Improvement in Clinical Outcomes in Routine Evaluation (CORE) outcome scores because of talking therapies provided by a national crisis helpline

Introduction Telephone crisis helplines provide around the clock support for individuals experiencing crisis situations, phys- ical/mental illness or experiencing suicidal related behaviour. Lifeline is a telephone crisis helpline which also offers talking therapies and face-to-face counselling sessions. The objective of this study was to examine changes in ‘Clinical Outcomes in Routine Evaluation’ (CORE) scores in those who participated in talking therapy packages provided by Lifeline. CORE scores which reflect quantitative data on the individual’s psychological state (before and after completion of talking therapy) was captured using two forms of CORE measuring tools. Methods CORE assessments were carried out for 5,578 individuals before-and-after they engaged with talking therapy from Lifeline between 2013-2020. Two forms of CORE measuring tools were used (CORE-OM and CORE-10). Mean scores for each client from pre-therapy assessments were compared to mean scores from post-therapy assessments for each form of measure. Results There was a significant decrease in CORE scores (p <0.001 for CORE-OM and CORE-10) across all forms from pre-therapy to post-therapy, signifying that clients’ mental wellbeing improved as a result from talking therapies provided by Lifeline. The proportion of clients who made Reliable and Clinically Significant Improvement (RCSI), Reliable Improvement (RI) No Reliable Improvement (NRI) and Reliable Deterioration (RD) for each CORE measurement are discussed. Conclusion Results demonstrate that talking therapy packages provided by crisis helplines can be effective in reducing levels of psychological distress in those who utilise the service. Robin Turkington, Catherine Millman, Maurice Mulvenna, Edel Ennis, Raymond Bond, Colin Gorman School of Computing, Ulster University, Belfast, UK Public Health Agency, Belfast, UK https://orcid.org/0000-0002-0257-3721 School of Psychology, Ulster University, Coleraine, UK

Introduction Telephone crisis helplines provide around the clock support for individuals experiencing crisis situations, physical/mental illness or experiencing suicidal related behaviour. Lifeline is a telephone crisis helpline which also offers talking therapies and face-to-face counselling sessions. The objective of this study was to examine changes in ‘Clinical Outcomes in Routine Evaluation’ (CORE) scores in those who participated in talking 1 Posted on 24 Mar 2025 — The copyright holder is the author/funder. All rights reserved. No reuse without permission. — https://doi.org/10.22541/au.174279079.90492250/v1 — This is a preprint and has not been peer-reviewed. Data may be preliminary. therapy packages provided by Lifeline. CORE scores which reflect quantitative data on the individual’s psychological state (before and after completion of talking therapy) was captured using two forms of CORE measuring tools.

CORE assessments were carried out for 5,578 individuals before-and-after they engaged with talking therapy from Lifeline between 2013-2020. Two forms of CORE measuring tools were used (CORE-OM and CORE- 10). Mean scores for each client from pre-therapy assessments were compared to mean scores from post- therapy assessments for each form of measure.

There was a significant decrease in CORE scores (p <0.001 for CORE-OM and CORE-10) across all forms from pre-therapy to post-therapy, signifying that clients’ mental wellbeing improved as a result from talking therapies provided by Lifeline. The proportion of clients who made Reliable and Clinically Significant Improvement (RCSI), Reliable Improvement (RI) No Reliable Improvement (NRI) and Reliable Deterioration (RD) for each CORE measurement are discussed.

Results demonstrate that talking therapy packages provided by crisis helplines can be effective in reducing levels of psychological distress in those who utilise the service. MeSH Keywords: Counselling, Mental Disorders, Mental Health, Psychological Distress, Suicidal Ideation, Telephone

Telephone Crisis Helplines, Counselling, Mental Health, CORE-OM, CORE-10, Lifeline NI

