a biased selection of participants
n participants’ responses leaning towards what
they believe will be helpful to the researcher
n the working out of external agendas in the
interview
n a reluctance to share sensitive or strategic
information
For these reasons, generally it is preferable for
interviews to be between people who have no other
mutual relationship. However, some types of study
such as action research (Freshwater 2005) specifically
focus on researching the effects of change within an
existing group, so taking account of existing relationship
dynamics becomes an intrinsic part of the project.
Wherever a researcher decides to interview people he
or she knows in another capacity, this decision needs
to be clearly justified, showing that the implications
have been carefully considered. See Bond (2004) for
a further discussion of the ethical implications of dual
relationships in therapy research.
Therapists interviewing their own clients
Member checking involves asking the participants to
comment on the interview transcripts, the analysis or
the findings.
See Information Sheet R14 (MIntz, 2010) for further
information on validity in qualitative research, and
Information Sheet R13 (Joseph et al 2009) and
(Dijksterhuis 2001; Joseph, Dyer et al. 2009) for further
information on validity and reliability in quantitative
research.
Ethical issues in therapy research interviews
It is essential that all researchers pay attention to
research ethics throughout the process of planning
and carrying out their work. This Information Sheet
focuses on specific issues relating to ethics in therapy
research using interviews: for a discussion of general
ethical issues in therapy research see Bond (2004).
BACP members are bound by the Ethical Framework
for Good Practice in Counselling and Psychotherapy
(BACP 2010) in their research, as they are in their
practice.
© BACP 2011
Particular caution and consultation are essential when
considering interviewing one’s own clients and it may
be wiser for a therapist not to undertake research
interviews with his or her on-going clients. If a therapist
is considering inviting clients to join a research project,
it is good practice to avoid asking for consent once
the therapy is underway (Bond 2004). It may be more
appropriate to give clients information and ask for their
written consent before the start of therapy when they
are not influenced by the therapeutic relationship, and
then to revisit both the information and the consent as
the time for the interview approaches. Time should be
allowed between the end of therapy and approaching
the ex-client for interview: a period of six months
is advisable. For more information, see the BACP
Ethical Guidelines for Researching Counselling and
Psychotherapy (Bond 2004).
Despite these reservations, there are examples of high
quality research in which therapists have interviewed
their own clients after the conclusion of therapy, and
this approach may offer a depth of understanding that is
otherwise inaccessible (Etherington 2000).
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Confidentiality
Interviews can foster strong trusting relationships
and participants may share a great deal of sensitive
information. In writing up the research report, the
researcher has the delicate task of maintaining
confidentiality whilst presenting the participant’s
authentic voice, usually through the use of direct and
substantial quotations. It is good practice to ensure
that whatever is published in a research report will not
identify the participant, even to someone who knows
them well.
Dallos, R. and Vetere, A. (2005) Researching
Psychotherapy and Counselling. Maidenhead, Open
University Press.
Dijksterhuis, A. (2001) Automatic social influence: the
perception- behavior links as an explanatory mechanism
for behavior matching. Social Influence: Direct and
Indirect Processes. J.P. Forgas and K.D. Williams.
Philadelphia, Psychology Press.
Elliott, R., Fischer, C.T. et al. (1999) “Evolving guidelines
for publication of qualitative research studies in
psychology and related fields.” British Journal of Clinical
Psychology 38: 215–229.
Conclusion
Interviewing is an important tool in therapy research
and many therapists have the core skills to become
good research interviewers. It is a method well-suited to
small scale practitioner research. In order to do a useful
project using interviews it is essential to ensure that this
is the best method to answer the research question,
to pay careful and continuing attention to the impact
of the research on participants and to draw on existing
sources of knowledge and experience in research. It is
advisable that all researchers using interviews arrange
for an experienced “critical friend” to help them develop
sound and useful projects, and novice researchers
have a particular responsibility to ensure that they
are working with adequate research supervision or
mentoring.
About the author
Sheila Spong teaches counselling and research
methods at the University of Wales Newport, and has
developed a particular interest in qualitative approaches
to therapy research. She has worked as a counsellor
with alcohol and drug services, with employee
counselling services and in private practice. Sheila has
undertaken a range of interview-based research studies,
including a recent project looking at counsellor influence
on clients.
Fontana, A. and Frey, J.H. (2008) The interview: from
neutral stance to political involvement. Collecting and
Interpreting Qualitative Materials. N. Denzin, K. and
Lincoln, Y.S. Thousand Oaks California and London,
Sage Publications: pp 115–160.
