Season 1, Episode 6: How Do We Know Counselling Works?
How do we know counselling works?
Your physical vital signs can be easily measured, but when it comes to mental health, how do we know that clients are benefiting from the counselling process?
In this episode, we talk with Cathy Keough, registered social worker and Director of Counselling Initiatives at Calgary Counselling Centre about the effectiveness of counselling, and how we can measurably see the difference counselling makes in people's lives. Learn how we ensure counselling treatment works, what tools you can use to help manage your mental health, and what to expect before and during your initial appointments at Calgary Counselling Centre.
Learn more about how we know counselling works:
Rousmaniere, T. (2017, April). What Your Therapist Doesn't Know. The Atlantic.
Anderssen, E. (2018, April 7). Rethinking therapy: How 45 questions can revolutionize mental health care in Canada. The Globe and Mail.
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Katherine Hurtig
Welcome to Living Fully, a Calgary Counselling Centre podcast. Each episode, we’ll bring you insights from our expert counsellors and tips and strategies to improve your mental well-being. I'm your host, Katherine Hurtig.
Calgary Counselling Centre and Counselling Alberta provide effective counselling for anyone in Alberta with no wait list and no financial barriers. Find us online at calgarycounselling.com or counsellingalberta.com.
In this episode, I'll be talking to Cathy Keough. She's the Director of Counselling with Calgary Counselling Centre and she's a registered social worker with over 25 years of clinical experience.
We're going to talk about measuring the effectiveness of counselling - so basically, how we know that counselling works. How we can measurably see the changes that counselling makes and how it can improve lives.
Katherine Hurtig
There’s a lot of aspects of our health that can be measured. Vital signs like our body temperature, heart rate and blood pressure they can let us and our doctors know if there's something not quite right, but when it comes to mental health and counselling, there's this idea that it's a bit more of a guessing game. Sitting on the stereotypical couch, talking to a stranger who’s taking notes, and it can seem like there's not a lot of concrete science behind what's going on or that the process of counselling is simply talking to someone about our feelings. How do we know that counselling works? How do we know that if you come to see a counsellor and you're struggling with anxiety or the loss of a loved one, or if you're having trouble in your relationships, that you can make changes and start to feel better and see positive results?
So, Cathy, can you start by telling me a bit about yourself in your background?
Cathy Keough
So my name is Cathy Keough. I'm the Director of Counselling Initiatives at Calgary Counselling Centre. I've been with Calgary Counselling Centre for many, many years, and I've been in the field of counselling or clinical counselling for over 30 years.
I've worked in crisis. I've worked in family violence. I've worked from a strength based perspective. I've worked from a solution focused perspective. I've worked from many perspective because the field changes continually. And I was drawn to Calgary Counselling Centre because of the innovative work that they were doing in the counselling field, and their focus on research, and that really intrigued me.
Going back to your question, how do we know counselling works - well, we've got over 40 years of clinical research in the field that tells us that counselling works, but there's a heated debate on what kind of counselling works best, and that's what I was interested in. Is there any data or research that indicates what works best for a particular problem or a particular person? And what we know at the this point is no, there isn't. There isn't one model or approach that works equally well for everyone all the time. So then it was of interest how to know when to do what and with whom. And in early 2000s, Calgary Counselling Centre was looking at that very same question. So like-minded people got together and our CEO, doctor Robbie Babins-Wagner, was at a conference and heard a speaker talk about an approach called Feedback Informed Treatment, which included a brief questionnaire that gives us mental health vital signs and another brief questionnaire just about the relationship or alliance between the counsellor and the client. Because over the many years, the 40 years, we understand that relationship is one of the key healing factors. So we had the opportunity to look at both of these tools and then to integrate it completely into our clinical work. And I think that was a big turnaround time in terms of the therapy world in general, but especially how Calgary Counselling uses Feedback Informed Treatment.
Katherine Hurtig
Right. So let's talk about these questionnaires and how Calgary Counselling Centre uses them with their clients. You talked about one that measures mental health vital signs. What's the experience for a client?
