Can you rely on registered counselling?

Trained, professional counsellors appear to get no better results than 'cowboys', reports Alex Howard

I recently took part in a radio phone-in with Isobel Palmer, press and publicity officer for the British Association for Counselling (BAC). The interviewer asked about quality and the prevalence of 'cowboys' in counselling. Isobel Palmer explained that a register of counsellors was in place and BAC would refer clients to registered counsellors first and foremost. Clients could 'therefore' be assured of finding a good counsellor and they would have 'no reason' for concern about abuse or incompetence.

This may sound reassuring, professional and responsible. But is it? Are registered counsellors better counsellors? Are they less abusive and more competent? Where is the evidence? Given, as Palmer agreed, that we have no usable definition of counselling, how confidently can we expect to receive 'good' counselling?

Allen Bergin and Sol Garfield's Handbook of Psychotherapy and Behaviour Change is arguably the bible of research on the effectiveness of counselling and psychotherapy. These writers have been assembling and summarising evidence for over 30 years. Their fourth edition stretches to 866 densely packed pages. Here are a few relevant questions, against which I have added quotations from the handbook:

Do more experienced therapists produce better outcomes?
'Overall, the meta-analytic reviews of psychotherapy that have proved correlational data have not suggested a substantial relationship between experience and outcome...' (p170)

Presumably professionals produce better results than ancillary staff?
'One hundred and fifty-four comparisons from 39 studies indicated that clients who seek help from paraprofessionals are more likely to achieve resolution of their problems than those who consult professionals (Hattie 1984).' (p171)

Training must be of help?
'In general, there was no difference between the outcome of patients treated by trained and untrained persons (Berman and Norton 1985).' (p171)

Which kinds of therapy work best?
'One of the most difficult findings to conceptualise theoretically or to use practically is the continuing and frequent lack of difference in the outcomes of various techniques. With some exceptions, which we will consider, there is massive evidence that psychotherapeutic techniques do not have specific effects; yet there is tremendous resistance to accepting this finding as a legitimate one.' (p822)

Individual counselling is more expensive and intensive. It is presumably more effective than group therapy?
'Group and family treatment methods show few differences in results as compared with individual methods.' (p822)

What happened to therapy focusing on behaviour?
'Most of the people who used to consider themselves behavioural therapists now identify themselves as cognitive-behavioural [where attention is paid to thoughts as well as actions].' (p824)

So presumably cognitive-behavioural practitioners achieve better results?
'Cognitive-behavioural approaches show little advantage over others in many instances.' (p822)

What about non-directive therapy?
'...overall the trend has been away from the non-directive orientation. This has largely been due to evidence indicating that therapy oriented entirely by the traditional client-centred, non-directive approach to treatment has not produced very large effect sizes.' (p824)

And 'person-centred approaches'?
'The Person-Centred Review, one of the major journals in this area, has recently stopped publication.' (p824)

Are Freudian and neo-Freudian approaches faring any better?
'Research evidence has also significantly undermined the notion that interpretation in general, and transference interpretation in particular, is the key to efficacy in this approach.' (p824)

At least psychoanalysis allows more time for clients?
'It appears from the trends in psychotherapy research that almost all psychotherapy is now brief.' (p826)

'Bibles' can, of course, be interpreted variously, according to where in the text you look. But it is clear that we do not have any basis for saying that registered counsellors are 'better' or 'safer' than anybody else is. Counsellors want to present a positive image of counselling, but how far is this an honest reality?

Counsellors are currently going down the path that many would-be professionals have travelled before: they are professing to a basis of knowledge and skill long before they can actually provide (or even describe) it. This helps to secure status and income, but it does clients and the public a great disservice.

Counselling has chosen the low road to professionalisation. The integrity route is slower, harder, less profitable, but more worthwhile in the longer term. It requires that professionals avoid stepping beyond the evidence. It means abandoning the claim that registration currently solves, or even ameliorates, concerns about quality and integrity.

Does it matter? It is often claimed that counselling, even when it is not doing much good, does little harm because counsellors merely listen. But it is impossible in principle 'just' to listen. Listening is a creative act. We hear only what we are willing and able to understand. All this requires not just ears, but ideas, experiences and values through which we construct and interpret what others are saying.

Counselling's most dangerous myth is that you can be a good listener quite independently of your ability to interpret, understand, value, prioritise, construct. Listening requires ears, yes, but more so, a brain and (metaphorically as well as literally) a heart. My cat could listen, but it would understand relatively little that concerns clients. If the central role of understanding is not itself understood, then what chance is there of assisting clients?

Alex Howard manages an adult education programme. His fourth book, Challenges to Counselling and Psychotherapy, is published by Macmillan