Freshwater, D. (2005) Action research for changing and
improving practice. Qualitative Research in Health Care.
I. Holloway. Maidenhead, Open University Press.
Jefferson, G. (1984) On the organisation of laughter in
talk about troubles. Structures of Social Action: Studies
in Conversation Analysis. J.M. Atkinson and J. Heritage.
Cambridge, Cambridge University Press.
Joseph, S., Dyer, C., et al. (2009) BACP Information
Sheet R13: Statistics in Counselling and Psychotherapy.
Lutterworth, BACP.
Litosseliti, L. (2003) Using Focus Groups in Research.
London, Continuum.
Mann, C. and Stewart, F. (2000) Internet Communication
and Qualitative Research. London, Sage.
McLeod, J. (2001) Qualitative Research in Counselling
and Psychotherapy. London, Sage.
References
BACP (2010) Ethical Framework for Good Practice
in Counselling and Psychotherapy. Rugby, British
Association for Counselling and Psychotherapy.
Bloor, M., Frankland, J. et al. (2001) Focus Groups in
Social Research. London, Sage.
Bond, T. (2004) Ethical Guidelines for Researching
Counselling and Psychotherapy. Rugby, British
Association for Counselling and Psychotherapy.
98
Etherington, K. (2000) Narrative Approaches to Working
with Adult Male Survivors of Child Sexual Abuse – the
Clients’, the Counsellor’s and the Researcher’s Story.
London, Jessica Kingsley Publisher.
MIntz, R. (2010) BACP Information Sheet R14:
Introduction to Qualitative Research. Lutterworth, BACP.
NCH “Express scribe.” Retrieved 27/7/10, from http://
www.nch.com.au/scribe.
O’Connor, Madge, H., C. et al. (2008) Internet-based
interviewing. The Sage Handbook of Online Research
Methods. N. Fielding, R.M. Lee and G. Blamk. London,
Sage.
Anthology of research information sheets – 2nd edition
© BACP 2011
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information sheet
Puchta, C. (2003) Focus Group Interviewing. London,
Sage.
King, N. and Horrocks, C. (2010) Interviews in
Qualitative Research. London, Sage.
Sarantakos, S. (2005) Social Research. Houndmills,
Basingstoke, Palgrave.
Kvale, Steiner (2007) Doing Interviews. London, Sage.
Rubin, H.J. and Rubin, I.S. (2004) Qualitative
Interviewing: the Art of Hearing Data. London and
Thousand Oaks, California, Sage Publications.
Further reading
The *starred references above are particularly useful as
further reading. Listed below are some additional works
on research interviewing.
Kvale, S. and Brinkman, S. (2009) Interviews. 2nd ed.
London: Sage.
Gubrium, J. and J. Eds. (2003) Postmodern
Interviewing. London: Sage.
Weiss, R (1995) The Art and Method of Qualitative
Interview Studies. London, Simon and Schuster.
First published February 2011
It should be noted that this Information Sheet offers broad guidance, which sets out professional good practice, but it should not be
substituted for legal and other professional advice, including supervision, applicable to your particular circumstances.
BACP is aware that law and practice are always in a process of development and change. If you have evidence that this Information
Sheet is now inaccurate or out of date feel free to contact us. If you know of any impending changes that affect its content we
would also be pleased to hear from you.
© BACP 2011
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information sheet
Practice-based evidence and practice
research networks
by Michael Barkham
Introduction
This information sheet sets out the key
features of practice-based evidence
and places it beside evidence-based
practice as a complementary approach
(ie, paradigm) to the design and
implementation of research for improving
practice and enhancing evidence. The
paradigm of practice-based evidence
incorporates all activities that are part
of routine practice as carried out in
naturalistic settings (for overviews, see
Barkham & Margison, 2007; Barkham et
al., 2010; Castonguay et al., 2013).
As the term implies, practice-based
evidence in relation to therapy is grounded
in research findings derived from studies
of various aspects of therapy practice and
can be viewed as a real-world test of any
particular psychological intervention or
service delivery model. Hence, because
practice-based research is carried out
in routine settings, thereby giving it high
external validity, the findings can generally
be applied to other routine settings.
Practice based evidence has a key role
along a continuum of research activities
comprising three major categories of
studies:
n
n
n
Efficacy studies – research carried
out under optimal conditions and
aimed at establishing cause and
effect relationships.
Effectiveness studies – research
activity derived from efficacy studies
and carried out in service settings
but relaxing some of the restrictions
of the efficacy study although still
retaining key trial characteristics
(eg, interventions that are set out in
a manual to ensure therapists are
implementing the same therapy).
