Counter the counselling culture
With an estimated half a million therapists =
now=20
advising us on how to live, Dr Jennifer =
Cunningham=20
counsels that it is high time Britain got up off =
the=20
couch
When I did my medical training in the =
1970s,=20
psychotherapy or counselling was regarded as =
nothing=20
short of quackery. Obviously it threatened =
vested=20
interests in psychiatry and psychology, but even =
outside=20
these fields it was generally seen as an =
unsubstantiated=20
fad - the indulgence of self-obsessed middle =
class=20
Americans or the philosophy of hippies.=20
Yet now, in Britain, an estimated half a =
million=20
people work full and part-time as counsellors. =
Both the=20
previous and present governments have =
institutionalised=20
counselling throughout the NHS, at all levels of =
education and the penal system. When the =
National=20
Lottery handed out funds for health projects, 25 =
per=20
cent went to advice and counselling schemes, =
compared to=20
five or six per cent for research charities. =
Why?=20
You would imagine that counselling must have=20
established its efficacy in dealing with a range =
of=20
modern emotional and psychological problems. It =
must=20
presumably have been answering a big popular =
demand for=20
'talking cures'. Well, as it happens, no.=20
The impetus for the huge expansion in =
counselling=20
services over the past 10 years never came from =
people=20
seeking help for themselves or their children. =
It came=20
from above: from government, state agencies and =
a newly=20
influential psychotherapy establishment. More =
than a=20
third of fund-holding GP practices now employ a=20
professional counsellor, following a government =
decision=20
in 1990 to reimburse up to 100 per cent of the =
costs of=20
hiring such people. The victims of major =
disasters such=20
as the Kings Cross fire, Hillsborough, Lockerbie =
or the=20
Dunblane massacre did not demand counselling - =
it was=20
provided by local government, health or social =
services=20
and any number of self-appointed 'experts', =
regardless=20
of whether or not individuals wanted it.=20
Choice does not come into this. In many =
situations=20
counselling has become obligatory - if you want =
an AIDS=20
test, genetic screening, infertility treatment =
or=20
termination of an unwanted pregnancy, for =
example, you=20
have to see a counsellor. The government has =
plans to=20
make counselling compulsory before both marriage =
and=20
divorce. Many employers make counselling a =
condition of=20
continued employment for employees with high =
rates of=20
absenteeism, and university authorities compel =
students=20
who seek deferment of examinations or essays for =
'personal reasons' to see a college counsellor.=20
Counselling is provided in many other =
settings - from=20
disasters, accidents and bereavement, to =
redundant=20
workers and victims of crime. Although these =
types of=20
counselling could be considered optional, this =
is not=20
entirely accurate. People frequently feel a =
sense of=20
obligation to take up the offer of help from =
various=20
professionals, especially in light of the widely =
promoted message that they could risk doing =
themselves=20
long-term psychological damage if they do not =
have=20
counselling.=20
What about the efficacy of counselling? Does =
it work?=20
In January psychologists and psychiatrists =
attending a=20
conference of the European Society for Traumatic =
Stress=20
Studies in Aberdeen felt compelled to recommend =
an end=20
to the policy of counselling trauma victims. =
This=20
embarrassing retreat has become unavoidable =
because of=20
mounting evidence that post-trauma debriefing =
can do=20
more harm than good.=20
Doubts were first raised in 1994, when army =
adviser=20
Dr Martin Deahl found no evidence that =
psychological=20
debriefing reduced the incidence of =
post-traumatic=20
stress disorder (PTSD) and other psychiatric =
problems in=20
Gulf War veterans (British Journal of =
Psychiatry, July=20
1994). The following year, a report in the =
British=20
Medical Journal (BMJ) reviewed a number of =
studies which=20
suggested that the debriefing of rescue workers =
and=20
soldiers appeared to make them more susceptible =
than=20
control subjects to post-traumatic symptoms =
(including=20
recurrent nightmares, poor concentration, =
irritability=20
and depression), and caused the symptoms to be =
more=20
persistent (10 June 1995). Researchers in =
Cardiff who=20
monitored the recovery of burns victims found =
that 26=20
per cent of those who received counselling soon =
after=20
injury went on to suffer PTSD, compared to only =
nine per=20
cent of those who had not been given counselling =
(British Journal of Psychiatry, July 1997). =
