Clinical Counselling in Primary Care

John Lees

• Publisher: Routledge
• Year: 2020
• Print ISBN: 9780415179539
• eBook ISBN: 9781317835394
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

Clinical Counselling in Primary Care examines the complexities and variety of uses of clinical counselling employed in a medical setting. With an estimated 2 in 3 GP sugeries now employing a counsellor or refering patients on a regular basis, this book tackles key debates head-on. It discusses a range of important clinical issues such as:
* therapeutic framework
* clinical work as part of the greater whole
* the need to develop suitable therapeutic models.
Clinical Counselling in Primary Care looks at possible developments in the future and argues for the improvement of the standing of counselling in relation to other primary care professsions.

1 The postmodern context of counselling in general practice¹

Marilyn Miller-Pietroni

Introduction

This chapter provides a conceptual framework in which to view the recent changes in the National Health Service and their implications for counselling in general practice, in particular the impact of the National Health Service and Community Care Act (Department of Health 1990). The ideas and theories of postmodernism are taken as a starting-point for consideration of the new professional categories and languages that have developed. Specific examples are drawn from a counselling service in one inner city GP practice to illustrate how some postmodern concepts can facilitate thought about the paradoxes that abound in this setting, in which the GP’s patient is the counsellor’s client and the Health Authority’s customer. Using case histories and drawing upon current thinking in the literature and training for counsellors working in primary care, some of the advantages and the question marks relating to an interprofessional approach to primary care are identified. The chapter concludes with the proposal that it is necessary, in a mixed economy of care, to recognize the implications of living and working in a postmodern world.

The contextual approach and the need for a meta-theory

The literature on counselling in general practice in the UK has been expanding rapidly (Comey and Jenkins 1994, Keithley and Marsh 1995, Jenkins 1994). Debate has centred on the need for outcome studies related to the dramatic increase in counselling activity and expenditure in this front-line setting (Parry 1994, Sibbald et al. 1993, Le Fanu 1995, Harris 1994). Evidence for the efficacy of specific counselling approaches e.g. Gestalt, cognitive, psychodynamic is also under review (Parry 1994, Jenkins 1995). The fruits of these debates have been used to propose a national curriculum for training in this field (Jenkins 1994).

Figure 1.1 A contextual approach: use of a meta-theory

This chapter seeks to contextualize these debates within a broader conceptual framework, or meta-theory, borrowed from the field of cultural studies, namely postmodernism. This perspective has been extensively applied to widely varying fields of academic enquiry and professional practice, e.g. architecture, electronics and literary criticism. These applications have been made extensively in the USA and Europe; the UK has however, been slower to realize the contribution postmodern interpretation can make to understanding rapidly changing fields of knowledge and practice.

Some recent exceptions are the work of Parton (1994), Rustin (1991), Richards (1994), Hoggett (1992) and Pietroni (1995). These authors demonstrate the case for a contextual theory that is capable of transcending the terms of debate used in one part of the system, and locating those terms within the broader intellectual frameworks of the day. They also demonstrate that a postmodern perspective can usefully relate theory and practices of all kinds to their cultural and historical context (see Figure 1.1).

To the two models traditionally applied to counselling in general practice, the bio-medical and psycho-social, will be added a third, the market model . The chapter will apply each of these three models to counselling in general practice. Key terms selected from these models will be used to explore typical referrals to the counselling service, namely ‘patient’, ‘client’, and ‘customer’. The first and second terms are used conventionally within the field: GPs refer to ‘patients’, counsellors to ‘clients’; the third term however contextualizes the other two within the new order of complexity brought about by the NHS and Community Care Act (Department of Health 1990), with its market framework, costed episodes of care, and purchaser/provider split. This market of care signifies those who use services as ‘customers, users or consumers’. From these, the term ‘customer’ has been chosen because it relates most explicitly to the idea of the market, and thus signifies the policy context.

Figure 1.2 The purchaser/provider framework

The three key terms, ‘patient’, ‘client’, ‘customer’ will be used as different perspectives from which to examine in detail four case studies. This multi-perspective approach exposes ambiguities and contradictions which are at the heart of counselling in general practice, and which, in the authors’ view, outcome studies or methodological debate can only go so far to illuminate.

The specific context

A diagram of the purchasing and providing framework of one counselling service is provided in Figure 1.2. This illustrates how the counselling service is part of an established general practice model of integrated health and social care, otherwise known as a holistic approach. The practice in question² is a provider of health and social care services with a list size of around 6,000, at one point twinned with another practice for fund-holding status.

The overall profile of this counselling service was first described by Webber et al. (1994), and is typical of a city with high rates of unemployment, refugees and other mobile populations, isolated single and elderly people, and ambitious young families.

What is postmodernism?

Postmodernism is a theoretical perspective with a set of core concepts that have been used in different ways in different fields, but about which there is an international consensus. It is called a meta-theory because it subsumes a range of other theories; these are drawn particularly from sociology and linguistics and are most frequently applied to the field of cultural studies.

The conceptual building blocks of postmodernism, hammered out internationally over the last fifty years, will be identified (Table 1.1). Sufficient consensus has now been reached for a series of overviews to be written, from which these are drawn (Natoli and Hutcheon 1993, Smart 1993, Bertens 1995). It can be seen that the idea of a rapidly changing, global market (similar to the one emerging in the UK on the edge of public sector health and welfare) is central to the postmodern perspective.

The concepts are drawn from primary sources on postmodernism such as Jameson (1991), Lyotard (1984) and Eco (1987), and the overviews referred to above. The concepts are illustrated with indicative examples drawn from the field of health and social care: some from the broader social context, others from changes in policy and practice which have occurred since the introduction of the GP contract and the NHS and Community Care Act (Department of Health 1990). Although more debate of the examples would be useful, at this stage the intention is only to indicate the broad conceptual framework of postmodernism, and its potential for wide application to the field of health and social care.

In summary

The terms and ideas of postmodernism were founded on a disillusionment with radical politics and the socialist promise of the early twentieth century…. Loss of certainty, the acceptance of a relativist philosophy and the fragmentation of values, thought and beliefs … have been identified as the normal features of postmodernism…. The nearest there are to facts are the constructivist nature of knowledge, the dizzy pace of change, the babel of professional languages, and the continuous erasure of categories of thought and formal structures of all kinds.

(Pietroni 1995: 45)

Table 1.1 The conceptual building blocks of postmodernism

1Connnodification and the global market • Expanding international market in independent consultancies, information networks, and health and social care provision • Commissioning of ‘care’ and the contract culture • The purchaser/provider split and associated chan...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• List of figures and tables
• Notes on contributors
• Acknowledgements
• Introduction
• 1 The postmodern context of counselling in general practice
• 2 The culture of general practice and the therapeutic frame
• 3 Holding the dance: a flexible approach to boundaries in general practice
• 4 Counselling within a time limit in general practice
• 5 A holistic approach to working in general practice
• 6 The matrix at work: a post-Jungian approach to general practice counselling
• 7 The generalized transference in general practice
• 8 Counselling for patients with severe mental health problems in the general practice setting
• 9 Working with different models: adapting to the context
• 10 Inter-disciplinary collaboration for group therapy
• 11 Evaluating clinical counselling in primary care and the future
• Index