Clinical Counselling in Context

An Introduction

John Lees

• Publisher: Routledge
• Year: 2014
• eBook ISBN: 9781317835363
• Topic: Psicología
• Subtopic: Salud mental en psicología

In the light of the current professionalization of counselling, Clinical Counselling in Context examines the hypothesis that counselling theory and practice is altered by the specific organizational context in which it takes place - the consequence of which is that context is an important force for therapeutic change.
It also argues that, with careful professionalization and a well-thought-out academic base, counselling can be a sophisticated activity which is not just the poor neighbour of psychotherapy.

1 What is clinical counselling in context?

John Lees

Plans fail for lack of counsel,

but with many advisers they succeed.

(Proverbs, 15:22)

This chapter will look at different perspectives on the talking cure over the last hundred years, from the point of both view of clinical practice and academic research. It will then identify some of the underlying trends in the profession and look at counselling as a specific development within the history of psychological therapy as a whole. These considerations, moreover, will form the foundation of the chapter, which will conclude by defining clinical counselling in context and showing how it is applied in practice. Overall, I believe that this undertaking is part of a much broader process that is currently taking place, which I would describe as counselling's ‘coming of age’ – a process which, in view of the rapid growth of counselling in recent years, involves asking such questions as: what is the place of counselling in the profession as a whole? How can it be distinguished from other talking therapies such as psychotherapy? Does it have a distinct identity?

The evolution of talking therapy

For thousands of years there has been a tradition of talking therapy (see, for instance, Ellenberger 1970). However, I would date the systematic development of the talking therapy in modern post-Enlightenment times from the work of Breuer and Freud at the end of the nineteenth century, so this is where I will begin. Significant turning points in this respect were Breuer's work with Anna O, between 1880 and 1882; Freud's earlier case studies, such as that of Elizabeth von R in 1892; Freud's first use of the term ‘psychoanalysis’ to describe his theories in 1896; and the publication of Freud's The Interpretation of Dreams in 1900 and Three Essays on Sexuality in 1902. I will argue that the theories of Freud have played a central role in the development of the different talking cures until the middle of the century, affecting both the development of theory and counselling research. I will briefly examine the theoretical consequences in this section and the research consequences in the next section.

As regards theory, most of the pioneers of the talking cure encountered psychoanalysis in one form or another. You either embraced it or rejected it, but you couldn't avoid it. As W.H. Auden noted of Freud, in a poem which he wrote on Freud's death in 1939, he was ‘no more a person … but a whole climate of opinion’. Indeed, many of the different therapies which developed in the course of this century arose – in part – as a reaction to psychoanalysis. This began with the early schismatics such as Jung and Adler, but has also included a continual stream of practitioners who were at one time involved with psychoanalysis, but went on to form their own schools of thought – such people as Fritz Perls, Carl Rogers, Aaron Beck and Albert Ellis, who were instrumental in founding the Gestalt, Person-centred and Cognitive Schools of therapy, respectively. Having said this, I fully recognize that all these practitioners were influenced by a variety of other philosophical, religious and psychological ideas: existentialism, phenomenology, religion, gestalt psychology, behavioural psychology, cognitive psychology, and so on. Yet I believe that an important strand of their thinking was that they saw psychoanalysis as limited, even mistaken. Jung, for instance, whilst still developing his friendship with Freud, had reservations about Freud's commitment to his psychosexual theory (Stevens 1990: 20), whilst cognitive therapists such as Beck and Ellis saw the whole notion of the unconscious (and psychoanalytic perspectives on early childhood development) as unscientific, and psychoanalytic therapeutic technique, such as interpretation, as subjective and speculative.

In view of these differences – the breakaway movements, the development of distinct therapies, and so on – the overall picture is thus of an ever-increasing network of therapies, with new branches being created all the time. For the purposes of this discussion, I will just point out four features of this development. First, it has led to a tremendous variety of outlooks which make up the profession (numbering some 450 according to Corsini, cited in Clarkson 1996: 143). Second, the profession has been subjected to an ever greater process of fragmentation. Not only did people form distinct schools, but within many schools there has been a splintering process: schools within schools. The Freudians split into the Freudians, the ‘Middle Group’ and the Kleinians, whilst the Jungians split into the Archetypal School and the Developmental School, the Person-centred School split into the purists and the integrationists, and so on. Indeed, there are now also the integrative schools which, in effect, form a fourth school of therapy, and are again divided into different schools. Third, it has led to many practitioners becoming isolated from their contemporaries in the profession, with a resulting tendency to regard other practitioners with suspicion and strive to maintain distinctness, purity and separateness. Yet one could argue perhaps that such tendencies were natural in the so-called Age of Modernism with its emphasis on the notion of the Grand Theory. Finally, in its extreme form, this process of isolation from peers can result in polarization and conflict – even bitterness. What about the academic perspective? Can the same features be observed?

