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