Author
HILL Andy; BRETTLE Alison
Title
Counselling older people: a systematic review
Journal citation/publication details
British Association for Counselling and Psychotherapy, 2004
Summary
This carefully conducted review is based on extensive electronic and hand searching of information sources, and covers 47 studies. It finds that counselling is effective with older people, especially in treating anxiety and depression, and in improving subjective well-being. Approaches based on cognitive-behavioural therapy have the strongest support in the literature, but several approaches in common use lack a research evidence base. More UK-based research is needed, including studies of the effectiveness of counselling in routine practice and in naturalistic settings.
Context
The UK population is ageing, and the government has responded by introducing the National Service Framework for older people. This includes a recognition of the under-detection of mental illness among older people, and the importance of mental health care for this population. If counselling is to form part of the therapeutic response, it is important to demonstrate that it meets the evidence based criteria of the Framework.
Methods
What sources were used?
The following databases were used: Medline; CINAHL (Cumulative Index to Nursing and Allied Health Literature); the Cochrane Library [including the Cochrane Database of Systematic Reviews and DARE - the Database of Abstracts of Reviews of Effectiveness]; PsycINFO; Caredata [now Social Care Online]; and Counsel Lit [a database developed by the Counselling in Primary Care Trust but traceable online]. The authors note that the database AgeInfo might also be a relevant source for reviews in this area. However, test searches indicated that the volume of relevant material was likely to be low, and did not warrant investment in a subscription given the resource limitations of the project.
In addition, ten journals were hand searched, internet sites were checked, and relevant organisations were contacted for information about further studies (details in Appendix B). The reference lists of all papers included in the review were checked, and these papers were also subjected to citation tracking. All references were entered into an Endnote database that 'was used to track and maintain an audit trail of all studies as they passed through the review process.'
What search terms/strategies were used?
Searches were undertaken from 1985 onwards and restricted to the English language. Search strategies for all the databases used are given in Appendix A.
What criteria were used to decide on which studies to include?
Eligible studies had to address at least one dimension of counselling delivery (effectiveness, appropriateness or feasibility), test interventions that fell within the British Association for Counselling and Psychotherapy's definition of counselling (given on p4), and draw samples from populations that were clearly over 50. Exclusion criteria are listed on pp6-7.
Who decided on their relevance and quality?
A total of 2,646 studies were identified by the search process, which is summarised in a flow diagram on p7. Titles and abstracts were checked by either one of the two authors, leading to the exclusion of 2,292 studies. The remaining 354 were obtained in hard copy for checking against the inclusion criteria, and 39 selected for inclusion in the review. The reference lists of these papers were checked, and they were subjected to citation tracking, identifying a further 60 potentially relevant studies, of which 52 were excluded after assessment. The final set of studies was assessed independently by 'two reviewers from a team of nine' using a set of quality checklists reproduced in Appendix C, with one paper assessed by all nine members of the team. Any disagreements were resolved by discussion.
How many studies were included and where were they from?
Forty-seven studies were reviewed, including 32 outcome studies. These are summarised in Appendix D, which gives details of aims, key findings and evaluative comments from the assessment process. In addition, they are listed in the references to the report, which also includes details of six potentially relevant studies identified at the end of the review process and not included in the analysis. A list of excluded studies is available from the authors on request. The geographical origins of the studies are not included in Appendix D, but in their conclusions the authors note that only seven were carried out in the UK , with the majority conducted in North America .
How were the study findings combined?
The review is narrative in nature and includes comment on the quality of the evidence base. The authors note that, because of resource limitations, the nine systematic reviews included in the review were assessed as studies in their own right rather than as sources of primary studies. However, in recognition of the 'higher level of evidence' provided by such reviews, 'extra weight has been placed upon their findings'. Although the studies summarised in Appendix D are quality rated from Excellent to Poor, the review findings 'on the whole are derived from the papers classified as excellent or good.'
Findings of the review
Counselling is found to be efficacious with older people, especially in treating anxiety and depression, and in improving subjective well-being. The outcomes for this population group are in line with those for younger people, suggesting that old age is no barrier to receiving benefit from counselling.
Of the various approaches to counselling, cognitive behavioural therapy has the strongest evidence base, but there is a lack of research into several routinely used approaches such as inter-personal, psychodynamic, client-centred, validation, goal-focused and gestalt therapies. Moreover, where different therapeutic approaches have been tested against each other in older populations, the outcomes are not significantly different: no one approach appears to be inherently better than another. The authors note that the evidence for the efficacy of reminiscence therapy and life review in the treatment of dementia and cognitive decline is weak 'but consideration should be given to the chronic and debilitating nature of these conditions as compared with more treatable disorders such as anxiety and depression.'
Older people living in the community seem to prefer individual to group counselling, and this may be the more effective approach with this group. The number of studies in this area is, however, small. In residential settings group counselling is a feasible mode of delivery 'although not necessarily reflecting older people's preferences'. For both community and institutional settings, a 'proactive approach to the identification of psychological problems is necessary' and it is feasible to train counsellors to work with older people. Some studies report good outcomes associated with highly qualified therapists who have undergone specialised training for working with this population.
Authors' conclusions
There is a need for more research on counselling approaches other than cognitive behavioural therapy, and on individual counselling with community-dwelling older people. In addition, future studies of group counselling in residential settings should address the potential therapeutic elements of group interaction rather than, as has generally been the case, treating interaction as a confounding factor. More UK-based research that focuses on 'UK populations, UK health and social care settings and the counselling approaches used by UK counsellors' is essential: much of the existing research is not only North American but focuses on interventions carried out by psychiatrists, psychologists, social workers and mental health nurses, rather than people who call themselves counsellors.
Having established a level of efficacy, future research will also need to assess the effectiveness of counselling with older people 'in routine practice and in naturalistic settings'. This may involve the use of 'pragmatic' randomised controlled trials, but other research designs will also be appropriate, and future systematic reviews 'will need to take a more pluralistic and inclusive approach to evidence in order to locate and appraise evidence of effectiveness'. The authors note the paucity of good quality qualitative research in their review, suggesting that qualitative methods are 'under-recognised' by researchers in this field.
Implications for policy or practice
No specific implications for policy and practice are drawn beyond the statement that 'a proactive approach to the identification of psychological problems among older people in all settings is necessary to ensure problems are not left untreated.'
Related references
The following papers based on this review are included on Social Care Online:
HILL Andy; BRETTLE Alison; Counselling older people: what can we learn from research evidence? Journal of Social Work Practice, 20(3), November 2006, pp.281-297.
HILL Andrew; BRETTLE Alison; The effectiveness of counselling with older people: results of a systematic review. Counselling and Psychotherapy Research, 5(4), December 2005, pp.265-72.