Cathy Keough
So the experience for a client would be, we use this at each and every session or meeting, no more than once per week. It's 45 brief questions that asks for information from sort of psychological approach, a cognitive approach, a behavioral approach, an emotional approach, spiritual approach - and flags the areas where people are doing well and where they have resources and support and also flags areas where there might be struggles and how this would look would be, that this is sent by an app to the client and they complete it, typically 24 hours before their session The counsellor reviews that, it comes back in to the counsellor. They review it before the session and then they'll open their session by asking for feedback from the client. “Does this fit? Does this make sense to you? Is there anything else you want to add? Is what we're doing working? Is it approaching the needs and the wants that you have right now? Are there other areas that we have to explore?” It also tells us if there's sort of more emergent or more sort of pressing concerns that the client and the counsellor can talk about together to look at where there's a piece around personal functioning that could really be getting in somebody's way. So it helps us prioritize the work. Prioritize with the conversations could look like.
And what we really want is to collaboratively be able to get a nice fit between the client and the counsellor about: what are we doing. What are we working on? How will this show up in your life? How will you know it? Who else would notice? And again, if there's anything else, how we can prioritize?
Now counselling works, but there are cases where it isn't going as expected - where somebody could even get worse under therapeutic care or where there's that risk of things staying the same. So these tools help the counsellor and the client address these issues if they are occurring early on so that there could be adjustments or adaptations to try to look at how do we fine tune this so that we can move and start getting on the track that we need to so the client experience is relief.
Katherine Hurtig
OK. so if there is a situation where a client is getting worse, what does the counsellor do? What actions are taken to reverse that?
Cathy Keough
Well, and this isn't talked a lot in in counselling, that there is a possibility that somebody could get worse for a lot of different reasons. The stressors might be getting worse. There could be something that's unexpected that had happened. There could be another part that the client hadn't considered that now would become important. Or it could also be something within the relationship between the client and the counsellor. That the counsellor wants more sort of specific feedback because they're trying to make this as personal and unique an experience as possible for the client and they might need to make some adjustments to their approach or to how they say things, or how they hear things, or what they're working on. Is the work that we're doing meaningful to you? Are the tasks appropriate? Do you think your point of view is being incorporated in the work that we're doing?
So the counsellor is listening carefully to whatever feedback they can get. And sometimes people give us great feedback, sometimes it's hard and they need to practice how to give feedback so the counsellor can make adjustments. And once the counsellor and the client kind of have that level of conversation and we're looking at how do we navigate the relationship maybe a little bit differently, maybe build some more trust or maybe we need to say things in a different way. Then we're going to monitor or measure that again to see if within a couple of sessions, does that make any difference? And usually it does, although there could be times when maybe it doesn't and then there be another conversation. Because we will work with people for as long as they're experiencing benefit. So we don't have a set number of sessions. What we're looking for is for therapy to be effective, for people not to be left feeling stressed or in pain. Sometimes we're able to do that and on some rare occasions we might need to refer to other services, but usually that type of conversation helps us recalibrate or reset and then the client and the counsellor continue and they move on with the work.
Katherine Hurtig
So you mentioned a couple of times about the relationship between the client and counsellor and that there's a questionnaire that that addresses that specifically. Can you talk a little bit about that?
Cathy Keough
So at the end of each session, it's a typical structure to leave time to be able to… the counsellor will send another brief tool - it's 10 questions that will ask for some feedback about what was this experience with me like today? And that can be a new experience for people sometimes. They haven't done it before. They don't know really how to do it. Or it could be something that people are looking forward to because there's certain things that we could change or adjust.
So as a counsellor, sometimes I might say something in a way that would be calming and soothing to 8 out of 10 people, but it's not to two out of 10. And that's important for me to know because I have an approach, I'm trying to make this personal and unique, but I still have myself and my own experience and some of my own habits that sometimes get in the way. So any feedback that I can get – and there are questions like: my counsellor understood me, I felt my counsellor respected me, I felt the counsellor was working on what I wanted to work on - questions like that. And we're just looking for even little pieces of information that could make a difference in the relationship and in the counselling experience for the client.