Similar=20
results were reported in the case of =
road-accident=20
victims at John Radcliffe hospital in Oxford =
(BMJ, 7=20
December 1996).=20
Other forms of counselling have been called =
into=20
question when evaluated scientifically. =
Researchers at=20
the University of York's influential NHS Centre =
for=20
Reviews and Dissemination examined all the =
available=20
studies of the effectiveness of various forms of =
counselling and found no evidence that =
counselling on=20
its own helps people suffering from bereavement, =
divorce=20
or reactive depression (Effective Health Care, =
August=20
1997). In Sheffield, counselling given to =
couples=20
undertaking in vitro fertilisation treatment was =
no more=20
effective in reducing levels of anxiety or =
depression=20
than simply providing information about the =
treatment=20
programme (Human Reproduction, August 1993). The =
same=20
was true for women receiving counselling after =
the loss=20
of a baby due to fetal abnormality, at St =
James's=20
University hospital in Leeds. There was no =
difference in=20
outcome, with respect to grief, anxiety or =
depression,=20
between women who had counselling by an =
experienced=20
psychotherapist and those who did not, 16-20 =
months=20
after the loss (British Journal of Obstetrics =
&=20
Gynaecology, April 1994).=20
What is more, counselling does not hold up =
very well=20
in comparative studies. There are more than 450=20
different approaches in psychotherapy. Outcome =
research=20
shows that the approach adopted is irrelevant in =
terms=20
of the effectiveness of the therapy in any =
disorder.=20
Petruska Clarkson, director of the Centre for=20
Independent and Qualitative Research in =
Psychotherapy=20
Training and Supervision, admits that 'there is=20
considerable research evidence which suggests =
that=20
training itself may not make much difference' =
(dialogue,=20
February 1998). She believes that it is the =
'therapeutic=20
relationship' rather than the technique which =
produces=20
the beneficial effects. However, the alternative =
interpretation is that any beneficial effects =
are due to=20
the value of entirely non-specific supportive=20
discussion. Dr Bruce Charlton argues that a =
friend may=20
be preferable to a psychotherapist in this case, =
because=20
most therapists are self-selected and frequently =
have=20
been treated themselves for emotional and =
psychological=20
problems. This does not preclude good practice =
but is=20
not necessarily the best guarantee of insight =
and=20
ability (see 'Life before health: against the=20
sentimentalising of medicine' in Faking It: the=20
sentimentalisation of modern society, D Anderson =
and P=20
Mullen (ed), 1998).=20
There is generally a dearth of randomised =
controlled=20
evaluations by which to judge the outcome of =
counselling=20
objectively. This is particularly evident in =
relation to=20
interventions among children. There have been =
some=20
studies of peer-group counselling, for instance =
with=20
bereaved teenagers at a comprehensive school in =
Oldham,=20
and in anti-bullying programmes in primary and =
secondary=20
schools. Statistical analysis of objective tests =
of=20
improvement in symptoms after the Oldham =
bereavement=20
counselling produced results of 'debatable =
significance'=20
(British Journal of Guidance and Counselling, =
May 1993).=20
Anti-bullying peer counselling has resulted in a =
reported increase in positive social attitudes =
among=20
pupils, but levels of bullying behaviour have =
scarcely=20
changed (H Cowie and S Sharp (ed), Peer =
Counselling in=20
Schools, 1996).=20
A key assumption behind the widespread use of =
counselling among children is that psychological =
trauma=20
or extreme emotional experiences in childhood =
will=20
produce disordered personality, psychology and =
behaviour=20
in adolescence and adulthood. Unless children =
learn to=20
deal with their emotional conflict and restore =
their=20
self-esteem through timely psychotherapeutic=20
intervention, it is assumed that drug and =
alcohol abuse,=20
juvenile delinquency, teenage pregnancy, =
unemployment,=20
crime and even suicide will follow.=20
However, research now suggests that there are =
striking differences in how different children =
make a=20
long-term psychological adjustment to traumatic=20
experiences, such as natural disasters or =
parental=20
suicide. The traumatic early experience itself =
is not=20
decisive. Whether or not childhood trauma leaves =
permanent effects depends on both the child's =
earlier=20
and later experiences. Several studies have =
shown that=20
children who suffer severe deprivation and=20
institutionalisation in the first three or four =
years of=20
