Introduction
The counselling field has come in for significant media criticism in recent times, but of at least as much concern is the increasing attention being paid to the growth of counselling by other 'mental health' professionals (Persaud, 1996; Wessely 1996) - not least, no doubt, because of the potential threat that the rise of counselling and its undoubted popularity poses to those professions. In the August edition of Counselling, Consultant Psychiatrist Raj Persaud detailed at some length his own unease about the growth of counselling. In what follows I offer a detailed response to his arguments; and while there are some significant points of agreement between us, ultimately, and as I will try to show, Persaud's analysis is based on an inadequate understanding of the nature and assumptive base of counselling (cf. House, 1996a).
Some points of agreement
First, I agree wholeheartedly with Persaud that 'the whole question of why people want to become counsellors has been largely neglected' (p. 199). In my own experience it takes very many years to get in touch with one's deepest unconscious motivations for entering the field - and what we then find isn't always very edifying.... Perhaps all aspiring and existing practitioners should read Sussman's excellent but highly sobering book on the unconscious motivations for practising psychotherapy (Sussman 1992). But what is far less clear is whether the existence of dubious or unacknowledged motivations for practising counselling (or psychiatry, for that matter) will necessarily have a deleterious effect upon clients, and set limits on the degree to which they can derive benefit from counselling - as Persaud seems to imply they might. Elsewhere (House, forthcoming), I have argued at length that successful outcomes in counselling are more a function of the ways in which clients 'use' (in the Winnicottian sense) their counsellor for their own healing than it is to do with counsellor competency per se. To the extent that this is so, then it throws into severe question many of the taken-for-granted nostrums in the field, particularly the view that there must necessarily exist a positive correlation between the extent of counsellors' training and the extent to which clients are helped through counselling (cf. Russell 1981/93).
I also agree with Persaud that 'In many situations it is appropriate to be unhappy' (p. 200). Peck (1993) argues very similarly in his notion of 'the necessary pain of living'. Yet Persaud is not necessarily correct in assuming that the raison d'etre of counselling is the alleviation of unhappiness or, concomitantly, the promotion of happiness (although of course, this is often the welcome by-product of a counselling experience): rather, in my view the very opposite is true, in that the aim of counselling is to help people engage as fully as they wish and are able to with the reality of their existence (including their 'necessary pain of living'), and to integrate such experience to live as full and meaningful a life as they can and wish to lead. That such help may also lead to significant 'cost-offset' effects (e.g. Mumford et al., 1984; Cummings 1991) is incidental to the benefits that clients derive from counselling; but it suggests that counselling in health care settings may well not only be the treatment of choice for many 'patients', but may also be cost-effective according to the rigorous economic criteria demanded by some commentators (Tolley and Rowland, 1995).
I also share Persaud's concern over 'whether the availability of counselling prevents people developing their own solutions to their problems by preventing them from struggling with these issues for long enough and finding the incentive to discover solutions themselves' (p. 200). Ivan Illich (1977) coined the term 'disabling professions' in making a very similar point in relation to medicine itself. In my view this legitimate concern actually adds considerable weight to arguments that caution against the centralised, didactic professionalisation of counselling (Mowbray, forthcoming); for again, Persaud and I would probably agree that what he terms 'the professionalisation of personal problems' (meaning the problems of living - p. 200) is singularly and to be avoided as far as possible.
There are enormous contradictions and lacunae at the heart of any therapeutic process, particularly in a private practice setting where the practitioner has an unavoidable vested financial interest in clients coming regularly, and in which certain therapeutic approaches actively encourage client dependency and infantilisation via regression. As Kunnes (1974: 21) wrote many years ago, 'The existence of therapists and therapy in part produces the demand for it'. And as Hopton and Williams (1994: 20) write, 'the BAC Codes of conduct... put no explicit obligations on individual counsellors to consider the ethics of paid private counselling practice'. I agree with Persaud, therefore, that the very availability of counselling (or psychotherapy) might actually 'act as a barrier to people negotiating and developing relationships in their own lives which would then be therapeutic' (p. 200). In my view such a danger would be magnified many times over under a professionalised and regulated framework which institutionalised and legitimised counselling in the wider culture via state regulatory mandate.
In sum, it is surely unfair both to criticise counselling as a form of mental health care intervention per se, and at the same time to criticise it for its failure to possess a 'proper' professionalised structure! - yet at times this is the kind of incoherent position that the 'professional' critics of counselling seem to be adopting.
Points of divergence
Persaud starts with the taken-for-granted and unquestioned assumption that counselling is an aspiring profession, which should therefore possess a clear consensus about its boundaries of expertise and their limits. However, the assumption that counselling necessarily and legitimately aspires to the status of a profession is by no means accepted across the field (e.g. Thorne, 1995; Mowbray, 1995, and forthcoming; House, 1996a, b); so to criticise counselling for its failure to adhere to the standards of a profession while it is by no means clear that counselling does, or could ever, constitute a legitimate profession on the model of the existing professions is a criticism which is to say the very least premature.