Katherine Hurtig
Do you find that it comes easy to clients? I could imagine that if the person who bags my groceries asked, “how did I do today?” And I legit had a criticism, that might be hard to give in the moment, let alone someone who's working with you on a really personal level. Have you found that clients generally are really open to giving that feedback? Is it difficult to open them up to giving that?
Cathy Keough
That's a great question and my answer would be it depends. Not everyone has feedback to give every time or always, and sometimes it's hard to give feedback to somebody because you're afraid of what this might mean for them, or what will this mean for me and the counselling. So it's really important that the counsellor continues to revisit - the purpose would be to see how we can make this more unique and personal. Lots of times, people think “that's exactly what I needed. All the ingredients were here and I got what I needed and I don't really have any specific feedback.” So there's a way of marking the questionnaire that would just correlate highly with that day.
But there might be another day where, “no, something was glitchy or just didn't feel right. And even though I thought it wasn't important, when I think back on my session, I think it was. I think something kind of held me up for a moment.” So it’s a depends kind of question. What's important is that at our organization, counsellors are trained to be able to give and receive feedback, and that they really do embrace the feedback, which can be a hard thing for some people to understand I think, but that helps us stay informed. It helps us make choices and decisions. It helps us work together. And we really value that feedback. But we also appreciate it when either people don't really have any feedback or there's something else that's holding them back. We know that any of those things could arise and it's “can we work through that together bit by bit.”
Katherine Hurtig
So these questionnaires, how do you know that these tools are benefiting the clients that we work with?
Cathy Keough
The very first part is because the tool mainly is about the conversation. It's not like a measurement of good or bad or right or wrong. It's more about measuring what's the conversation like between the counsellor and the client and what are we working on, because often we're working to develop skills, develop resources, developing other ways of approaching things, other ways of making decisions. There's lots that can come into it. And the tool gives us an idea of the people who could benefit most from counselling, the people who might be approaching counselling because they have something very narrow that they want to work on, which might be a decision or something else. But it also tells us where there's improvements, where people are experiencing enhancements in their lives that show up in their life and other people can notice and recognize. And then we as counsellors get feedback from the client about “what do you think that's about? What's contributing to this? What else are you doing? When we stand for a moment and maybe don't respond, does that make a difference?
So it's about being kind of intentional and deliberate, but also very conversational because we know counselling works and we want people to experience those benefits as much as possible. And the tools kind of give us a bit of a road map of where we are, where they want to go, and then once they get closer to approaching their destination, how are they going to maintain the changes that they've made so that they move on and embrace other challenges of life.
One of the things that we all know more than ever is uncertainty is a part of what we all deal with. Change is something that we all deal with. There's opportunities that are continually inviting us into new situations, and there's also challenges around that. New things often can create anxiety. And anxiety can create avoidance and avoidance can create problem solving that maybe gets in our way, maybe worked at one time but isn't working now. So the tools help us gauge that and then work intentionally with the information, and with the idea that people should benefit and we know that they do.
We also know at our organization. There's kind of a baseline in counselling. We are well above that baseline in terms of benefit. So we know that our clients do well in their counselling and in their therapy. And we also know that our counsellors in training, that they're, we call them outcomes, that their way of working and approaching is really just the same as a full time registered person or in many cases slightly better. And there's reasons for that. But that's important for clients to know too. The healing for humans typically is a social experience, and sometimes when we're feeling overwhelmed or unhappy or sad, we tend to isolate, and that builds into other kinds of challenges, and the important piece is for people to seek help or to seek counselling earlier rather than later, and to be able to take some risk around engaging with conversation with another person around areas that are really tough to talk about.
Katherine Hurtig.
Walk me through a “typical first counselling session.” How do our counsellors get to know the client and come up with a plan and process on how to help them.