The academic perspective

The academic perspective – particularly in psychology departments – usually consists of research into the efficacy of counselling and psycho-therapy and its status as a science. Essentially the questions researchers ask are: Does it work? If so, how?

Research has not, over the years, been a primary feature of the work of most clinicians. Indeed, I think it would be fair to say that clinicians have been more interested in the development of theories and clinical techniques than research. This may have been influenced to some extent by the development of the profession. Perhaps this is a second legacy left by Freud. His research methods were confined to case studies and he essentially eschewed conventional experimental methods (Hill & Corbett 1993: 3) – a pattern that has, arguably, influenced the psychodynamic and, to some extent, the humanistic traditions ever since. Essentially, the development of psychoanalytic technique and thinking was based on a lengthy and intensive process of self-reflection, hypothesizing about clinical experience and reviewing theory and technique in the light of these reflections. It is thus essentially a subjective activity – a form of qualitative research. Many practitioners pursuing this approach would agree with the psychoanalyst Guntrip (1973) that therapy is so individualized it is difficult, if not impossible, to study it using normal experimental methods, or Arlow (1984: 24), who expresses a highly subjective view of research into therapy, stating that the psychodynamic tendency to link present difficulties with early childhood ‘is not a theory; it is an empirical finding confirmed in every psychoanalysis’. In other words, the clinician's direct experience is viewed as a scientific activity. It is thus not surprising that the clinical literature abounds with case studies and that this has constituted the principal form of psychoanalytic research. This view contrasts to the commonly held pragmatic academic view that good therapy does not just depend on ‘whether doctors, patients or clients like counselling or perceive it to be helpful, but whether it is effective in bringing about an improvement in symptoms or in the client's problems’ (Corney 1997: 8). Indeed, some researchers are extremely critical of the subjective case study approach. The practitioner/researcher Meehl (1997: 94), for example, states, in no uncertain terms, that ‘if I insist that my anecdotal impression must prevail, I am not being merely arrogant and unscholarly, I am being immoral’.

Another major form of therapy research has been process research, which can be dated from the 1930s. Hill & Corbett (1993: 4), for example, refer to recordings that were made of sessions in order to ascertain the amount of ‘talk time’ of therapists in counselling interviews. They then describe how more sophisticated methods of process research gradually developed, concerned with illustrating the effectiveness of counsellor interventions. They examined how counsellor interventions influenced the client's subsequent statements, and thus continued the clinician's tradition of developing new theories and clinical techniques, as opposed to evaluating outcomes and efficacy (albeit in a different manner from the psychoanalytic method). Foremost amongst these developments was the work of Carl Rogers at Ohio State University in the 1940s, which attempted to show that nondirective interventions by the therapist – such as accepting, clarifying and reflecting the feelings expressed by the client – helped clients to see themselves in a more positive light and were thus therapeutically beneficial. Indeed, this research influences the development of many basic counselling and counselling-skills trainings and, at a more advanced level, underpins some of the debates between the different theoretical orientations.

A more recent development in the research field is outcome research, which essentially dates from the 1950s. Eysenck's (1952) seminal review of the literature on psychotherapy outcomes was particularly influential. According to his analysis of the results there was a success rate of 44 per cent for psychoanalytic treatment of neurotic patients, as opposed to 64 per cent for other therapeutic approaches, and 72 per cent for two groups of comparable patients, who were not treated by any form of therapy. In other words he claimed, in effect, that therapy – and, in particular, psychoanalysis – made people worse. In saying this it should be noted that Eysenck's claims have, in turn, been challenged (for example, by Bergin 1971). He argues, for instance, that it is difficult to obtain an accurate figure for spontaneous recovery (i.e. the untreated groups) since many individuals who are denied therapy may, for example, go elsewhere and are thus not necessarily untreated. There is also the question of whether any study can be value-free. In conclusion, we are left to ponder whether Eysenck's study constitutes a scientific breakthrough or a biased attack on psychoanalysis based on distorted figures.

Whatever view we take of Eysenck, outcome research has been clearly on the agenda since his study. More recently, with the rapid expansion of counselling and the consequent need for counselling practitioners to justify the usefulness of their work to funders, it has become increasingly important. However, there is a divergence of opinion about how to evaluate outcomes, ranging from those people (such as Clarkson 1996) who favour qualitative studies using a range of subjective criteria including peer scrutiny of case studies, questionnaires, interviews and so on, to those (such as Corney 1997) who favour quantitative studies using statistical analysis and such scientific methodology as the clinical trial, which, as a result of using control groups, attempts to eliminate other possible reasons for recovery.