Crisis helplines According to the World Health Organisation, around 800,000 people die by suicide each year (World Health Organisation, 2019). There have been numerous strategies and interventions developed to tackle this global health issue. One of the most popular forms of suicide prevention interventions are telephone crisis helplines. Telephone crisis helplines aim to help people who are experiencing a personal crisis situation. Normally, these services operate 24 hours per day, 7 days per week and all year round. They are deemed as an immediate, impactful and cost-effective resource. Their aim is to aid callers in creating a plan to help manage the crisis situation, whether they are experiencing suicidal related issues, physical or mental ill-health or other interpersonal difficulties (Kalafat et al., 2007; Spittal et al., 2015). Much of the research on telephone crisis helplines has investigated the types of callers which have availed of the service based on their caller behaviour and interactions with the service through qualitative approaches (Middleton et al., 2016) and through analysing large telephony datasets (Spittal et al., 2015; Grigorash et al., 2018; O’Neill et al., 2018). Other studies have explored the effectiveness of crisis helplines in de-escalating levels of psychological distress and changes in caller’s suicidal state (Gould et al., 2007; Kalafat et al., 2007; Mishara et al., 2007). Lifeline is Northern Ireland’s regional crisis helpline, which has been in operation since 2008 un- til present day, as part of the Protect Life 2 - Suicide Prevention Strategy11https://www.health- ni.gov.uk/publications/protect-life-2-suicide-prevention-strategy . Service users who contact Lifeline are as- sessed within 24 hours. Individuals who contact the service undergo a needs assessment and, if appropriate, are offered additional face-to-face counselling service with the aim of mitigating their crisis situation and/or improve their overall mental wellbeing. All Lifeline counsellors were BACP/IACP registered (or working towards) and had received suicide prevention training and in-house training on procedures that include risk assessment and identification of main presenting issues. Clients are offered a package of talking therapies, which usually consist of around 6 sessions but the number of sessions can be increased following a clinical 2 Posted on 24 Mar 2025 — The copyright holder is the author/funder. All rights reserved. No reuse without permission. — https://doi.org/10.22541/au.174279079.90492250/v1 — This is a preprint and has not been peer-reviewed. Data may be preliminary. case review (M=5, range 1-17 sessions). Therapeutic intervention is person-centred and therefore tailored to client need. The majority of counselling sessions are conducted face-to-face (approximately 83%) but telephone counselling is offered based on client need. Clients are assessed on what is considered the most important aspects of their psychological well-being using one of a battery of measures from the Clinical Outcomes in Routine Evaluation (CORE). The main form of CORE is the CORE Outcome Measure (CORE-OM). This tool was designed to be a non-proprietary measure of psychological distress, and its creation was informed by feedback of practitioners within psychotherapy (Mellor-Clark et al., 1999; Barkham et al., 2006). This tool has been validated and verified for use in primary care (Gilbody et al., 2007; Holmqvist et al., 2014) and in secondary care (Barkham et al., 2001; Barkham et al., 2006). It is not known how many other crisis helplines offer similar services nor whether they have a positive impact on the client’s mental wellbeing. Using data provided by Lifeline, the current study examines whether the psychological distress of individuals reduces as a result of participating in talking therapy provided by the service. In this study, we examine the change in outcomes from two different CORE measures at pre-therapy to post-therapy. Call data was collected in the period 23 September 2013 – 30 October 2020. We determine the proportion of individuals who have improved or deteriorated according to the two variations of the CORE questionnaire, and to what magnitude in which they have done so.

