Myles Harris, Magic in the Surgery. Counselling and the NHS: A Licensed State Friendship Service, Social Affairs Unit (no place of publication given); Research Report 20, ISBN 0 907631 56 8, £5.50 (p/b), 38pp, 1994


Introduction
In a recently published polemical tract (called a 'research report') from the right-wing free market Social Affairs Unit, the view that counselling constitutes an effective form of health care intervention is disdainfully rejected. Harris's monograph is so replete with unsubstantiated innuendo, and grossly distorted and ill-informed analysis masquerading as 'fact', that it is quite frankly difficult if not impossible to treat it seriously.... And yet in another sense, it quite clearly must be taken seriously, for not only does it potentially add balast to the series of well publicised attacks to which counselling and psychotherapy have been subjected in the media in recent times, but the monograph is also produced by an ideologically driven free market pressure group which no doubt has the attentive ear of at least some influential members of the current Conservative government. For this latter reason alone, therefore, it is important that the 'arguments' developed in the report are carefully dissected and scrutinised to expose the uninformed misconceptions and ideological prejudices that underlie and feed them.

Some points of agreement
First, however, there were two points in which I found myself in some kind of agreement with Harris. First, I agree with his stated opposition (p.33) to the drive towards the professional registration of counsellors and psychotherapists (see, for example, Mowbray, 1995; House 1996a, forthcoming) - though I suspect that he would be as disdainful of my reasons for scepticism about the movement towards registration as I am critical of his.

Second, Harris makes the interesting point that 'Counsellors should be obliged to tell their clients, before they begin treating them, what their political and religious beliefs are and to which organisation they belong' (p.34). Of course, analytically inclined practitioners will likely object that such self-disclosure will interfere with the development of the transference and dilute the client's projections upon the counsellor/therapist; yet such practitioners must surely also acknowledge the power and depth of the introjection process, in which clients with significant developmental deficits or disturbances tend to introject the characteristics of their counsellor (the so-called 'introjection of the good-enough object' theorised by psychoanalyst W.R. Bion), which presumably includes attitudes, beliefs and so on. In the light of this process, some kind of case can certainly be made for the kind of disclosure at the start of counselling that Harris advocates: Mowbray (1995, pp. 205-9), for example, has carefully detailed what he calls 'full disclosure provisions', which '...are concerned with empowering the public to make informed decisions in their choice of practitioner by allowing them access to full relevant information' (p. 205) - which proposal, incidentally, forms one arm of Mowbray's programme for an accountable field that functions adequately without the need for statutory registration. Perhaps these arguments carry especial weight in contexts like GP surgery counselling, where many clients may effectively have little or no choice in whom they see for counselling help.

This complex question clearly needs more detailed consideration, but Harris has clearly given food for thought here. I suspect, however, that his motivation for this suggestion probably has more to do with his belief that those who work as counsellors are likely to hold to left-liberal political views and/or a morally relativistic Weltanschauung, than it has to do with any wider ethical or clinical considerations.

In the remainder of Harris's tract, however, there is very little that I can agree with, and much to which I take vehement exception. In the remainder of this review article, I will highlight the main points on which I strongly disagree with Harris's discussion. At this point it is appropriate to declare my own interest in this debate - for I work as a professional humanistic-dynamic counsellor in general practice in Norwich, and have done so for nearly six years. I have a passionate commitment, contra Harris, to the universal availability of humanistic-dynamic counselling within NHS general practice (see, for example, House 1994), and the arguments I develop in what follows should be seen in this context.

Points of divergence
First, at the most general level, Harris repeatedly invokes 'objective, empirical science' as the criterion against which counselling should have to 'prove' its efficacy (e.g. pp.13-14, 16, 20, 24, 27, 34); yet the substance of Harris's calculated attack on counselling is long on polemic and vituperative prejudice, and falls woefully short of being anything like a balanced, rational and objective consideration of the arguments. Apparently, his own standard of argumentation does not in his view have to fulfil the same truth criterion that he demands should be applied to counselling efficacy.

