Counselling Haverhill

Depression is 'a period of at least two weeks during which there is either depressed mood or the loss of interest or pleasure in nearly all activities'š. Frequently clients do not realise they are 'depressed' and may only report difficulties at work and or at home. As well as these aspects of depression there may be 'changes in appetite or weight, sleep, psychomotor activity [feeling agitated or feeling 'slowed down']; decreased energy, feelings of worthlessness or guilt; difficulty thinking, concentrating, or making decisions; or recurrent thoughts of death or suicidal ideation, plans or attempts'š.

NOTE: The information provided on this website is for general information only and not intended as a substitute for diagnosis or treatment; if you are concerned about your health please contact an appropriate practitioner.

Research suggests women are twice as likely as men to be diagnosed as 'depressed'. During their lifetime 10-25% of women and 5-12% of men will be depressed. At any one time 5-9% of women and 2-3% of men are 'depressed'. Episodes of depression may last several months or years and may recur several times during an individual's lifetimeš.

Outcomes for clients presenting at this counselling service with symptoms of depression are shown below. At the time of writing there were 86 clients who had started with some level of clinical depression and who had a subsequent measurement of their depression, measured using the Beck Depression Inventory, Second Edition (BDI-II˛).

The average start score was 27.0 (SD 9.9), equivalent to a moderate/severe level of depression, and the average subsequent score was 12.9 (SD 9.8), equivalent to no longer being depressed. In this case the effect of counselling (ES = 1.42) is a 'large' effect; One way of considering the size of the effect of counselling at this service is that the average client was less depressed at the end of an average of eight counselling sessions than 92% of clients at the start of counselling. These average scores are illustrated in the graph below:

Using the methodology described by Elliott, Greenberg and Lietaer (2004) these average outcomes compare well with the published literature for depression outcomes in clinical trials and practice-based studies. The average number of sessions was 8.1 (range 2-67 sessions). At the start of counselling 18 clients (20.9% of the 86 clients) were taking anti-depressants prescribed by their doctor and at the end of counselling 9 clients (10.4%) were still taking or phasing out anti-depressants. The average observed improvements were not simply due to clients taking concurrent medication.

In addition to looking at average outcomes it is good practice to look also at the proportions of clients achieving 'reliable change' (Jacobson and Truax 1991). All psychological questionnaires suffer with measurement error. In this research changes greater than 9.4 BDI-II units were found to be 'reliable' at better than 95% confidence, i.e. improvements in individual client depression scores of more than 9.4 BDI-II units are improvements we can rely upon, rather than just being artifacts of the questionnaire used. The following graph shows changes in depression scores for all 86 clients:

The bottom axis shows the depression score for each client at their first session. The upright axis shows the depression score for each client at their subsequent session. For example, at the extreme bottom right of the graph a client started with a BDI-II score of 44 (severe depression) and at a subsequent measurement their score had reduced to 2 (not depressed).

The diagonal line going up at an angle of 45ş from left to right is the line of no change. The dotted tramlines either side of this diagonal are the boundaries of reliable change at 95% confidence. The circles representing clients on this graph within these tramlines have not changed sufficiently to be changes we can rely upon, i.e. their changes are within the measurement error of the questionnaire.

'Even under the best circumstances, such as in carefully crafted and controlled clinical trials research, roughly 10% of patients show negative outcome (deterioration), while another 25 to 40% will fail to improve and show no reliable change' (Lambert, Hansen and Harmon 2010, page 149). By extension 50-65% of clients in a typical clinical trial achieve reliable improvement.

The graph above shows that for these 86 clients, none have reliably deteriorated (0.0%, compared with 10% in an average clinical trial), 27 have no reliable change (31.4%, compared with 25-40% in an average clinical trial) and 59 (68.6%, compared with 50-65% in an average clinical trial) have reliably improved.

A further factor which makes these results particularly striking is that clinical trials typically exclude clients who have more than one presenting problem e.g. in this case they might include clients who only have depression. This practice-based research includes clients who are usually excluded from clinical trials on the grounds that they may be suicidal, and/or suffering with anxiety and/or panic attacks, and/or have a so-called 'personality disorder' and/or may have problems with drink or drugs, in addition to their depression.

The lowest line going across the graph is the boundary between 'depressed' and 'not depressed' at the subsequent measurement. Of the 86 clients who started with clinical depression, 46 (53.5%) have a subsequent measurement score that is both below the cut-off for 'depression', indicating they no longer meet the criteria for depression, and outside of the tramlines, so these improvements are 'reliable' - so called 'reliable and clinically significant improvement' (RCSI, Jacobson and Truax 1991).

One reason why clients do not always achieve reliable and clinically significant improvement in therapy, but by no means not the only reason, is if clients do not have enough sessions to make the changes they say they want to make.

This point is illustrated by considering those clients who started therapy with 'severe depression'. The graph above shows there were 32 clients (37.2% of 86) who started with severe depression (the extreme right-hand column on the graph). Of these 32 clients with severe depression, 6 (18.8%) still had severe depression at their subsequent measurement, 5 (15.6%) had moderate depression, 5 (15.6%) had mild depression and 16 (50%) were no longer depressed.

The clients who were no longer depressed at their subsequent measurement had on average 9.4 sessions (range 4-28), the still mildly depressed clients had on average 6.0 sessions (range 2-10), the still moderately depressed clients had on average 4.8 sessions (range 2-9) and the still severely depressed clients had on average 4.8 sessions (range 3-6, with one singular exception).

Restrictions upon the number of sessions are often placed by insurance companies or employers who need to manage their costs; sometimes things turn out that clients only have access to a limited number of sessions, e.g. relocation, change in circumstances, etc. Even so, this research suggests improvement in depression is often possible with only a relatively small number of sessions, even if there are other co-occuring symptoms.

1. American Psychiatric Association (2000) Diagnostic and Statistical Manual of Mental Disorders - Fourth Edition, Text Revision). Washington DC: Author.

2. Beck, A T, Steer, R A, and Brown, G K (1996) 'Beck Depression Inventory Manual - Second Edition'. San Antonio: The Psychological Corporation.

3. Elliott, R, Greenberg, L S and Lietaer, G (2004) 'Research on Experiential Therapies'. In M J Lambert (2004) 'Bergin and Garfield's Handbook of Psychotherapy and Behaviour Change' 5th Edition New York: John Wiley & Sons.

4. Jacobson, N S, and Truax, P, (1991) 'Clinical significance: A statistical approach to defining meaningful change in psychotherapy research'. Journal of Consulting and Clinical Psychology, 59(1), 12-19.

5. Lambert, M J, Hansen, N B, and Harmon, S C, (2010) 'Outcome Questionnaire System (The OQ System): Development and practical applications in healthcare settings'. In M Barkham, G E Hardy and J Mellor-Clark (2010) 'Developing and delivering practice-based evidence: A guide for the psychological therapies' Chichester: John Wiley & Sons.