Materials There are different variations of CORE tools which can be used to assess the severity of mental health problems. In the context of the current study, results from two forms of the CORE system were used: CORE-OM, and the CORE-10. The full CORE-OM was administered for self-completion at the first and final counselling sessions within the package offered to clients. The CORE-10 was administered in all other sessions but could be completed at first and final sessions if the client preferred. Descriptions of each of these tools are as follows. The Core Outcome Measure (CORE-OM) is a 34-item questionnaire used to measure levels of psychological distress. This is a self-report questionnaire which is designed to be implemented before and after therapy and uses a 5-point Likert scale. According to Evans et al., (2002), the CORE-OM measures four different domains: 1. Well-being (4-items) 2. Symptoms (12-items) 3. Function (12-items) 4. Risk (6-items) In total, there were 5,067 individuals who completed therapy, their package of counselling (M=5 sessions) with the use of CORE-OM; 224 of these individuals completed therapy more than one package of counselling, therefore, the total number of completed therapy plans (using the CORE-OM) available for analyses is 5,294. Another adapted version of the CORE-OM is the CORE-10 which is a 10-item version. Items cover anxiety (2 items), depression (2 items), trauma (1 item), physical problems (1 item) functioning (3 items - day to day, close relationships, social relationships) and risk to self 1 item). The measure has 6 high intensity/severity and 4 low intensity/severity items. In total, there were 257 individuals who completed treatment using the CORE-10, with 2 of these individuals completing more than one package of treatment. Therefore, the total number of completed treatments (using CORE-10) available for analyses is 259. 3 Posted on 24 Mar 2025 — The copyright holder is the author/funder. All rights reserved. No reuse without permission. — https://doi.org/10.22541/au.174279079.90492250/v1 — This is a preprint and has not been peer-reviewed. Data may be preliminary. Level of Improvement There has been much discussion within counselling literature in trying to determine what constitutes as a meaningful therapeutic change in an individual’s condition. Jacobson and Truax (1991) described two basic principles to help provide practitioners determine whether individuals have made meaningful improvement as a result of undergoing treatment or therapy for their condition: Reliable change: The reliable change index (RCI) shows the degree of change in a measure which may have occurred by chance or by measurement error. It is essential that when examining pre-post change in the individual’s state that the level of change has exceeded past this point (Jacobson & Truax, 1991; Mullin et al., 2006; Barkham et al., 2006). In relation to CORE measurements, the RCI which has been broadly used is .48 (rounded up to .5), which is a clinical score of 5. If individuals show an improvement greater than or equal to 5 from pre to post measurement, then practitioners can be confident that reliable change has been made as a result of treatment. Clinical Improvement: In relation to CORE measurements, the clinical cut-off relates to whether individuals belong to clinical or non-clinical populations. An accepted cut-off point for CORE measurements is 10. There are 6 types of bands in which an individual completing CORE measurements can belong to: Healthy (0 to <6); Low Level (6 to <10); Mild (10 to <15); Moderate (15 to <20); Moderately Severe (20 to <25); Severe (Over 25). An individual completing CORE who scores within ‘Healthy’ and ‘Low Level’, a score of below 10, (pre or post) is suggestive of belonging to a non-clinical population. Whereas individuals scoring higher than 10 are considered as belonging to a clinical population. An example of clinical improvement would be if an individual scores above 10 on the CORE-OM in pre-treatment, but scores below 10 post-treatment, then practitioners can conclude that individuals have made the criteria for clinical improvement. Mullin and colleagues (2006) describe four types of main outcomes from pre to post completion of the CORE questionnaire. Firstly, reliable and clinically significant improvement (RCSI): In research which aims to evaluate therapeutic change, a broadly accepted criterion is RCSI. As proposed by Jacobson and colleagues (Jacobson et al., 1984; Jacobson & Revenstorf, 1988; Jacobson & Truax, 1991), there are two main criteria for RCSI. Firstly, improvement in outcomes from pre to post must be reliable, that is, being large enough that it cannot be attributed to measurement error. Secondly, the improvement must be clinically significant, which is described by Jacobson and Truax (1991) as beginning in dysfunctional clinical population and ending in the functional clinical population or moving above to below a clinical cut-off score as determined by experimenters (Jacobson and Truax, 1991; Barkham et al., 2006). Reliable improvement is an improvement by 5 or more in the clinical score, while clinical improvement is moving from above to below the clinical cut-off from pre to post treatment (Mullin et al., 2006). Secondly, reliable improvement (RI): This is when clients have made the criteria of reliable improvement but did not make the criteria of clinical improvement. An example here is when a client makes an improvement of 5 or more but does not cross the clinical cut-off from pre to post therapy. Also, we take into consideration the proportion of clients who showed RI, we clarify the amount of these clients who were above (RI A) or below (RI B) the clinical cut-off to begin with. The third main outcome is no reliable improvement (NRI): Clients who have made no reliable change are those who failed to meet the criteria of reliable improvement. A client who makes an improve of up to 4, makes no improvement with a score of 0, or worsens from pre to post by up to 4 points can be considered as making no reliable improvement. The analysis was conducted following a similar procedure to Mullin et al. (2006). There were some clients who met the criteria for clinical improvement (that is, crossing the clinical cut-off point of 10 from pre to post therapy), but did not meet the criteria of making reliable improvement (an improvement of 5 or more points). We state that these clients cross the clinical cut-off but did not make reliable improvement (CI NRI); these clients were ultimately classified as NRI, as to otherwise state that they have clinically improved may be misleading (Mullin et al., 2006). We clarify which proportion of clients who did not make the criteria for clinical or reliable improvement but were either above clinical 4 Posted on 24 Mar 2025 — The copyright holder is the author/funder. All rights reserved. No reuse without permission. — https://doi.org/10.22541/au.174279079.90492250/v1 — This is a preprint and has not been peer-reviewed. Data may be preliminary. cut-off (NCI NRI A) or below the clinical cut-off (NCI NRI B). Lastly, we state the proportion of clients who made NRI when their pre to post scores deteriorated (NRI D). Lastly, reliable deterioration (RD): Clients who have shown reliable deterioration were more than 5 points worse from pre to post treatment. Data Analytics and Statistical Software R Studio (version 3.5.1) was used throughout. The tidyverse package was used for the data wrangling process, while base R was used to conduct statistical analyses. ggplot2 package was used to create visualisations. A Welch Two Sample t-test was used for hypothesis testing using an alpha value of 0.05 when testing for statistical significance.