More specifically, the text is littered with highly selective and grossly misleading invocations of 'the evidence' about counselling's efficacy: Harris cites just two empirical studies from the GP counselling literature, based on research carried out around 1980! - and this from what is now a very considerable empirical literature on GP counselling (Corney, 1992; Corney and Jenkins, 1993). Thus, Harris chooses to highlight the very few empirical studies which appear to cast doubt on the efficacy of GP counselling, and completely ignores the very extensive number of clinical and empirical studies which have quite unambiguously pointed to the efficacy of GP counselling - particularly in terms of the subjective ratings given by clients of the GP-counselling experience (for reviews see Corney, 1992; House et al., 1994). It is also noteworthy that Harris offers no discussion of the very great, and quite possibly insurmountable, methodological difficulties entailed in carrying out controlled scientific studies of the counselling process (King et al., 1994; Mowbray, 1995) - as Mowbray graphically puts it, 'one cannot do a "double-blind" trial on a particular individual's life for the purpose of a control study. Reincarnation apart, we each only have one shot' (p. 107).

It should be noted in passing that Harris also unsurprisingly quotes with breathtaking selectiveness from the literature that questions the efficacy of psychotherapy - completely ignoring in the process both the mass of empirical evidence that supports psychotherapy efficacy (e.g. Smith et al., 1980; Milton, 1993), and also those studies that have decisively refuted the faulty methodology of the research he cites that is favourable to his case e.g. McNeilly and Howard, 1991).

Harris writes that 'In the accepted medical sense counselling does not work' (p.27, my emphasis), and 'counselling has no substantial agreed body of empirical scientific evidence to back its claims' (p.24) (note that for Harris, the medical-model world-view is 'accepted' and therefore apparently not open to epistemological scrutiny or criticism). It is a supreme irony that Harris may well be right here! - but for reasons very different from those he would posit, and which lead to conclusions very different from those reached by Harris. Thus, a humanistic perspective eschews and rejects a medical-model conception of the counselling process (House, 1996b), and, relatedly, sees the positivistic model of science as being singularly inappropriate for the study of the human psyche and human relationships (Castoriadis, 1995). Thus, that the efficacy of counselling is not supported by the kind of 'objective' empirical evidence favoured by Harris is not because it doesn't 'work' (as Harris is claiming), but because this very way of assessing and understanding the personal development and change that occur within an intersubjective relational milieu is substantially inappropriate, and can only pose and answer extremely limited mechanistic, symptom-oriented questions.

In sum, it seems clear to this reviewer that Harris has started out with a pre-conceived and rigid set of prejudices against counselling, and has then self-fulfillingly and highly selectively chosen to highlight the alleged 'evidence' (much of it anecdotal and inevitably of questionable methodological validity) that confirms his prejudices. In the process, Harris not only ignores the vast body of research literature that does present strong evidence for some kind of efficacy in GP counselling, but he also adopts a thorough-goingly positivistic conception of scientific validation which is in my view an epistemologically and methodologically inappropriate means of conceptualising the counselling experience (House, 1996a,c).

At several points, Harris fails to contain his real ideological interest in this debate, and lets slip revealing clues as to why he might have such an anti-counselling bias - namely, that counselling is essentially propagated by reconstituted hippies and left-wing subversives! Thus, on page 17 he writes, 'confessional counselling [Harris's broad term for person-centred counselling] has its political roots in the left liberal movements of the 1960s'; on page 26, 'much counselling has largely been taken over by liberal revolutionaries.... Their philosophy is... a radical socialist one of emotional revolution'; on page 14, 'confessional counselling tends to follow fairly current liberal-socialist beliefs'; and finally, on page 8, Carl Rogers's work is described as 'a form of sanitised Hippiedom'!.

Since the advent of Margaret Thatcher and the cultural hegemony of free-market ideology, the political standard-bearers of this ideology have systematically and unashamedly set themselves the task of eliminating and marginalising any counter-cultural opposition to the New Right's values and political agenda. Having effectively emasculated and marginalised so many of the more obvious obstacles and opposition to their project, it is hardly surprising that they should now begin to turn their attention to counselling - for of course, if we dare to give people the opportunity to increase their self-awareness, develop their critical faculties, and create their own embodied moralities rather than having them coercively imposed by a materialistic and morally authoritarian culture, then they might actually freely choose to embrace values which are antithetical to those of neo-conservative ideology.

