Counselling: a radical vision for the future
作者: John McLeod / 5002次阅读 时间: 2010年3月16日
来源: Therapy Today Archive. 标签: John Counselling McLeod
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 Counselling: a radical vision for the future
 
 by John McLeod 
 
 The idea that it can be helpful for someone who is troubled in some way to seek out a trained professional who will listen, and help them to work through their difficulties, is widely accepted in contemporary societies. The question of what we call this activity has been the source of considerable debate and conflict. There are many different positions that have been taken around how the terms ‘counselling’ and ‘psychotherapy’ should be defined and understood. There are some who believe that counselling and psychotherapy are fundamentally the same thing. There are others who assert that counselling is more appropriately understood as a junior partner of psychotherapy. From this latter perspective, counsellors receive a shorter training than psychotherapists, and work with clients or patients with less severe problems. 
 
 Although this kind of debate has gone on for a long time, it has not mattered a great deal, at least in the UK, because counselling and psychotherapy have tended to rub along in typically tolerant British fashion. However, we are now entering a new phase in the debate. It seems that forthcoming government regulation intends to differentiate between counselling andpsychotherapy. This decision provides a historic opportunity to re-focus the debate around the nature of counselling. 
 
 The purpose of this article is to make the case for counselling as a distinctive professional activity. Rather than revisiting old arguments about the relationship between counselling,psychotherapy and other models of helping, or trying to map out the current roles and training levels of counsellors and psychotherapists, I wish to look to the future, and present a vision of what counselling might become. This endeavour is based on an appreciation that language is not merely used to label what exists, but also operates to bring things into being. This article can therefore be read as a manifesto for bringing a particular conception of counselling into being. As with any manifesto, the ideas that are being proposed can only be brought into being if they are embraced and acted on by a large enough number of people. This article is therefore also a call for action on the part of organisations, groups and individuals that are concerned to promote the role of counselling in our society. 
 
 What is counselling?
 A vision of counselling that reflects what people want would be based on a set of core principles.Counselling would be viewed as a ‘front-line’ form of help, which is readily available within communities. Counselling would take for granted the idea that people have different understandings of problems, and different ideas about what will help. Counselling would be a collaborative process in which the service user and the counsellor work together to find the most effective means for the person to address his or her life difficulties, drawing on a flexible range ofstrategies for change. The person would be understood as existing within a life space or personal niche, which included relationships, places, institutions, organisations and discourses. 
 
 Life difficulties which might lead a person to seek counselling would be regarded as arising from disjunctions in the relationship between the person and the context within which he or she lives their life. Conversely, the everyday life-world would be acknowledged as providing resources that could be used to resolve problems in living. Counsellors would work not only with individuals and families but also with the social and cultural contexts that they inhabit. Issues of culture, class and ethnicity would become a primary concern in counselling, rather than being tacked on after the client’s psychological state has been assessed. Counselling would be defined not as a medical intervention, but as an opportunity for learning new ideas, skills and strategies (or remembering old ones) that the person can actively apply on an on-going basis to resolve problems in living. While also providing a space to share experiences of suffering and emotional pain, counsellingwould be fundamentally strengths-oriented. 
 
 In their emphasis on collaboration, flexibility and context, these principles describe a form of practice that is distinct from psychotherapy. Mainstream approaches to psychotherapy, such as CBT, psychodynamic and person-centred/experiential, operate on the basis of an individualised concept of the person. By contrast, counselling chooses to view the person in a social, cultural and organisational context. Most approaches to psychotherapy are based on the delivery of a narrowly defined protocol or model, whereas counselling explicitly involves a collaboration between service user and practitioner to find the blend of concepts and methods that make most sense in each case. 
 