Descriptive Statistics Core-OM Results A Welch Two Sample t-test was conducted to compare mean CORE-OM scores between Pre and Post therapy. Statistical differences were found between both conditions (t(10527)=75.435, p <0.001). Figure 1 displays the distribution of scores of those clients who completed the CORE-OM tool. Figure 1. Plots of CORE-OM Scores before and after talking therapy. Clients had a higher mean CORE measure score in the pre-therapy condition (M=19.45, SD=6.16) than in the post-therapy condition (M=10.04, SD=6.66). Scores were non-normally distributed, with pre-therapy showing skewness of -0.09 (SE=0.08) and a platykurtic distribution (kurtosis=-0.37); post-therapy condition showed skewness of 0.79 (SE=0.08) and had a leptokurtic distribution (kurtosis=0.19). Pre-therapy condition scores ranged from 0-37 (Median=19, IQR=9) while post-therapy scores ranged from 0-38 (Median=9, IQR=9). Whilst the central tendency statistics (mean and median) changed from pre to post scores, the standard deviations and interquartile ranges were similar. 5 Posted on 24 Mar 2025 — The copyright holder is the author/funder. All rights reserved. No reuse without permission. — https://doi.org/10.22541/au.174279079.90492250/v1 — This is a preprint and has not been peer-reviewed. Data may be preliminary. Figure 2. Number of clients per band (CORE-OM). In Figure 2, akin to a reflection in a mirror, we can see an inverse trend in the number of clients per band from pre to post therapy (results in Table 1). In the Pre-Treatment condition, we see a steep increase from the number of clients in the “Low Level” risk band to “Mild”, and then again to “Moderate”; from here, the number begins to decrease. There is a visible decrease across all bands in the post-treatment condition, with a shift in the bulk of clients being classed within the “Healthy”, “Low Level” and “Mild” bands. Table 1. Number of clients per band (CORE-OM) from Pre to Post therapy. Band Pre-Therapy Post-Therapy Abs. difference Healthy 55 (1.04%) 1579 (29.81%) 28.77% Low Level 250 (4.72%) 1282 (24.21%) 19.49% Mild 872 (16.47%) 1187 (22.41%) 5.94% Moderate 1488 (28.1%) 702 (13.26%) 14.84% Moderately Severe 1472 (27.8%) 384 (7.25%) 20.55% Severe 1158 (21.87%) 162 18.81% Total 5295 (100%) 5296 (100%) As can be seen in Table 1, while 5.76% of clients are in the Healthy or Low Level bands pre-therapy when entering the service, a majority of 54.02% of clients post-therapy exit the service in the Healthy or Low Level bands. CORE-10 Results A Welch Two Sample t-test was conducted to compare mean CORE-10 scores between Pre and Post treat- ment. Statistical differences were found between both conditions (t(503.42)=12.205, p <0.001). Figure 3 displays the distribution of scores of those who completed the CORE-10 tool. 6 Posted on 24 Mar 2025 — The copyright holder is the author/funder. All rights reserved. No reuse without permission. — https://doi.org/10.22541/au.174279079.90492250/v1 — This is a preprint and has not been peer-reviewed. Data may be preliminary. Figure 3. Distribution plots of CORE-10 scores. Clients had a higher mean CORE measure score pre-therapy (M=21.16, SD=6.42) than