When we include the research, in addition to the clinical, perspective on talking therapies, the overall impression is one of yet more fragmentation, polarization and conflict. What can we make of this tremendous variety of views, often held with conviction and vehemence? How can we locate ourselves in relation to it? There are, it seems to me, two primary responses to these questions. We can take sides in the disputes and disagreements. Alternatively, we can see the different theoretical and research standpoints as all containing elements of truth. We see them, so to speak, as different perspectives rather than absolute truths. We don't just argue for a research-based objective approach based, say, on the notion of the clinical trial, or a deeper understanding of human nature based on a more subjective case study perspective, but take the view that both of these viewpoints have something to say (see Lynch 1996: 146). For instance, most clinical trials show equivocal results (Corney 1997), which is a salutory reminder to counsellors to reflect on their technique and practice for the benefit of their clients. Case studies, on the other hand, enable practitioners to portray the complexities and nuances of therapeutic work and provide a basis for reflecting on, and improving, technique and conceptual understanding.

Having surveyed ‘the different’ points of view in the development of the counselling profession I will now adopt an approach to these differences which will be inclusive rather than exclusive, inasmuch as it will accommodate different viewpoints on counselling. Furthermore, I feel that this is appropriate today since it fits well with the so-called postmodern age and with the complexities of the broad variety of organizational settings in which counselling is usually practised.

The postmodern perspective

Surveying the history of the talking cure one may come to the conclusion that it is fragmented and divided, with no common standards about what constitutes good practice. This may seem, at first sight, to be a lamentable state of affairs. However, it can also be seen as a welcome diversity that is a great advantage. Indeed, this is the view held by the government and given as a reason for not imposing statutory regulation. Richardson (cited in House & Totton 1997: 2), expressing the government view, said that regulation would ‘prevent that diversity and would be unwelcome’ since it would exclude such therapeutic activities as stress management and some forms of psycho-educational activity. Furthermore, the diversity of perspectives is also in keeping with the prevailing postmodern Zeitgeist, which has been described as ‘a multiplicity of fragmented, and frequently interrupted “looks”’ (McRobbie 1989: 165). In other words, it is a viewpoint which says that our outlook on the complexity of existence is always limited. It is contextual rather than definitive: it provides an interpretation of existence rather than a definitive understanding (Lynch 1997: 21). Moreover, such a perspective doesn't necessarily reject the different viewpoints, but sees them as limited perspectives and part of a larger whole. It is deconstructive. It subverts the notion of the all encompassing explanation, or the Grand Theory, but accepts the place of such all encompassing theories in the pantheon of knowledge.

This postmodern view accepts that differentiation – even fragmentation and conflict – is inevitable and normal. It can be creative and needn't be destructive or divisive. It accepts the possibility of there being, on the one hand, both right and wrong viewpoints and, on the other, a multiplicity of viewpoints (Samuels: 1989). In other words, it accepts that we may sometimes take a standpoint which we believe to be right and, at other times, the apparently contrasting viewpoint. It says that thinking in terms of right and wrong is too limiting and absolutist since it leads to one-dimensional thinking in which we speak, think and converse in only one way. By accepting the validity of different viewpoints (even if we don't agree with them) we create a field of activity which is alive and creative. We engage in a dialectical process of argument and counter-argument where the different viewpoints create something entirely new rather than variations on the same theme. Indeed, it has even been argued that the mind functions in a complementary manner and that such polarities – including the possibility of conflict – are an inevitable part of healthy human development (Gordon 1993: 27).

Postmodernism and counselling

This differentiated postmodern perspective fits very well with the circumstances of much counselling practice. Counsellors are likely to work with colleagues from many different theoretical perspectives, in a variety of different contexts where there is an awareness of social, as well as psychological, values (such as the needs of minority groups) – a fact which lends itself to holding a variety of viewpoints, and which corresponds with postmodern principles of differentiation, diversity and pluralism. Indeed, the development of counselling coincided with the emergence of postmodernism. The counselling movement generally dates from the 1970s (McLeod 1993), at least in Britain, as does the age of postmodernism (Appignanesi 1989). So although it has its roots in the development of talking therapies generally, as already described, counselling per se is a relatively recent phenomenon.

In order to both illustrate and demonstrate a differentiated postmodern approach to clinical counselling in contex...

Table of contents

• Cover
• Half Title
• Clinical Counselling in Context
• Title Page
• Copyright Page
• Table of Contents
• List of figures and table
• Notes on contributors
• Acknowledgments
• Introduction
• 1 What is clinical counselling in context?
• 2 A pragmatic approach to clinical counselling in context
• 3 Assessment of psychological change and the future practice of clinical counselling
• 4 Time-limited work in context
• 5 The problem-solving pilgrim: a goal-orientated approach to clinical counselling
• 6 Establishing a therapeutic frame
• 7 The therapeutic space and relationship
• 8 Issues of cultural difference in staff teams and client work
• 9 Working directly with political, social and cultural material in the therapy session
• Index