Ironically, I find myself agreeing with Persaud about the lack of a professionalised identity for counselling - but probably for reasons very different from his own. I believe that counselling is inherently unprofessionalisable - or more accurately, any attempt to professionalise the field cannot but do a fundamental violence to the core humanistic values on which counselling is typically based (House and Totton, forthcoming). From this perspective, it is legitimate to criticise the attempt to professionalise counselling, but it is not legitimate to criticise (as Persaud implicitly seems to) the counselling field's failure successfully to professionalise itself, given the inappropriateness of such a development.
Persaud then focuses on the issue of client redress in the face of inadequate or abusive counselling. He seems implicitly to assume that it is perfectly possible both in principle and in practice to guarantee and/or monitor the efficacy of counselling as a mode of health care, and that what he calls 'the counselling industry' is reprehensible because it currently fails to provide such protection to clients. However, such an assumption is embedded within a positivist-scientific world-view that assumes an objectively measurable counselling process (House, 1996b). Yet if, as McTaggart (1996) has forcefully argued, some 80 per cent of conventional medical treatments have never been proven to work scientifically, let alone be safe, medical critics should look very carefully at their own specialties and the alleged efficacy of its own 'treatments' before casting stones in the direction of counselling.
However, as Mowbray (1995: 106-7) argues, and as Castoriadis (1995) makes clear, the central tenets of a positivistic scientific approach - relicability, predictability, substitutability and falsification - are quite inappropriate when applied to the realms of the human psyche and the counselling process (House, 1996b). In our field, as Mowbray argues, it is actually impossible for us ever to know what would have happened if a given client had not received a counselling intervention - and this is by no means purely because we are still comparatively ignorant about the so-called 'natural history' of emotional difficulties. And the implication of this - which is quite possibly disturbing for those operating within a medical-model ontology - is that it is in principle impossible in any objective scientific sense to prove that counselling, or a particular counsellor, has been the major causal agent of client change within a counselling relationship. Or to quote Lynch (1996: 147), 'ultimately we can have no objective, intellectual certainty about the truthfulness of a piece of reserach'. On this view, then, the alleged failure of counselling 'objectively' to 'prove' its efficacy says much more about the severe limitations of a positivist world-view and its obsession with trying to guarantee and control knowledge, than it does about the value of counselling to clients and to our culture more generally (House, 1996b).
So the difference between Persaud, Wessely and myself is this: we all agree that at present, counselling is not being evaluated in an 'objective' way (that is, according to the canons of positivist science); but for Persaud and Wessely this is a weakness or flaw to be rectified (perhaps by confining interventions to allegedly testable cognitive-behavioural approaches - Fahy and Wessely, 1993) - whereas in my view counselling is intrinsically untestable according to the totems of positivist science. What's more, far from our being apologetic about this state of affairs, we should actually be championing the values of our work - as an alternative to the social and cultural malaise and crisis (or 'spiritual emergency') which is so endemic in global human society (Grof, 1988), the existence of which is by no means unrelated to the emotional and spiritual sterility of the scientific and technological Zeitgeist whose values practitioners steeped in the medical model seem to embrace with enthusiasm.
Persaud's discussion of the relative 'trust-status' of counselling as compared with friend/friend relationships seems to be suggesting that a client or person can obtain from a friend/friend relationship what they derive from a counselling relationship. Now sometimes this might be true, but it seems highly plausible to assume that at least some clients wouldn't choose to seek counselling if they felt able to obtain the required level of support or sustenance from a friend or family member. (Of course, there is an important balance to be struck here with the arguments about the 'professionalisation of personal problems' and the potentially 'disabling' effects of a professionalised counselling, discussed earlier.)
Persaud's use of the term 'counselling industry' betrays a fundamental misunderstanding of the nature of counselling as a vocation, or as a calling (I am grateful to Jutta Gassner for this way of seeing counselling). No doubt there are those in the field, particularly at the more extreme professionalising end of it, who would commercialise and commodify the counselling 'profession', inserting it in the process into the world of full-blown market relations. Yet my strong impression and experience is that the majority of practitioners are deeply humane, caring people, who work in the field for altruistic rather than pecuniary reasons, who often do significant amounts of voluntary counselling by choice, who tailor their fees according to clients' ability to pay (which is of course a subversion of the commodity form - where else does that happen in private 'industry', Dr Persaud?), and so on. Indeed, one of the strongest arguments against didactic professionalisation and commercialisation of the counselling field is precisely that such a development might well be destroying the very qualities that make for successful counselling and counsellors: for if the heart is ever lost in our field, sacrificed on the altar of professionalisation, commercialisation and career-mindedness, we may then have lost the very qualities and values that give counselling its distinctive and unique defining characteristics.