Practice-based studies – activity
carried out in routine service
settings with no restrictions other
than would normally be in place
within the service.
Practice-based evidence results from a
body of research derived from a bottom-up
approach by starting with the routine work
of practitioners (ie, achieving high external
validity) and, from this base, building
up an evidence-base across multiple
practitioners. At the heart of practicebased evidence lies the use of routine
measurement (see BACP information sheet
R7). In addition, practice-based evidence
encompasses the widest range of research
methods (ie, qualitative and quantitative
methods) that help to build the richest
understanding of routine practice.
By contrast, evidence-based practice
attempts to control as many factors as
possible so as to keep any variation to a
minimum (eg, all clients will have a specific
diagnosis, none will be on medication,
etc). This helps to achieve high internal
validity that enables such studies to make
cause and effect links but always raises
questions as to how these situations mirror
the real world where such factors cannot
be controlled.
The evidence may then be disseminated
as policy directives down to influence
practice in everyday settings.
While efficacy studies – and, to a lesser
extent, effectiveness studies – may carry
direct funding (eg, from the National
Institute for Health Research) that
provides a supportive infrastructure for
the research, practice-based studies
have invariably needed to develop their
own organisational network and support
systems. These organisations have
commonly been termed Practice Research
Networks (PRNs) or Practice Based
Research Networks.
BACP Information Sheets
are intended to be read in
conjunction with the BACP
Ethical Framework for Good
Practice in Counselling and
Psychotherapy.
The Information Services
ethics helpdesk team is
available to members who
wish to explore any ethical
issues concerned with their
practice.
It should be noted that this
Information Sheet offers
broad guidance, which
sets out professional good
practice, but it should not
be substituted for legal
and for other professional
advice applicable to your
particular circumstances.
© BACP, First published November 2012
R17
Practice Research Networks have been defined as
‘…large numbers of practicing clinicians and clinical
scientists, brought together in collaborative research on
clinically meaningful questions in the naturalistic setting
for the sake of external validity and employing rigorous
scientific methodology for the sake of internal validity’
(Borkovec, 2002). Importantly, PRNs are not a defining
feature of practice-based evidence but they reflect the
collaborative activities between multiple practitioners
and researchers that enable the development of large
and representative data sets that underpin practicebased evidence.
In the field of counselling and the psychological
therapies, the literature and activities relating to
practice-based evidence have steadily grown since the
late 1990s. Because practice-based evidence takes
routine practice as its starting point, the paradigm
has considerable appeal to practitioners who seek
to work in collaboration with other practitioners. This
contrasts with a view that more traditional research
is disconnected from the realities of routine practice.
However, practice-based evidence is not a panacea
for the perceived shortcomings of research activity
generally. Each research tradition has its own strengths
and vulnerabilities and a range of methods and
paradigms are required in order to build a robust and
meaningful knowledge base of counselling and the
psychological therapies.
information sheet
except for the intervention. Then, if there is a difference
between the groups, it can only be attributable to the
intervention. Although trials methodology has become
more sophisticated in recent years, there has also been
a growing realisation that such an approach cannot
capture and address all the questions of interest to
practitioners, clients, or policy makers. In addition,
specific developments have made practice-based
evidence more feasible and include the following:
n
n
n
n
n
A growing culture of individual accountability and
collective responsibility for delivering quality care
to clients.
Broad acceptance of the value of mixed research
methods together with methods for synthesising
qualitative results.
Increased availability of outcome measurement
systems, particularly electronically-based client
information systems.
Development and increasing implementation of IT
systems and computer technologies (ie, cheaper
hardware and availability of standard software).
Adoption of more advanced statistical and
analytical tools (eg, multilevel modelling) for
analysing large routine data sets.
The aim of this information sheet is to set out the
reasons for the rise of practice-based evidence, its
characteristics, relationship to evidence-based practice,
and potential for improving practice. It then focuses
on the history, features, and yield of practice research
networks that support individual practitioners working
collectively. Finally, it presents examples of practicebased studies and how they can contribute towards
an enhanced evidence-base for the psychological
therapies.
Many of the features of practice-based evidence are
central to the closely related activity of patient-focused
research (Lambert et al., 2001; Lutz, 2002). At the
heart of patient-focused research is the individual
client and the purpose is to address the fundamental
question: Is this particular treatment working for this
particular client? This focus on the individual client has
led directly to work on patient or client tracking and
feedback systems whereby the progress of individual
clients is monitored and information fed back to
participants in real time. Using qualitative methods to
investigate the impact and meaning of such procedures
to clients and practitioners would enhance this
work further.