Thus, no wonder Harris is concerned that 'counselling might have a political or religious influence on the views of clients. This should be an area of civil tort'! (p.34). And little wonder that there are tell-tale signs of paranoia and panic when we read that 'there is no limit to those who could do with a spot of [counselling]... [counselling] is becoming increasingly compulsory' (p.3 - an extraordinary claim for which no evidence is adduced); the growth of counselling in general practice is described as 'sinister' (p. 35); on page 32, we read, 'That governments everywhere have seized upon counselling with such enthusiasm as a means of "helping" their citizens to remain healthy is terrifying' (my emphasis); and on page 34, we are asked, 'Can we protect ourselves from this new ideology?' (of counselling).


I will now outline and refute, one by one, the more important charges and accusations that Harris makes against what he calls 'confessional counselling', psychotherapy and psychoanalysis.

Harris's charge: 'now [the state] is offering to treat ordinary human difficulties as illnesses' (p.6); 'by offering to treat it under the NHS it is the first time that [the state] has recognised unhappiness as a disease' (p.20); and 'The right to be unhappy..., to dissent, will be denied us not by political officers and state torturers, but by benign therapists - mental hygienists - with our "best" interests at heart' (p.35).

Response: The claim that, by employing counsellors in medical settings, the state is treating unhappiness as an illness or disease is quite simply factually incorrect. Indeed, and quite to the contrary, by embracing the value of counselling, 'the state', far from medicalising emotional difficulties, is actually recognising (albeit reluctantly and ambivalently in many cases - House, 1996b) that psychological and emotional difficulties which have previously been treated through strictly medical interventions are very often far more successfully treated by a counselling intervention, the focus of which is healing and psychic change rather than curing and mechanistic symptom removal. Further, the final quotation set out above (p.35) really lays bear the squalid style into which Harris occasionally lapses: thus, to equate by rhetorical association what counsellors do with 'state torturers' is as deeply offensive as it is absurd, as is his use of the term 'mental hygienist'.

More generally, Harris seems to get so carried away with his anti-counselling rhetoric and paranoia that his argument at times lapses into incoherent nonsense. The claim that counsellors (or 'the state') wish to 'take away' people's right to be unhappy is not just plain wrong; it betrays the author's woeful misunderstanding of the values of counselling, so much of which is concerned with precisely the opposite - namely, enabling clients to connect up with and integrate their 'unhappinesses', rather than to deny their right to them, as Harris would have us believe.

Harris's charge: 'The real criterion [for efficacy] is faith. Nobody so far has been able to demonstrate the benefit of counselling in the way that, for example, the efficacy of penicillin might be demonstrated' (p.13).

Response: Ironically, Harris is right here (see, for example, Menninger, 1963; Frank, 1989); but the implications he draws, that counselling is somehow inferior and of lesser stature, does not follow logically from his stated view. Harris can only leap to this implication because he holds an extremely limited, constraining view of the nature of 'science'. Recently, the psychoanalyst Cornelius Castoriadis (1995) has convincingly shown that the positivistic scientific method, emphasising as it does the tenets of replicability, predictability, substitutability and falsification, is in principle totally inappropriate to the study of the human psyche and the therapeutic change process. Harris is clearly reifying the positivistic scientific method without any understanding of its epistemological shortcomings and inadequacies (which, incidentally, apply just as much in the natural sciences as they do in the social sciences).

Elsewhere, I have set out detailed critiques of the 'scientific mentality' and its underlying dynamics (House, 1996a,b,c): suffice to point out here that the post-modernist (Lather, 1992) and the deconstructionist critiques (Parker et al., 1995) of the positivist scientific world-view have, in my view, fundamentally and decisively exposed the ideological and pathological basis of the empiricist mentality - devastating critiques to which there has as yet been nothing remotely resembling an adequate response in the literature. One of the central tenets of a non-positivist conception of the counselling process is that it is precisely those 'non-specific', non-quantifiable factors of human experience like faith, hope and love which are the most crucial 'active ingredients' of the healing or change process; and a positivist ontology by its very assumptive nature is unable to understand such 'unscientific' concepts.