 What can a person seeking help expect from a counsellor?
 Within this way of defining counselling, anyone who consults a counsellor should be able to expect that he or she will meet with someone who will engage in a collaborative conversation in which the service user and practitioner would explore the nature of the person’s difficulties and goals, and identify the step-by-step tasks that might contribute to the resolution of the problem.1 The end result of this process is to enable the person to get his or her life back on track. The person and the counsellor will also collaboratively consider the possible methods that might be employed to facilitate the achievement of these tasks. A counsellor would not assume that a once-and-for-all agreement on how to proceed would necessarily ever be finalised. Instead, a counsellor would be willing to review and renegotiate the basis for working together, at any point. 
 
 These aspects of collaborative working represent a strong and explicit acknowledgement of the importance in any therapeutic work of the creation and maintenance of an agreement between practitioner and service user around goals and tasks.2 These ideas also reflect an emphasis on a commitment to a moral and ethical stance that highlights the significance of genuine informed consent.3 
 
 In order to be able to respond effectively to the range of preferred change processes that clients may identify, it is necessary for counsellors to possess adequate levels of competence in a range of change strategies. These strategies would include:
 
 using conversation, dialogue and expressive techniques to develop understanding and create meaning in relation to problematic events and experiences, and to help the person to tell his or her story; 
 working with the client to identify aspects of thinking and behaviour that the client wishes to change, and developing a structured programme of activities that would enable these changes to be implemented over a period of time; 
 identifying ways of finding meaning and possibility in areas of bodily, felt, emotional experience that the person has reported as troubling or shameful; 
 reviewing and reflecting on the life narrative of the person, with the goal of achieving a greater degree of coherence and self-acceptance; 
 enabling the person to draw on their personal strengths and previous achievements as a means of addressing current issues; 
 reviewing the cultural resources that are available to a person, and finding ways in which the possibilities arising from these resources can be put to use. 
 The implication is that, as a generic front-line worker who needs to be able to respond to service users with different needs, a counsellor has to have access to a wide repertoire of ideas and methods, rather than being a specialist in only one therapeutic modality (eg CBT, psychodynamic, person-centred, etc). 
 
 A person seeking help from a counsellor should also be able to expect that their counsellor will be well networked. If specialist services exist within the community (an eating disorders therapygroup, a private practice psychotherapist who specialises in working with dreams, a literacy scheme, a support group for Muslim women, etc) then a counsellor should be in a position to provide information on these facilities to service users who might be helped by them, and be able to facilitate referral or a joint working. 
 
 How is counselling organised and delivered?
 Historically, counselling has developed in response to social problems such as marriage breakdown, the pressures of various forms of organisational life, sexual violence, and other social issues.4 Counselling services are typically linked to particular social issues and contexts, for example student counselling and bereavement counselling. By contrast, psychotherapy tends to be oriented toward psychological or psychiatric problems of individuals, such as depression and anxiety. 
 
 There are many examples of good practice in counselling that demonstrate the dynamic engagement of counselling agencies with the social contexts and issues within which they operate. For example, effective student counselling services are actively involved in the life of their university or college. Counsellors advise on procedures for welcoming and assimilating newly arrived international students, or on the needs of mature students with childcare responsibilities. Counsellors network with other groups within a college, such as the chaplaincy, student union or gay and lesbian student society. Counsellors have a responsibility to give feedback (appropriately anonymised) to university management on recurring issues that are reported in counselling. 
 
 The concept of embedded counselling5 in which counselling is part of a wider professional role, is relevant for student counsellors in that university lecturers and accommodation officers can fulfil a counselling function for some students at specific moments of crisis. Student counsellors may therefore organise training, consultation and supervision for academic and accommodation colleagues (and others) who provide embedded counselling within the university community. The effectiveness of a student counselling service, therefore, cannot be evaluated merely in terms of symptom improvement in the individual clients who are seen, but in the contribution that it makes to the organisation as a whole. 
 
 The ways in which student counselling services engage with their context is mirrored in many other counselling settings. A vision for the future of counselling would see counsellors and counselling agencies embrace and extend these contextual practices in a systematic manner. 
 