The paradigm of practice-based evidence
What are the aims of practice-based evidence?
Reasons why practice-based evidence has come
to prominence
There are two general aims of practice-based evidence:
improving practice and enhancing evidence.
The earliest references to practice-based evidence
within the field of counselling and the psychological
therapies appeared at the turn of the millennium (for an
early review, see Margison et al., 2000). The reasons for
its growth are multifaceted but a key factor has been
the wish to complement the dominant paradigm of
evidence-based practice that prioritises the randomised
controlled trial (RCT) as the gold standard method
for obtaining data. In randomised controlled trials,
people are allocated at random to receive one of two,
or sometimes three, psychological interventions. In
principle, all the groups are matched with each other
© BACP 2012
n
n
Improving practice: This aim underpins the
principle of beneficence in the BACP Ethical
Framework. Specifically, in order to ensure that
a client’s best interests are achieved requires
appropriate assessment and systematic
monitoring of practice and outcomes by the best
available methods. Meeting this agenda can
be an end in itself and can provide individual
practitioners with helpful feedback on their
practice.
Enhancing evidence: Once such monitoring is
in place, it is logical that the data from multiple
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practitioners can be collated into an evidence
base that may be disseminated widely and
used to inform professional training, guideline
development, funding opportunities, and the
wider policy space relating to the psychological
therapies.
The characteristics of practice-based research activity
The major characteristics of practice-based research
comprise the following:
n
n
n
n
102
Routine practice: The activity reflects practice
as it occurs naturally when delivered by the
individual practitioner, group of practitioners,
or within a service. This activity is captured
by the adoption of some form of systematic
measurement.
Measurement systems: A bona fide
measurement system is at the heart of practicebased evidence. Examples of measurement
systems include the Clinical Outcomes in
Routine Evaluation system (CORE; Barkham et
al., 2010), the Treatment Outcomes Package
(TOP; Kraus & Castonguay, 2010), and Outcome
Questionnaire system (OQ; Lambert et al.,
2010). Such systems use outcome measures
that have been specifically designed to
capture the breadth of a client’s life, including
relationships and functioning, rather than a
dominant focus on symptoms, as exemplified,
for example, by the Patient Health Questionnaire
(PHQ-9) measure that has currency in GP
services because of the government focus on
depression. In addition, the systems above also
collect information on the client’s context. These
systems – and others – now use web-based
technology to collect, feedback, and analyse
client and service data.
Design: The design for a practice-based study is
imposed on the data in response to the question
to be addressed. Hence, practice-based studies
may use the whole cohort as the sample of
interest. Alternatively, a specific design can be
decided and client data then selected from the
total sample to populate the design (eg, selecting
only clients who meet specified criteria). In this
way, designs can be tailored to specific questions
and many designs, and therefore studies, can
be applied to a large data set. Because data is
drawn from routine practice and randomising
clients to interventions is not part of routine
practice, it follows that randomisation is not a
feature of practice-based studies.
Ethics: Because the yield of practice-based
research presents ‘new knowledge’, projects
require research and governance approval within
the NHS or related organisations. However, as
n
data is routinely collected, specific informed
consent is not required, but a standard form
stating that the data will be used to improve
services is advisable. A research ethics form
would state that the data used (a) was being
collected routinely, (b) would be anonymised (ie,
stripped of strong identifiers), (c) and would be
analysed at an aggregated level (ie, not analysed
at such a level that individuals might be able to
identify themselves). In addition, the information
chain linking the data to the client should be
broken so that individual data cannot then be
tracked back to the client.
Study specific data collection: Additional
requirements can be imposed for specific
purposes – but collection of such data goes
beyond that obtained routinely and would be
a consequence of the research. Hence, the
ethical requirements change and informed
consent would be required from participants for
the collection of additional data that was not
routinely collected.
Improving practice
How individual practitioners can start building
practice-based evidence
The vast majority of information that is generated by
every practitioner every day is lost. It has been stated
that in relation to everyday practice, [W]e are letting
knowledge from practice drip through the holes of
a colander (Kazdin, 2008). In order to capture data,
practice-based evidence incorporates a large variety
of existing methods. One principle is that practicebased evidence starts with the individual practitioner
collecting some form of data on all their clients. This
data can be qualitative, quantitative, or both. The
crucial point is that this data will become a golden
thread across multiple practitioners who will collect
similar data. With this in mind, it is understandable
that a majority of practice-based data is of a
quantitative nature.
However, there is a rich diversity of qualitative
approaches and, with access to audiotapes, the
opportunity for endless hours of research. But the
reason why some practice-based research fails to
progress is that practitioners try to be too ambitious.