Harris's charge: 'Although religious in form, psychoanalysis and confessional counselling are rationalist materialist philosophies of mental hygiene' (p. 14).

Response: First, again, Harris betrays his extremely limited view of science, by implying that anything which is not 'scientific' (under his definition) must by definition be 'religious'. So again, the rigidity of his position determines the highly distorted way in which he views the world (hammers and nails....). In addition, there is no logical necessity internal to the logic of the counselling process that it be a 'rationalist materialist' philosophy (although just what Harris means by this philosophically opaque and confused term is by no means clear); and the grotesque term 'mental hygiene' surely has much more to do with Harris's distorted projections than it has to do with the reality of counselling as a practice.

Harris's charge: 'Counselling is not about moral worth but about comfort and satisfaction.... There are no moral absolutes, no rights or wrongs..., only the shifting light of moral relativism' (p.14); 'Counselling has played a very important part in creating an atmosphere of moral relativism in modern society' (p.19); 'Counselling denies the reality of the ultimate moral sanction of sin and looks instead for reasons.... In the end, an ideology of excuses (is created)' (pp.33-34).

Response: Harris's expressed fear of a morally relativistic world seems to entail the assumption that the moral sphere must either be wholly determined by universal moral absolutes, or else we must necessarily be condemned to a post-modernist formless relativism that leads to chaos and immorality. Such a dichotomous ontology ignores the possibility of there existing a constructable, coherent and experiencable space between these two polarities that transcends the rigid 'either/or' logic that is so pervasive and damaging in, and limiting of, Western psyche. According to the values of humanistic counselling, a healthily grounded, embodied and integrated morality and ethics will necessarily be experientially based -organically derived from real human experience - and not an externally imposed didactic set of rules handed down ex cathedra as 'commandments' from on high that should be uncritically obeyed.

Counselling is centrally concerned with the taking of full personal responsibility for one's being in an extremely complex intersubjective world (Hall, 1993); and the uncritical embracing of universal moral absolutes is quite antithetical to the development of a fully responsible and self-reflexive personhood. Of course, such a view entails a fundamentally optimistic view of 'human nature'; while perhaps Harris is far less sanguine about the capacity of humankind to embace full adulthood and mature responsibility - which is hardly surprising when we read Harris's view that 15 per cent of the population have personalities which are beyond anybody's help! (p. 25).

Harris's charge: 'Confessional counsellors talk about holding up a neutral mirror in which their clients can see themselves.... Counselling becomes a highly managed conversation...' (p.15); counsellors '"train" themselves vigorously to avoid influencing their client' (p.15); 'The therapist tries, using some simple psychological devices such as imitation and sympathy, to persuade her client to talk.... Counsellors... often adopt the same postures, sympathetically copying the gestures of their distress' (p.17); '...because of transference it is almost certain that you are being at least partly, sometimes wholly directed by your counsellor' (p.18); 'The ultimate counsellor is a machine, a perfect electronic mirror for the patient to see himself in' (p.20).

Response: These various quotations once again display a woeful ignorance and constitute a gross misrepresentation of the nature of the counselling process as currently practised by professional counsellors. Perhaps 10-15 years ago, these various statements might have been more representative of what counsellors actually did (or believed they did); but today, there is far less naivity within the field about the highly complex and subtle power dynamics that obtain in any healing relationship, and concomitantly, a much clearer sense of the therapeutic process being one of co-created intersecting mutualities and subjectivities (Orbach and Eichenbaum, 1994; Ogden, 1994), rather than the counsellor or therapist being a neutral 'blank screen' using mechanistic devices and skills with which to relate to the client. Theorists are beginning to address a more realistic but philosophically challenging view of 'mind' in which the 'we-ness' of relationship goes beyond first- or third-person consciousness - a development that by far transcends the simplistic and out-dated understanding of the counselling relationship that Harris describes.