 Who are counsellors and how should they be trained?
 Research into the effectiveness of all forms of psychotherapeutic intervention consistently finds that a major factor that predicts good outcome is the quality of the relationship between the service user and the counsellor or psychotherapist.6 One of the significant accomplishments of the counselling profession in the UK is to have established a workforce model that maximises the chances that practitioners will be relationally competent. The majority of counsellors enter training not directly from school or university, but following successful careers in fields such as nursing, teaching and social work. What this means is that counsellors are selected for training on the basis of their previous track record in being able to establish and maintain caring relationships, often in highly challenging situations. 
 
 A further notable aspect of the counselling workforce in the UK is that many counsellors are willing to work for free in voluntary agencies. There is good evidence that counsellors who work for free are highly trained, qualified and competent.7 There are a range of motivations involved in being a volunteer counsellor, including a wish to make a contribution to society, and the intrinsic satisfaction of the work. One of the by-products of the large pool of volunteer counsellors is to enable the dissemination of counselling skills across a wider range of social and cultural contexts: an engineer who attends weekend counselling training events, and sees two or three clients on a weekday evening, does not lose his counselling skills when he is at work, or is interacting with his family. A future vision for counselling must retain these two key features of the counselling workforce: the recruitment of trainees who are emotionally and relationally mature, and opportunities for volunteer counsellors. 
 
 The evolution of counselling as a distinctive professional activity, along the lines proposed in this article, implies that future counsellor training needs to provide counsellors with:
 
 competence in a range of change strategies and perspectives, in order to be able to accommodate client preferences; 
 a critical and yet inclusive stance in relation to existing models of therapy, to allow them to be viewed as sources of good ideas and effective methods, rather than as monolithic ‘truths’; 
 a framework for integrating concepts and methods from different sources; 
 an interdisciplinary perspective that acknowledges the relevance of theory and research from sociology, social anthropology, philosophy and biology, 
 as well as psychology; 
 strategies and models for working within social systems, including supporting the efforts of those within such systems who are engaged in embedded counselling. 
 The areas of learning and inquiry listed above should not be read as suggestions for designing even longer and even more expensive counsellor training programmes. As with any vocational training, it is important to retain 
 a sensible balance between introductory coverage of topics that might be included in a basic training course, and more advanced coverage that would be available within the context of continuing professional development. For example, trainee counsellors are not ready to offer supervision and support to those engaged in embedded counselling, but they do need to learn that working as a counsellor within a social or organisational system requires an appreciation of the limits and possibilities associated with an embedded counselling role. 
 
 Building an evidence base for counselling
 Over the last decade there has been a growing expectation, particularly within the National Health Service, that counselling practice should be evidence based, and should adopt the definition of ‘evidence’ espoused by the National Institute for Health and Clinical Excellence (NICE). It has been hard for the counselling professional to fulfil these requirements.8 I believe that this is because we have been looking in the wrong places and asking the wrong questions. 
 
 It is perfectly reasonable for the public, and their elected representatives, to demand that professions should provide evidence of effectiveness. However, this evidence needs to be appropriate to the outcomes that the professional group is seeking, or claiming, to deliver. The message of the present article is that counselling is not a medical intervention, and that its primary aim is not to bring about a reduction in psychological problems or psychiatric symptoms. Instead, counselling is a form of assistance that is intended to help a person to get his or her life back in order, or on track, or to enable a person to reconstruct aspects of their life. From this perspective, some of the ways in which the effectiveness of counselling might be evaluated include studies of:
 
 changes in people’s lives, for example whether they have been able to change aspects of their life that they experienced were holding them back, or develop a more coherent life story, or make more of a contribution to community life; 
 what people have learned in counselling, and the extent to which they have been able to apply this learning to make a difference in their lives; 
 the impact of counselling within organisations and communities (eg when counsellors are employed in a GP practice over a period of time, what difference does this make to the working practice of GPs, or to the attitudes toward mental health issues of patients who have never received counselling?); 
 how recipients of embedded counselling assess the helpfulness of micro-counselling episodes, and how these episodes influence the trajectory of their help-seeking pathways. 
 These suggestions should not be interpreted as implying a rejection of randomised controlled trial (RCT) methodology. As with any research, the method should be determined by the question that is being asked. However, the epistemological stance that underpins the vision of counselling that is being proposed does not sit easily with research in which people are conceptualised as passive objects. It is more in tune with research that is driven by service user perspectives. An ideal scenario for the next generation of counselling research would be for 50 per cent of research to be designed and conducted by groups of service users, to enable true dialogue to take place between users and professional practitioners, within the research arena. 
 