A more feasible approach is for practitioners to start
collecting small amounts of data on all clients. For this
purpose, using a short and focused measure, such
as the PHQ-9 or the Hospital Anxiety and Depression
Scale (HADS) could be one option. The robustness of
the model then comes from combining the data of many
practitioners so as to build larger data sets that capture
the richness and variability that exists in everyday
routine practice.
Anthology of research information sheets – 2nd edition
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Reflective practice and theory building case studies
Starting with simple data collected routinely on all
clients, the aim would be for practitioners to reflect
on the data, using it akin to supervision. The purpose
is to generate a dialogue with the data in order for
practitioners to challenge or confirm perceptions
about their own practice. For example, a practitioner
may possibly obtain an alternative view about their
relative effectiveness with younger clients or with
people from ethnic minority groups. Reflecting on the
data may challenge pre-existing assumptions and the
task is then to understand any discrepancy between
data and perceptions. From this might stem, for
example, an interest in research in the area of ethnic
minority groups. However, with the number of clients
being small, the aim would then be to see if other
practitioners – who are collecting similar data – have an
interest in working towards pooling their data, thereby
initiating a practice research network (see later section).
Individual practitioners may then develop more
complete data collection methods together with data
perhaps derived from listening to recordings of their
own practice. This fine-tune listening can generate
data that is then applied to advancing theories of
psychological change derived from routine practice.
Every practitioner engages in private theory building
within his or her routine practice. Making that public
through practice networks is a way of advancing theory
development (see Stiles, 2010).
In sum, the first step in developing practice-based
evidence is the adoption, implementation, and use of
some form of bona fide measurement system.
Practice research networks
How individual practitioners can start building
practice-based evidence
Practice-based evidence progresses from a focus on
the individual practitioner to studies comprising many
practitioners. This can be achieved in different ways,
one of which is to develop a practice research network
(PRN; Audin et al., 2001). The contribution of PRNs in
the UK and the US has been reviewed (see Parry et
al., 2010). The term practice-based research networks
(PBRNs) has also been used. Key features common
to PRNs/PBRNs have been identified as follows (see
McMillen et al., 2009):
n
n
Describing the client’s journey: Client tracking,
feedback, and benchmarking
The central role of measurement systems has led to the
development of procedures for using routinely collected
data to mirror a client’s journey in therapy. For example,
repeated session-by-session data can be used to
determine whether a client’s progress is ‘on track’
by comparing it with the expected response to the
intervention by similar clients. In effect this is equivalent
to comparing client progress with a tailored benchmark.
The provision of an external perspective, perhaps
comparable to certain types of formal supervision of
therapeutic practice, is important and is different from
simply judging a client’s outcomes. At an overall level,
a key component in improving practice is to be able
to locate the processes and outcomes of individual
clients or services in the context of similar clients
and services – that is, to benchmark outcomes of a
practitioner or service against a meaningful comparison.
This comparison (or comparator) may be a similar
service or published data, or might derive from a trial
of the therapy being employed. The purpose of these
procedures is always to place or locate local work with
clients within the broader world of other clients (see
Leach & Lutz, 2010).
© BACP 2012
information sheet
n
n
PRNs generate data that derives from and
therefore reflects routine practice. This might
comprise NHS delivered psychological
therapies or comprise independent
practitioners. It excludes data derived from
research clinics or activities specifically set up
to generate research evidence, unless these
activities are inextricably linked with a broader
initiative to collect a combination of routine and
research data.
PRNs provide an infrastructure upon which to
develop subsequent research projects. Hence
the infrastructure is not yoked to any single study
but exists to support using routinely collected
data for the purposes of improving practice and
enhancing evidence.
PRNs are a partnership between practitioners
and researchers. This is partly a philosophy
but also needs to be evidenced in the form of
meetings, joint activities, and/or newsletters, etc.
Practitioners drive the research questions in that
they should be practice-relevant and important to
the individual practitioners or the service.
Although PRNs share these common features, they also
differ in how they originate, who sets them up, their
specific focus, the range of their membership, and the
extent to which practitioners or researchers lead the
research agenda of the network.
Examples of Practice Research Networks (PRNs)
There are a number of examples of PRNs and their
hybrids that help focus on commonalities and
differences across these networks. Five examples of
PRNs are provided, the first two being set up in the US
and the others in the UK.
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n
n
n
n
information sheet
In the US, the Agency for Healthcare Research
and Quality provided support to 36 PRNs
comprising in excess of 10,000 clinicians serving
in the region of 10 million clients.