As for the perfect counsellor being 'a machine' - well, such a view simply betrays Harris's mechanistic world view, and his inability to comprehend the humanistic view that humanness and personhood are an absolutely essential ingredient in the healing process in any counselling relationship.

Harris's charge: 'Therapy may have no effect on most people, or it may harm them while they are in its grip...' (p.16).

Response: Again, notice the language - 'in its grip' - which may well say much more about Harris's own fear than it does about the realities of the counselling experience. In addition, it is outrageous to suggest that counselling has no effect on most people, or that it sometimes harms them, when such a view is based partly on anecdote, and partly on a very small number of largely discredited studies (see, for example, McNeilly and Howard, 1991) that purport to show that counselling and psychotherapy are no more effective than a placebo.

Harris's charge: '...in terms of wages a counsellor can cost between a third to three times as much as the GP for each patient he sees. On this reckoning counselling is an extraordinarily wasteful use of NHS funds, and can only be justified if its long-term effect leads to markedly diminished use of other services' (pp.22-23).

Response: Again, the argument is logically incoherent and sense-less. Whether or not expenditure on counselling is wasteful is logically quite independent of the unit cost per patient treated of employing a counsellor relative to that of a GP. Harris could just as well have made the equally absurd claim that (for example) surgical operations constitute a wasteful use of resources because more money is spent on surgical treatment of patients than on GP treatment of the same patients. As Davis (1994, p.1581) has written, if the arguments which are sometimes marshalled against the cost-effectiveness of long-term psychotherapy were equally applied to, for example, palliative treatments available for patients with intractable somatic disease, then the result would be that such patients would simply be denied treatment (and even left to die): in practice, 'these patients' needs are not neglected because the drugs and surgery involved are unlikely to effect an outright cure or be proved to be cost-effective in the terms of reference of the profession of accountancy as contrasted to that of medicine. Perhaps we should bear in mind that the purpose of medicine is to cure sometimes, to ameliorate often, to comfort always' (ibid.).

The crucial point is, of course, that counsellors can and do help their clients in a way that doctors are neither able, nor have the time to do. And as for 'cost-offset' savings a fundamental tenet of health care is that patients are entitled to receive a given treatment simply by virtue of its being effective, and not because it is cheaper than some other form of (inferior) treatment. Counselling embraces a 'philosophy of the person' that is typically holistic (House 1996b), and which is qualitatively different in nature from the mechanistic conception of the person implicit in much of the Western bio-medical approach to treating psycho-emotional difficulties (Engel, 1977). Counselling therefore constitutes a unique form of help which places at its core the healing aspects of an inter-personal healing relationship, and for this reason it cannot be substituted with an equivalant form of medical treatment that has identical effects, for there exists no such substitutable treatment.

Finally, had Harris examined the literature more carefully, he would have discovered that there is in fact considerable empirical evidence of substantial cost-offset effects consequent upon psychotherapeutic interventions in health care settings (see, for example, Cummings, 1991; House et al., 1994); but these savings should be seen as a welcome concomitant of counselling interventions rather than a raison d'etre for GP counselling (cf. Mumford and Schlesinger, 1987, p.360).


Harris's charge: '...about 15 per cent of the population have chronic problems due to their personalities which are beyond anybody's help' (p.25).

Response: From where precisely Harris obtains this figure is unknown; and it reveals not only the author's attitude towards the possibility of personal development and change, but also a kind of 'scrap-heap mentality' which will be highly distasteful to many - including this reviewer.

Harris's charge: 'Gradually it is being realised - but... far too late - that the counsellor is the placebo, the pill that makes people feel better. Is it therefore a technique of persuasion or influence?' (p.28).

Response: Even if this grossly simplistic and caricatured view were sustainable, it is hard to see what Harris's objection is to this - for if counselling is the means by which (however realised) patients/clients feel better, then surely this is what matters more than anything else in terms of counselling's efficacy. And again, one is left wondering about the whiff of paranoia that surrounds the phrase 'a technique of persuasion or influence'.