Cathy Keough
So they would have had a connection with their counsellor, either through e-mail or through some kind of telephone contact, introducing the counsellor, talking about counselling, talking a bit about what to expect, talking about the appointment and how long the appointment would be. Talking about the tools, letting them know that you can expect to receive these tools in this way, please complete between 24 hours and at the time of our session so that we can use them during our meeting. A session would be set up, and it could be, a lot of our work right now is remote or using kind of telehealth through our Microsoft Teams. There would be an invitation that would go out from the counsellor to the client. They would talk about the technology, how to set up technology and what to expect from that end. Also how to get in touch with the counsellor if something goes wrong. We always have lots of requests for therapy. We don't have a wait list and we want to be able to work as efficiently as we can. So if something comes up for a client, if they let us know, we can then rebook.
When they enter into the Teams meeting, there's a phase of introductions: talking a little bit about the counsellor, introduce themselves, talk about themselves, talk about the experience. They will then at that point talk to the client about the tools. Were they available? Were they easy to use? Did they have any other challenges and they would open up and share a graph. A graph gets generated. They would share that with the client. Explain it a little bit and that's the information comes from the tools we're talking about. Ask the client if this fits. Ask the client if this makes sense. Ask the client if there was anything surprising that they learned. They'd have a conversation between client and counsellor, and then the counsellor would ask, “what is it that you want? How can I be of help? If your concerns, if they were alleviated, what would that look like?” And they'd start an initial conversation about what's happening, what are you looking for and where do we go next?
Katherine Hurtig
OK. So it sounds like a lot of open-ended questions.
Cathy Keough
And getting to know each other, getting a feel for each other. Answering questions. I think there's an opportunity for curiosity, both from the counsellor’s perspective and the client’s perspective.
Katherine Hurtig
And then throughout those first those initial sessions, how does the counsellor kind of decide the best way for that particular client, like the best approach? Does that make sense?
Cathy Keough
That's an excellent question. What I would say is there's not usually one best approach There's many, many different ways that problems, situations, challenges can be approached.
Katherine Hurtig
Right, and of course, I bet it depends on what they're there for.
Cathy Keough
Exactly. It depends on what's bringing the person into counselling in the 1st place, but then it's collaborative. It's designed with the expertise, experience and lived experience of the counsellor with the expertise, experience and lived experience of the client to talk about what's going on, what's keeping this thing going for you? What have you already tried? Here's some other areas that maybe some skill building or strength building would really assist you. And often we're looking at when we're starting is where can we start with success, how do we start off to pick something where the person can start working on something in a different way and feel some success. And then we can move into other areas from that. But it's a great question - how do you prioritize what you work on? And it's often the client that gives us that information and often they give us a bit of a road map, and we're looking for what are their strengths and their resources that they have, and maybe where are some areas where further development would be really useful. Because maybe something's changed or grown or they're coping is not meeting the requirements or the need, or they're kind of getting lost in a lot of information and ruminating, which means kind of thinking through things over and over, but not being able to take meaningful action to kind of alleviate what else is going on, or solve problems or make decisions.
Katherine Hurtig
So it sounds like it's a lot about skill building.
Cathy Keough
That's, I think for many of us, that's where we sometimes we have to step outside of ourself. We're too stuck in our own frame of reference, our own mind for some of us. We're too focused on what everybody else thinks, and it's important that we understand when our needs are being met or not. It could be really many different ways. We're looking at what people have and then what can they develop that will give them another opportunity to approach whatever the situation that's bringing them in, or it depends on how complicated it is.
Katherine Hurtig
You’ve been listening to Living Fully, a Calgary Counselling Centre podcast, thank you for tuning in.
If you'd like to learn more about how we know that counselling works and about Feedback Informed Treatment, go to our show notes where we’ll link to a couple of articles, one from The Atlantic. The article is: What Your Therapist Doesn't Know by Tony Rousmaniere and another from The Globe and Mail called: Rethinking Therapy: How 45 Questions Can Revolutionize Mental Healthcare in Canada. Written by Aaron Anderson.
This episode was produced by Luiza Campos, and by me, Katherine Hurtig.
A special thanks to Cathy Keough.
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Living Fully is a production of Calgary Counselling Centre and recorded in Calgary, on Treaty 7 territory.
Living Fully podcast is not a substitute or alternative for professional care or treatment. If you're in Alberta and need help, please go to calgarycounselling.com or counsellingalberta.com
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