An exemplar for a US-based PRN focusing on
the psychological therapies is the Pennsylvania
PRN (Borkovec et al., 2001). The infrastructure of
the PRN comprises three main components: (1) a
core outcome battery; (2) a standard diagnostic
assessment procedure; and (3) a selection
committee representing all stakeholders.
A parallel UK-based network is the CORE Users’
Network. Key components include: (1) a common
outcome system; (2) infrastructure for feedback;
and (3) a national data set (CORE Information
Management Systems; http://www.coreims.
co.uk/).
A PRN for those involved in school based
counselling has recently been launched by
BACP: www.bacp.co.uk/schools. SCoPReNet’s
mission is to promote psychological health and
emotional wellbeing among schoolchildren in
the UK. In supporting high quality and rigorous
research the network seeks to improve the quality
and effectiveness of school based counselling for
the benefit of service users and to widen access
to such services by influencing policy makers
and those responsible for the commissioning
of services.
Further UK examples include the British
Association of Art Therapists’ PRN (ATPRN;
www.baat.org/atprn.html), and feasibility activities
relating to a PRN for the UK Association for
Cognitive Analytic Therapy (ACAT PRN; Parry et
al., 2006).
A key advantage of PRNs is that they provide a platform
for practitioners to be equal partners in the activity of
research. However, six challenges to the yield of PRNs
have been identified (McMillen et al., 2009):
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n
n
n
104
Managing relationships with PRN memberships:
effort and time needs to be spent ensuring that
expectations are realistic and that decisionmaking is transparent.
Ongoing and sustainable financial support:
PRN activity requires sustainable but relatively
low-cost financial/resource support. Given the
large cost of trials, there is the potential for
practice-based evidence to show its activity to be
cost effective, providing it can deliver improved
practice and evidence of scientific value.
PRN productivity: The yield of research from
PRNs needs to increase in order to build a robust
evidence base.
Responsible conduct of research issues: Securing
ethical and governance arrangements is crucial
and may require co-ordination across differing
services/geographical regions.
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Recruitment and generalisability: It is important
to ensure that practitioners and clients included
in PRN data sets are representative of routine
practice – that is, the sampling frame of the PRN
needs to be determined.
Measurement validity: Data collection derived
from busy practices will be vulnerable to random
errors (eg, inconsistencies) and also validity
challenges arising from data being based on
reports and accounts of participants rather than
from independent researchers (ie, traditional
model of an assessment by a trained assessor).
Overall, PRNs offer great potential for delivering
practice-based evidence but the scientific yield needs
to be increased (Parry et al., 2010).
Enhancing evidence
What practice-based evidence adds to the collective
knowledge-base
If data is collected and used to improve practice, it can
then be collated across settings or time to be used to
enhance the knowledge base relating to counselling
and the psychological therapies. Because data is
being collected routinely, it becomes a key role for
practitioners to use this data to address topical issues
raised by the research community – and because the
data has already been collected, it provides a very real
counterbalance to traditional research. Examples of
practice-based findings and how they can be used are
presented here in response to key areas:
Effectiveness of person-centred therapy: Practice-based
data has focused on the comparative effectiveness of
person-centred therapy.
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Data from a single service over a five year period
showed person-centred therapy to be effective
(Gibbard & Hanley, 2008).
A practice based research report compared
person-centred therapy as delivered in the UK
NHS with cognitive-behavioural therapy and
with psychodynamic-interpersonal therapy.
The findings showed no overall superiority to
one treatment over another although the rate
of clients meeting the criterion for reliable and
clinically significant change was highest in CBT
(Stiles et al., 2006). This finding was replicated in
a larger UK practice-based sample (Stiles et al.,
2008).
Benchmarking services and practitioners: Benchmarks
for practitioners and services have been established.
n
Data from a single primary care service can be
benchmarked against UK national data on a
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range of services and used to show where there
are meaningful differences and hence improve
service delivery (Evans et al., 2003).
Benchmarks can be generated for services and
for practitioners but the issue of case-mix needs
to be considered to ensure that appropriate
comparisons are made (Mullin et al., 2006).
Practitioner effects: Evidence of practitioner effects has
been established.
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Findings from the US have reported evidence
of therapist effects indicating that some
practitioners are considerably more effective than
the average for a given service (eg, Okiishi et al.,
2003; 2006).
A report using a CORE data set across many
services showed some therapists to be twice as
effective as other therapists (Saxon & Barkham,
2012).