 What needs to be done to put these ideas into practice?
 This article has offered a sketch of a vision for what counselling might become. It is a vision that places a strong emphasis on the capacity of counselling to contribute to the development of organisations and communities in which relationships, pluralism and inclusion are highly valued. It is a vision of counselling as a form of social action, that uses the potential for learning and healing that is inherent in counselling relationships as a means of leverage to build networks of mutual caring and support. From this perspective, counselling and psychotherapy become areas of professional specialism that are linked but separate. 
 
 There are many millions of people who have been helped by psychotherapy to overcome psychological and psychiatric problems, and to become more individuated or self-actualised. There is nothing in the present proposal that would seek to undermine the good work being done by psychotherapists, and the huge contribution that psychotherapy theories have made to counselling as well as to other fields such as social work and education, and indeed to the discourses that are available to the general public. What is being suggested, instead, is that counselling occupies a separate space, and has a different kind of contribution to make to individuals and to society. 
 
 My guess is that 90 per cent of the people who read this article will disagree with it. I believe that there are a large number of people who work as counsellors who are really functioning as ‘brand name’ psychotherapists, and are not interested in developing a more collaborative, contextualised, pluralistic and socially-oriented way of working. However, in the longer term, a vague understanding of counselling as a dilute, ‘lite’ or ‘junior’ version of psychotherapy will result in its eventual disappearance and replacement by evidence based therapies. Securing a sustainable future for counselling requires us to have the courage to decide on what we want counselling to be, and to work together to make this happen. I am convinced that the image of counselling articulated in this article is what most members of the public want, and what many organisations want. There are many within the profession who are concerned about the future of counselling. My hope is that the ideas in this article can lead to further respectful dialogue and debate around this issue.
 
 John McLeod is Professor of Counselling at the University of Abertay Dundee. 
 
 With thanks to Mick Cooper and Pete Sanders for assisting in the preparation of this article. 
 
 
 Open University Press is offering Therapy Today readers 20 per cent off the RRP of An Introduction to Counselling (4th edition) by John McLeod at www.openup.co.uk by entering the promotional code TT09 (RRP £31.99, discount price £25.59, publication date 7 July 2009). This offer is available until 31 August 2009 for online purchasers. P&P will be charged according to destination.
 
 References:
 
 1. Cooper M, McLeod J. A pluralistic framework for counselling and psychotherapy: implications for research. Counselling and Psychotherapy Research. 2007; 7:135-143.
 2. Bordin ES. The generalizability of the psychoanalytic concept of working alliance. Psychotherapy: Theory, Research and Practice. 1979; 16:252–60.
 3. O’Neill P. Negotiating consent in psychotherapy. New York: New York University Press; 1998.
 4. McLeod J. An introduction to counselling (4th edition). Maidenhead: Open University Press; 2009.
 5. McLeod J. Counselling skill. Maidenhead: Open University Press; 2007.
 6. Cooper M. Essential research findings in counselling and psychotherapy: the facts are friendly. London: Sage; 2008.
 7. Bondi L, Fewell J, Kirkwood C. Working for free: a fundamental value of counselling. Counselling and Psychotherapy Research. 2003; 3:291-299.
 8. McLeod J. The effectiveness of counselling. In Power M, Freeman C (eds) Handbook of evidence-based psychotherapy. Chichester: Wiley; 2006.
 
 Article quotes
 
 Most approaches to psychotherapy are based on the delivery of a narrowly defined protocol, whereas counselling involves a collaboration between service user and practitioner 
 
 Counselling has developed in response to social problems such as marriage breakdown, the pressures of various forms of organisational life, sexual violence, and other social issues
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