in post-therapy (M=13.74, SD=7.35). Scores were non-normally distributed, with the pre-therapy condition showing skew- ness of -0.17 (SE=0.4) kurtosis was -0.13; post-therapy showing skewness of 0.20 (SE=0.46), kurtosis de- creased to -0.6. Both conditions show platykurtic distributions. Pre-therapy scores range from 3-28 (Me- dian=22, IQR=8); post-therapy scores range from 0-35 (Median=14, IQR=12). Figure 4 displays the number of clients per band from pre-therapy to post-therapy conditions after completing the CORE-10 (results in Table 2). Figure 4. Number of clients per bands (CORE-10). We see a gradual increase from ‘Healthy’ to ‘Moderately Severe’ (peaking at ‘Moderately Severe’). We see a reduction in ‘Moderate’, ‘Moderately Severe’ and ‘Severe’ conditions from pre-therapy to post-therapy 7 Posted on 24 Mar 2025 — The copyright holder is the author/funder. All rights reserved. No reuse without permission. — https://doi.org/10.22541/au.174279079.90492250/v1 — This is a preprint and has not been peer-reviewed. Data may be preliminary. conditions; the biggest proportion of clients are within the ‘Mild’ band. Table 2. Number of clients per band (CORE-10) from Pre to Post Therapy. Band Pre-Therapy Post-Therapy Healthy 3 37 Low Level 7 46 Mild 33 57 Moderate 58 49 Moderately Severe 84 52 Severe 73 16 Summary of CORE Outcomes Table 3 summarises the numbers and percentage of clients per main outcome across both CORE tools included in this analysis. Out of the total number of clients who completed the CORE-OM after the talking treatments, 2480 (46.85%) of clients showed reliable and clinically significant improvement after the therapy (RCSI). 1625 (30.53%) of clients did not show clinical improvement (their pre-post scores did not cross the clinical cut-off point of 10) but showed reliable improvement (RI). 1135 (21.44%) clients showed no reliable improvement (NRI) and 54 (1.02%) deteriorated (RD). Table 3. Summary of Main Outcomes per CORE tool (as percentages). Main Outcome CORE-OM % CORE-10 % RCSI 2480 (47%) 72 (28%) RI 1625 (31%) 95 (37%) NRI 1135 (21%) 80 (31%) RD 54 (1%) 9 (4%) Out of the total number of clients who completed the CORE-10, 72 (28.4%) showed RCSI, 93 (37.36%) showed RI, 80 (31.37%) showed NRI and 9 (3.54%) showed RD. Figure 5 shows the percentage clients per main outcome across both CORE tools. 8 Posted on 24 Mar 2025 — The copyright holder is the author/funder. All rights reserved. No reuse without permission. — https://doi.org/10.22541/au.174279079.90492250/v1 — This is a preprint and has not been peer-reviewed. Data may be preliminary. Figure 5. Percentage clients per main outcome across both CORE tools. Table 4 provides detail on the numbers and percentage of clients per sub-outcome across both CORE tools included in this analysis. Table 4. Main & Sub Outcomes per CORE Tool. Main Outcome Sub Outcome CORE-OM Total/Percentage CORE-10 Total/Percentage NRI CI NRI 92 (1.74%) 5 (1.96%) NCI NRI A 855 (16.15%) 71 (27.84%) NCI NRI B 179 (3.38%) 3 (1.18%) NRI D 9 (0.17%) 1 (0.39%) RCSI – 2480 (46.95%) 72 (28.24%) RD – 54 (1.02%) 9 (3.53%) RI RI A 1518 (28.67%) 92 (36.08%) RI B 107 (2.02%) 3 (1.18%) Total – 5294 256