Process of change: Enhancing our knowledge base
about what brings about change in the course of
counselling and therapy has been achieved.
n
Data from 1500 helpful and hindering events
has suggested that increased self-awareness is
the most helpful event experienced by clients
(Castonguay et al., 2010).
Locating practice-based evidence within the
landscape of research activity
In considering practice-based evidence, it is crucial to
see it as part of the larger research landscape. This is
because no single research paradigm (whether trialsbased or practice-based research) or research method
(whether it be qualitative or quantitative) is without
its vulnerabilities. The point is that there are different
research paradigms to address different questions.
Research paradigms and methods are fit for specific
purposes and are not suitable for every occasion.
Accordingly, to build the most informed knowledge
base requires researchers and practitioners to view
these paradigms and methods as complementary.
Hence, the most rigorous, robust, relevant, and richest
knowledge base for counselling and the psychological
therapies will derive from an equal valuing of evidencebased practice and practice-based evidence and their
associated methods.
information sheet
of the team that developed the CORE measures and
system and is co-editor of Developing and delivering
practice-based evidence: A guide for the psychological
therapies (Wiley, 2010).
References
Paradigm of practice-based evidence
Barkham, M., Hardy, G.E. and Mellor-Clark, J. (Eds.)
(2010) Developing and delivering practice-based
evidence: A guide for the psychological therapies.
Chichester: Wiley.
Barkham, M. and Margison, F. (2007) Practice-based
evidence as a complement to evidence-based
practice: From dichotomy to chiasmus. In C. Freeman
and M. Power (Eds.), Handbook of evidence-based
psychotherapies: A guide for research and practice.
Chichester: Wiley. pp. 443–476.
Castonguay, L.G., Barkham, M., Lutz, W., & McAleavy,
A. (2013). Practice oriented research: Approaches and
applications. In. M.J. Lambert (Ed.), Bergin & Garfield’s
handbook of psychotherapy and behavior change. 6th
Edition. Hoboken, N.J.: Wiley.
Lambert, M. J., Hansen, N. B. and Finch, A. E. (2001)
Patient-focused research: Using patient outcome data
to enhance treatment effects. Journal of Consulting and
Clinical Psychology, 69, 159–172.
Lutz, W. (2002) Patient-focused psychotherapy
research and individual treatment progress as scientific
groundwork for an empirically based clinical practice.
Psychotherapy Research, 12, 251–272.
Margison, F., Barkham, M., Evans, C., McGrath, G.,
Mellor-Clark, J., Audin, K. et al. (2000) Measurement
and psychotherapy: Evidence based practice and
practice-based evidence. British Journal of Psychiatry,
177, 123–130.
Bridging practice-based evidence and evidencebased practice
Kazdin, A.E. (2008) Evidence-based treatment and
practice: New opportunities to bridge clinical research
and practice, enhance the knowledge base, and improve
patient care. American Psychologist, 63, 146–159.
About the author
Measurement systems and tracking
Michael Barkham is Professor of Clinical Psychology
and Director of the Centre for Psychological Services
Research, University of Sheffield. He was a member
© BACP 2012
Barkham, M., Mellor-Clark, J., Connell, J., Evans, R.,
Evans, C. and Margison, F. (2010) The CORE measures
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information sheet
& CORE system: Measuring, monitoring, and managing
quality evaluation in the psychological therapies.
In M. Barkham, G.E. Hardy and J. Mellor-Clark (Eds.),
Developing and delivering practice-based evidence:
A guide for the psychological therapies. Chichester:
Wiley. pp. 175–219.
Kraus, D. and Castonguay, L. (2010) The TOPS:
Development and applications in the psychological
therapies. In M. Barkham, G.E. Hardy and J. MellorClark (Eds.), Developing and delivering practice-based
evidence: A guide for the psychological therapies.
Chichester: Wiley. pp. 155–174.
Lambert, M.J., Hansen, N.B. and Harmon, S.C. (2010)
The OQ-45 System: Development and practical
applications in health care settings. In M. Barkham,
G.E. Hardy and J. Mellor-Clark (Eds.), Developing and
delivering practice-based evidence: A guide for the
psychological therapies. Chichester: Wiley. pp. 141–154.
Leach, C. and Lutz, W. (2010) Constructing and
disseminating outcome data at the service level: Case
tracking and benchmarking. In M. Barkham, G.E. Hardy
and J. Mellor-Clark (Eds.), Developing and delivering
practice-based evidence: A guide for the psychological
therapies. Chichester: Wiley. pp. 257–283.