life can thrive emotionally and developmentally =
when=20
adopted or moved into more stimulating =
environments,=20
becoming confident teenagers and competent =
adults (see=20
Rudolph Schaffer, Psychology Review, February =
1996). In=20
other words, they can cope without counselling.=20
Most children who experience bereavement do =
not=20
subsequently develop depression or commit =
suicide, just=20
as the majority of people abused as children do =
not turn=20
into delinquents or child abusers. The =
counselling=20
industry claims that therapy is necessary to =
raise these=20
people's 'self-esteem'. Yet as psychological =
researcher=20
Robyn Dawes points out in his excellent critique =
of=20
cherished clinical assumptions, there is =
absolutely no=20
scientific evidence that feeling good about =
oneself is a=20
necessary condition for engaging in desirable =
behaviour=20
- just as feeling bad about oneself is not =
necessary for=20
engaging in undesirable activity (House of =
Cards:=20
psychology and psychotherapy built on myth, =
1996). Dawes=20
examines research commissioned by the California =
State=20
Assembly to investigate the role of low =
self-esteem in=20
social problems. Having spent three years and =
several=20
million dollars looking at over 30 000 research =
papers=20
dealing with self-esteem, researchers were =
forced to=20
conclude that the evidence of a link was not =
there, even=20
in the presumed association between low =
self-esteem and=20
sexual abuse.=20
It should be obvious by now that counselling =
has not=20
become a major British institution because of =
any=20
scientifically proven value of psychotherapeutic =
theory=20
and practice. Something else must be at the root =
of its=20
aggressive proliferation. A couple of examples =
help to=20
illustrate one key factor which underpins the =
explosion=20
of counselling: a significant lowering of =
society's=20
expectations of our ability to cope with =
personal=20
demands and difficult decisions.=20
Take medical counselling. Today counselling =
is=20
obligatory before any abortion can be carried =
out, in=20
either an NHS or private facility. It is also =
compulsory=20
before genetic screening tests are undertaken. =
The=20
assumption is that people simply cannot cope =
with making=20
important decisions for themselves.=20
Shortly after I had participated in a debate =
on=20
counselling at last year's Edinburgh Science =
Festival, I=20
received a letter from a man who had just been =
through=20
this process. His mother had been found to have=20
Huntington's chorea, a degenerative dementia =
that is=20
progressive and fatal. It is an autosomal =
dominant=20
genetic disorder, which means that the children =
of=20
sufferers have a 50 per cent chance of =
inheriting the=20
condition. After considerable thought and =
extensive=20
research into the disease, my correspondent =
decided to=20
be tested and hopefully obviate the need for his =
own=20
children to undergo testing. But despite his=20
protestations, it was made clear that he could =
not have=20
the test unless he submitted to counselling =
first. The=20
test was negative, and this man was left feeling =
angered=20
by a process he considered both a waste of time =
and an=20
insult to his intelligence and experience. I =
could only=20
sympathise with his frustration at what he =
described as=20
this patronising 'the state knows best' =
attitude.=20
Another example is counselling in schools. =
Many=20
schools now 'buy in' services from independent=20
counselling centres, social services, local =
health=20
authorities and children's charities, often in =
response=20
to traumatic incidents involving pupils such as =
injury,=20
suicide, bereavement and divorce, or for =
disruptive=20
children and truants. The assumption today is =
that=20
families are unable to provide children with =
adequate=20
support or supervision without professional=20
intervention. In fact, the child-parent =
relationship is=20
itself seen as part of the problem. It is =
regarded as=20
potentially traumatising in the case of divorce, =
or=20
deficient after a bereavement, when a parent's =
own grief=20
is presumed to prevent them recognising their =
child's=20
emotional needs.=20
I do not believe that there are any =
convincing=20
reasons why we should be any less capable of =
handling=20
personal challenges and stress today than people =
were 10=20
years ago. What has emerged over this time is a=20
society-wide perception that we are all much =
more=20
vulnerable emotionally. No doubt this perception =
has=20
come about as a result of different factors; =
certainly=20
many of the social and demographic changes in =
the past=20
10 to 15 years have increased everybody's sense =
of=20