More generally, of course someone with Harris's positivistic world-view will be forced to label counselling's 'active ingredients' as 'a placebo' because with such a world-view it is extremely difficult to admit to the real, tangible influence of intersubjective factors like faith, hope and love in the healing or counselling process.

Harris's charge: 'There were stories of marriage and relationships broken by counselling' (p.31); '...the spectacular cases of families who have been broken up by counsellors' (p.34).

Response: This Fay Weldon-type view of counselling implicitly denies people the right to discover that their current relationship(s) are not fulfilling their needs, and to leave those relationships should they so choose. Of course, the partner who is left will tend to want to blame counselling for the relationship ending, rather than taking full responsibility for their own position in the relationship, and allowing their partner the right to leave it - no matter how painful the loss of that relationship might be.

Furthermore, there is the quite distasteful and condescending implication here - which in fact surfaces at several points in Harris's monograph - that people are not somehow able to exercise a free, informed choice about their own lives - for example, that it is counsellors who 'break up families', rather than adults freely choosing to end their own relationship. One is left wondering what conception of the human psyche Harris subscribes to, when he seems to have such little faith in people's capacity to make utility-maximising decisions... not to mention how he can possibly reconcile such a view with his own free-market ideology which places such store by sovereign free choice in the market-place.

Harris's charge: '...people ruined in trying to defend themselves against totally false or unprovable accusations' (p.34) (the so-called 'false-memory syndrome).

Response: Blaming counselling or therapy per se, as a generality, for the existence of a few appallingly incompetent therapists who might have an unconscious personal investment in making clients admit to memories of abuse is no different from arguing (for example) that capitalism should be written off because of the existence of a few corrupt and crooked entrepreneurs! No doubt Harris would be one of the last to accept the latter proposition, so it is utterly inconsistent for him to adopt a similar form of argument in relation to counselling.

'Consumer satisfaction' and counselling efficacy
There is, further, a massive irony at the heart of Harris's anti-counselling position, which is revealed in several places - for example, where he quotes King, who 'suggests that such is the popularity of counselling that it may no longer be easy to test its efficacy.... People are so convinced that it works they would object to being excluded from counselling in a randomised trial' (p.24, my emphasis); on page 27, Harris admits that 'many patients... insist that it works'; and on page 20, he berates counsellors for '(citing) faith - or its modern equivalent, "consumer satisfaction" - as sufficient evidence (of counselling's efficacy)'. But if the 'consumers' (or clients) believe and experience that counselling helps them (and all the empirical survey research on subjective satisfaction points quite unambiguously to this conclusion - House et al., 1994, pp.8-9), surely this is the ultimate test of the very 'consumer sovereignty' that the ideologues of neo-classical free-market thinking are supposedly so enamoured with and set such store by!

Conclusions
Despite the numerous subtleties, complexities and mysteries of the counselling process, one thing at least is clear: that perhaps the central feature of counselling, when it works well, is that the client is given the experience of a relatively healthy, non-neurotic reparative relationship, in contrast to the deeply damaging neurotic foundational relationships to which so many of us are exposed in early life, and to which the profound malaise - political, environmental, cultural, moral - in which our species currently finds itself is ample testimony. Anyone who has experienced, either as counsellor or client, the transformative effects of a long-term counselling relationship can surely only gasp with incredulity at the cynicism that is currently being displayed towards our field - of which the attack of Myles Harris in the monograph under review here is an extreme and particularly vituperative example.

Of course, as Sussman (1992) has admirably shown, all therapeutic practitioners should, as an indispensable aspect of their work, be as open as possible to discovering their own deep motives for building a career on 'misery and sodden tissues' (Bennett, 1994, p.14); but equally and by the same token, public figures and critics (Myles Harris, Fay Weldon, Jeffrey Masson, Hans Eysenck...) have an equal responsibility to examine their ownconscious and unconscious motives for rubbishing our field. Certainly, there is an urgent need for an in-depth psycho-social critique of the anti-counselling and therapy media bandwagon which has been gaining momentum in recent times, if we are to protect our field from gross misrepresentation and destructive, even nihilistic bigotry.


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