Theory building case studies
Stiles, W.B. (2010) Theory-building case studies as
practice-based evidence. In M. Barkham, G.E. Hardy
and J. Mellor-Clark (Eds.), Developing and delivering
practice-based evidence: A guide for the psychological
therapies. Chichester: Wiley. pp. 91–108.
Practice Research Networks and PRN studies
Audin, K., Mellor-Clark, J., Barkham, M., Margison, F.,
McGrath, G., Lewis, S. et al. (2001) Practice Research
Networks for effective psychological therapies. Journal
of Mental Health, 10, 241–251.
Borkovec, T.D. (2002) Training clinic research and the
possibility of a national training clinics practice research
network. The Behavior Therapist, 25, 98–103.
Borkovec, T.D., Echemendia, R.J., Ragusea, S.A. and
Ruiz, M. (2001) The Pennsylvania Practice Research
Network and future possibilities for clinically meaningful
and scientifically rigorous psychotherapy effectiveness
research. Clinical Psychology Science and Practice, 8,
155–167.
Castonguay, L.G., Boswell, J.F., Zack, S.E., Baker, S.,
Boutselis, M.A., Chiswisk, N.R. et al. (2010) Helpful and
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hindering events in psychotherapy: A practice research
network study. Psychotherapy Theory, Research,
Practice, Training, 47, 327–344.
McMillen, J.C., Lenze, S. L., Hawley, K.M. and
Osborne, V.A. (2009) Revisiting practice-based research
networks as a platform for mental health services
research. Administration, Policy, and Mental Health and
Mental Health Services Research, 36, 308–321.
Parry, G.D., Castonguay, L., Borkovec, T.D. and Wolf,
A.B. (2010) Practice research networks and service level
research in the UK and US. In M. Barkham, G.E. Hardy
and J. Mellor-Clark (Eds.), Developing and delivering
practice-based evidence: A guide for the psychological
therapies. Chichester: Wiley. pp. 311–325.
Parry, G., Dunn, M., Potter, S., Saxon, D. and Sloper,
J. (2006). An ACAT Practice Research Network: Report
on a feasibility study. Association for Cognitive Analytic
Therapy, at www.acat.me.uk
Practice-based evidence: Research examples
Evans, C., Connell, J., Barkham, M., Marshall, C.
and Mellor-Clark, J. (2003) Practice-based evidence:
Benchmarking NHS primary care counselling services
at national and local levels. Clinical Psychology &
Psychotherapy, 10, 374–388.
Gibbard, I. and Hanley, T. (2008) A five-year evaluation
of the effectiveness of person-centred counselling in
routine clinical practice in primary care. Counselling and
Psychotherapy Research, 8, 215–222.
Mullin, T., Barkham, M., Mothersole, G., Bewick, B.M.
and Kinder, A. (2006) Recovery and improvement
benchmarks in routine primary care mental health
settings. Counselling & Psychotherapy Research, 6,
68–80.
Okiishi, J., Lambert, M.J., Nielsen, S.L. and Ogles, B.M.
(2003) Waiting for supershrink: An empirical analysis of
therapist effects. Clinical Psychology & Psychotherapy,
10, 361–373.
Okiishi, J.C., Lambert, M.J., Eggett, D., Nielson, S.L.,
Vermeersch, D.A. and Dayton, D.D. (2006) An analysis
of therapist treatment effects: Toward providing
feedback to individual therapists on their patients’
psychotherapy outcome. Journal of Clinical Psychology,
62, 1157–1172.
Saxon, D., & Barkham, M. (2012). Patterns of therapist
variability: Therapist effects and the contribution of
patient severity and risk. Journal of Consulting and
Clinical Psychology, 80, 535–546.
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Stiles, W.B., Barkham, M., Mellor-Clark, J. and Connell,
J. (2008) Effectiveness of cognitive-behavioural,
person-centred, and psychodynamic therapies in UK
primary care routine practice: Replication with a larger
sample. Psychological Medicine, 38, 677–688.
information sheet
Stiles, W.B., Barkham, M., Twigg, E., Mellor-Clark,
J. and Cooper, M. (2006) Effectiveness of cognitivebehavioural, person-centred, and psychodynamic
therapies as practiced in UK National Health Service
settings. Psychological Medicine, 36, 555–566.
First published November 2012
It should be noted that this Information Sheet offers broad guidance, which sets out professional good practice, but it should not be
substituted for legal and other professional advice, including supervision, applicable to your particular circumstances.
BACP is aware that law and practice are always in a process of development and change. If you have evidence that this Information
Sheet is now inaccurate or out of date feel free to contact us. If you know of any impending changes that affect its content we
would also be pleased to hear from you.
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