uncertainty about their roles and relationships, =
or made=20
us feel more isolated as individuals.=20
But one essential ingredient in forming this=20
perception, I would argue, has been the =
development of a=20
close symbiotic relationship between government =
and the=20
counselling fraternity. The raison d'être =
of=20
psychotherapy is intervention to limit =
psychological=20
stress or foster emotional development, in the =
belief=20
that it will not only enhance personal wellbeing =
but=20
also inoculate society against problem =
behaviour.=20
New Labour's favourite psychotherapy lobby, =
Antidote,=20
argues the importance of teaching people =
emotional=20
literacy in these terms: 'By attending to the=20
development of our emotional and social skills, =
we=20
ensure an improvement in the nation's emotional =
wealth=20
and social capital. The possible consequences of =
doing=20
this are: decreased costs for the justice =
system, the=20
care system, the social security system, the =
health=20
service...More interest in participating in the=20
structures of civil society...Less addiction to =
drugs,=20
alcohol or self-harm...Less bullying, truancy =
and=20
vandalism...Increased commitment to work...More=20
community activity...Less acquisitiveness...Less =
discontent...Less conflict', etc. ('Emotional =
education=20
for all', Antidote, 1997) Little wonder that, in =
an age=20
when social change is off the agenda, =
politicians like=20
Tony Blair are so keen to embrace the =
psychotherapeutic=20
approach to solving people's problems.=20
Counselling is promoted on the basis that we =
are all=20
susceptible to psychosocial stress. This is a =
broad=20
concept which appears to trail behind it an=20
ever-expanding number of causes - job =
insecurity,=20
unemployment, bullying, academic pressure, =
marital=20
strife, bereavement and so on. It now seems to =
be=20
assumed that virtually any personal misfortune =
or test=20
of character can have the potential to disable,=20
overwhelm or corrupt us psychologically. At the =
very=20
least, counselling philosophy holds that most =
people=20
will at some time have problems that they lack =
the=20
emotional resources to resolve.=20
This view of our psychological vulnerability =
has=20
helped to lower expectations of what people can =
cope=20
with, and reduce the demands we make of =
ourselves and=20
each other. For example, it is no longer =
expected of=20
rescue workers, firemen and medical personnel =
that they=20
should be able to deal with human tragedy =
without=20
themselves becoming emotional victims of =
post-traumatic=20
stress. Fewer academic demands are being made on =
pupils=20
and students for fear that they will not cope =
with the=20
pressure or will lose confidence and self-esteem =
if they=20
fail.=20
Such low expectations of our psychological =
resilience=20
are likely to become self-fulfilling. They can =
only=20
encourage everybody to become more passive, =
conservative=20
and self-indulgent, rather than struggling with =
the=20
demands of an active and adventurous life. We =
are often=20
at our most creative when we accept challenges, =
take=20
pressure and try to overcome adversity.=20
The notion that people cannot cope well =
without=20
external support also means that professionals =
are now=20
involved directly in the management of our =
mental life.=20
In every major decision we have to take and =
dilemma we=20
face, we are encouraged or obliged to bring in a =
third=20
party to advise us. This takes on an ever-more =
intrusive=20
character. For example, the problematising of=20
child-parent relationships predisposes =
counselling=20
professionals to want to regulate family life. =
The form=20
of this intervention varies, but more often than =
not it=20
is done through the agency of the =
'multidisciplinary=20
team', in which social workers and health =
professionals=20
are ineluctably drawn into a family counselling =
role.=20
When professionals begin to manage our private =
life and=20
mental state they cannot help but promote an =
almost=20
childlike dependency, whatever their intentions. =
It is high time that more of us started =
making a fuss=20
about counselling's dubious record and insisting =
on our=20
right to refuse untested, useless or potentially =
harmful=20
procedures. Contemporary counselling culture is =
bad for=20
us individually, and bad for a society that has =
been put=20
on the couch.=20
Dr Jennifer Cunningham is a community=20
paediatrician, working in one of Glasgow's four =
child=20
assessment centres. Her critique of 'primal =
therapies'=20
appears in Controversies in Psychotherapy and=20
Counselling, Colin Feltham (ed), published by =
Sage in=20
March 1999=20
Reproduced from LM issue 118, March 1999