for RCSI and RD have been previously mentioned. In relation to the CORE-OM, the number of clients who made RI A were 1518 (28.67%) and the number of clients who made RI B were 107 (2.02%). Regarding the types of NRI outcomes, 92 (1.74%) clients were classed as having made CI NRI, 855 (16.15%) were classed as having made NCI NRI A, 179 (3.38%) made NCI NRI B and 9 (0.17%) made NRI D. In relation to the CORE-10, the majority of clients made RI A; 92 (36.08%), while 3 (1.18%) clients made RI B. Regarding the NRI outcomes, 5 (1.96%) clients made CI NRI, 71 (27.84%) made NCI NRI A, 3 (1.18%) made NCI NRI B and 1 (0.39%) made NRI D. 9 Posted on 24 Mar 2025 — The copyright holder is the author/funder. All rights reserved. No reuse without permission. — https://doi.org/10.22541/au.174279079.90492250/v1 — This is a preprint and has not been peer-reviewed. Data may be preliminary.

The aim of this study was to examine the effectiveness of talking therapy packages, provided by a telephone crisis helpline, on improving the mental wellbeing of the individuals availing of the service. The findings show that, on average, the mental wellbeing of individuals who engage in talking therapies tend to improve significantly for those who have a planned ending to therapy. There appeared to be an inverted trend in the number of clients within the risk bands, with a decrease in the number of clients who scored above the clinical cut-off point prior to talking therapy, to an increase in the number of clients below the clinical cut-off post talking therapy across both forms of the CORE measurements used. As well, there was a clear decrease of average CORE score from pre to post talking therapy. The proportion of clients who either improve in some aspect, show no improvement or show deterioration tend to vary depending on the type of CORE measurement used. For those clients who completed CORE-OM, nearly 47% showed reliable and clinically significant improvement, nearly 31% showed reliable improvement, around 21% of clients showed no reliable improvement and 1% of clients showed reliable deterioration. With regards to clients completing the CORE-10, around 28% showed reliable and clinically significant improvement, 37% showing reliable improvement, nearly 32% showing no reliable improvement and nearly 4% showing reliable deterioration. The current study also examined the proportion of clients within each main outcome that scored above or below the clinical cut-off. Just under one-third of all clients, across all measures, achieved reliable improvement only but remained above the clinical cut-off. While these clients are still within the clinical population, this suggests that this proportion of clients are making a recovery and that their mental state is improving. There was a much smaller proportion of clients who made reliable improvement but were below the clinical cut-off from pre to post assessment (RI B); around 1.2-2.0% of clients across all measures met this criterion. Results for those clients who achieved clinically significant improvement, but not reliable improvement (CI NRI) ranged from 1.7-2.0% across both forms. For those clients who did not achieve clinical or reliable improvement and were above the clinical cut-off (NCI NRI A), the proportion of clients ranged from 16.0-28.0% across all both forms. It could be suggested that talking therapies may be ineffective for these clients with this outcome, or that further sessions were required to achieve clinically significant and reliable improvement. Also, the proportion of clients who did not meet the criteria for clinically significant and reliable improvement but were below the clinical cut-off (NCI NRI B), ranged from 1.2-3.4% From an operational point of view, it could be viewed that proceeding with talking therapies with clients who are classed as being within the non-dysfunctional population (people who score beneath the clinical cut-off) to begin with, is an unnecessary use of service resources. As well, these clients cannot meet the criteria of clinically significant improvement, as they do not cross the clinical cut-off point (Mullin et al., 2006). However, excluding such clients from further therapy sessions could result in an eventual deterioration of their mental state, thus requiring intervention at a later stage, and that such a service should not exclude clients that have been referred to the service based on this reason. Furthermore, a systematic review highlighted a limitation in completing CORE measures which centers around the clients’ ability to complete the CORE measures (Duncan & Murray, 2012). It is possible that difficulties in understanding CORE items may result in low mean scores on entry into counselling. Importantly, it is recommended that decisions about therapy are made based on wider contextual information and Barkham et al. (2005) argue that the self-report CORE measure is used in conjunction with the practitioner-completed Therapy Assessment form (CORE-A). The combination of the CORE measures and the CORE-A are used within the Lifeline service to inform decision-making for therapeutic intervention. Therefore, it would not be appropriate to exclude clients categorized below clinical cutoffs based solely on the self-completed CORE measures. Policy and practice implications It would be beneficial for other crisis helplines to adopt face-to-face counselling service and to offer talking therapy packages to clients for several reasons. Adopting such a model may help increase the appeal of crisis helplines as an option which offers a comprehensive service for individuals who may be experiencing a 10 Posted on 24 Mar 2025 — The copyright holder is the author/funder. All rights reserved. No reuse without permission. — https://doi.org/10.22541/au.174279079.90492250/v1 — This is a preprint and has not been peer-reviewed. Data may be preliminary. crisis or mental health issues. Having an additional option such as this service can help to empower those individuals who are experiencing mental illness. It can help in bypassing some of the common barriers to treatment/therapy, such as lengthy waiting times to be seen by a consultant/practitioner, or even act as an alternative to (or complement) some medication such as antidepressants, which can have some unfavourable side effects. Having such an additional choice can help individuals with creating a bespoke treatment plan which would allow them to have an improved self-image and to reach their treatment goals (Chinman et al., 1999; Linhorst et al., 2002). However, as this is not a common service which is offered by other crisis helplines, there needs to be further research into the effectiveness of such a service and development of practices so that such a service is delivered in an appropriate and efficient way.