Persaud's reference to the difficulty of 'objectively assessing safety' and of 'guarantees' of safety reveals an extraordinary view of human relationship. For the reality is that safety can never be guaranteed in any human relationship - and if it were experienced as such then such a relationship would surely either be idealised, or sterile, or both. A counselling relationship consists of 'two animals sitting in a room' struggling with the irreducible existential difficulties of living, relating and trust-building (Holmes et al., 1996). Thus, Persaud's claim that there exists a 'complacency about guaranteeing and regulating the provision of a safe relationship' (p. 199, my emphasis) simply falls away when we realise that it is never possible either to guarantee or to regulate safety in the way Persaud seems to be yearning for.
Persaud refers to the 'unresolvable tension between the need for privacy and the requirement for regulation' (p. 199). Of course, there can only exist such a tension if one accepts there to be 'a requirement for regulation', and there are very strong arguments in the literature that quite fundamentally challenge this assumption (Mowbray, 1995; House, forthcoming; House and Totton, 1997).
Persaud is implicitly critical of counselling and counsellors for not 'discern[ing] when unpleasant mental states end, and definable psychological problems or medical illnesses begin' (p. 199, my emphasis). Perhaps no such discernment is made not through ignorance or neglect, but because the typically humanistic counselling world-view simply does not accept this distinction. I have discussed at length elsewhere the fundamental philosophical differences that exist between a medical-model and a humanistic approach to human suffering (House, 1996c). Ian Parker et al. (1995), in a recent and devastating critique of psychiatric theory and practice, argue convincingly that no ontological distinction between 'normality' and 'abnormality' is philosophically sustainable. In the process, such a 'deconstructive' view also challenges at root the conventional, taken-for-granted distinction commonly made between 'health' and 'illness'. For Parker et al., 'deconstruction... overturns the opposition between... illness and health.... a measure of sickness is needed to survive in this world.... The division between sickness and health is not discontinuous' (p. 4, their emphasis).
If Parker et al. are anything like right, then the distinction that Persaud attempts to sustain between counselling that relieves suffering, on the one hand, and counselling that promotes happiness and well-being, on the other, simply falls away into irrelevancy. Furthermore, Persaud's discussion of the idea of a 'par' human state sounds suspiciously like some kind of highly dubious notion of 'normality' dressed up in different language.
Of course, the psychiatric world-view accepts as an unproblematic given the notion of 'abnormality' and 'abnormal psychology'. Yet as Parker et al. show, a deconstructive perspective reveals how the distinction between the normal and the abnormal is an ideological artefact, socially constructed and sustained through power-infused linguistic practices, rather than being a universal and 'objective' description of an independently existing reality. As soon as we begin to question the medical model's taken-for-granted assumptions about '(ab)normality', then truly revolutionary consequences begin to follow - not least, the 'treatment' ideology that medicalises and objectifies human suffering (physical, emotional, spiritual) is revealed as being fundamentally ideological rather than 'scientific' in nature, with the further consequence that many if not all of the discussions within medicine about the efficacy of counselling are based upon ideological assumptions. One of Persaud's principal conclusions, that 'the state should not be under an obligation to provide counselling on demand' (p. 201), also becomes unsustainable as it is based on a false distinction between alleviating suffering (or an 'illness' focus) and promoting well-being (or a 'health' focus).
Conclusion: Counselling and the future of 'health care'
The form and content taken by our health care system should surely be driven by what people want and find most desirable and helpful, rather than being based on highly dubious distinctions and abstract, disembodied ethical arguments about 'rights'. Persaud rests much of his argument against the rise of state-funded counselling on a distinction between rights to happiness and rights to health. Even if this distinction were a valid and sustainable one (which is extremely doubtful), it ignores the very substantial interdependence that exists between subjective well-being and 'physical' health (cf., for example, the burgeoning field of psychoneuroimmunology - Erskine and Judd, 1994).
If enhanced well-being and happiness lead to less 'ill-health' (as medically defined), and concomitantly, if unresolved emotional/spiritual difficulties significantly contribute to 'physical ill-health' (Taylor, 1987; McDougall, 1989; Wilson and Mintz, 1989 - my quotation marks indicate the ontologically uncertain scientific status of these concepts), then it is clear that a compelling case can be made for the wide availability of counselling in medical and health-care settings, contrary to the view expressed by Dr Persaud.
Postscript
More generally, I welcome the decision of Britain's leading counselling journal to offer a prominant psychiatrist a platform for expressing his unease about the rise of counselling; but at the same time I really can't help wondering whether the same privilege would be afforded to a prominant counsellor submitting a detailed critique of the psychiatry profession to a major psychiatry journal - for there is certainly more than ample recently published literature on which to base such a critique (e.g. Breggin, 1991/1993; Johnstone, 1989, 1994; Lowson, 1994; Parker et al., 1995).
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