and Future Work Firstly, the current study included clients who had completed both a pre and post treatment CORE assess- ment. There were a proportion of clients within the current dataset who completed a pre therapy CORE assessment but did not complete a post therapy assessment. There are a couple of possible explanations for this. For instance, such clients may not have returned to participate in further talking therapy sessions, or that clients did return to complete further talking therapy sessions and a post assessment, but only after the end of the observable dataset. For these reasons, it is not possible to determine whether talking ther- apy packages provided by Lifeline was effective in improving the mental well-being of these individuals. A

may also be the use of t-tests as some may infer to use an alternative test given the results for skewness and kurtosis. Another limitation is that the number of talking therapy sessions per client was not taking into consideration for the current study. As an idea for future research, it would be of interest to determine whether there is any relationship between the number of talking therapy sessions a client takes and the type of outcome that they have at the post therapy stage. In doing so, it could be possible to determine the optimum number of sessions required to have a positive, or even a detrimental outcome. Other analysis including bivariate and multivariate analysis could be carried out to determine any relationships between CORE score changes and demographic variables (e.g. gender, age etc.) Further work could also characterise the cohort that do not improve as a result of the therapy. Detailed analysis of individual CORE items/questions pre and post therapy would also shed light on which items typically see the most and least change as a result of the therapy. Clustering on the item-by-item pre-post changes may also reveal the types of clients that improve in different ways. Moreover, AI-based algorithms could also be developed and tested to predict CORE outcomes based on the initial characteristics/features of clients entering the service.

Telephone crisis helplines are widely used by those experiencing crises, physical/psychological distress, and suicidal behaviour. This study examined the effectiveness of talking therapies provided by a national tele- phone crisis helpline in alleviating mental distress. Clients either completed CORE-OM or CORE-10 in which scores were collected at pre and post stages of therapy and then compared. Across both measures, significant differences in scores were found between pre and post therapy, with a large proportion of clients showing improvement in their condition. The findings from this study lends support for the adoption of face-to-face counselling services by crisis helplines, as results suggest that it is beneficial in reducing levels of crises and mental ill-being experienced by individuals who avail of Lifeline. Ethical approval Ethical approval for this research was granted by the Ethical Committee at Ulster University. 11 Posted on 24 Mar 2025 — The copyright holder is the author/funder. All rights reserved. No reuse without permission. — https://doi.org/10.22541/au.174279079.90492250/v1 — This is a preprint and has not been peer-reviewed. Data may be preliminary. Acknowledgments The authors would like to thank Contact NI, Lifeline NI and the Public Health Agency Northern Ireland for providing the service data. Declaration of conflicting interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or pub- lication of this article: This study was funded by the Department for the Economy for Northern Ireland.

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