While suffering somewhat from a lack of focus on the book’s intended themes, the individual contributions in this edited collection of 16 chapters nonetheless make worthwhile reading in and of themselves. (Review originally published in 2003.)
What’s the Good of Counselling & Psychotherapy? The Benefits Explained
Edited by Colin Feltham, 2002. ISBN 0761969543. Sage. x + 285 pages.
Based on the title, I had imagined this book might focus on exploring and articulating the benefits of counselling and psychotherapy. Explorations and articulations do feature throughout, but it’s that other word — ‘focus’ — which seems to capture what I feel is lacking in the volume. To be fair, as an edited volume with 16 chapters written by 22 authors, the book shouldn’t really be expected to show the same kind of sustained organization and focus which might be taken for granted in a monograph, but I still can’t help feeling a little disappointed. (And as a side note for researchers, who might find the book a valuable point of departure for uncovering additional resources in other focus areas than their own, beware that something has gone badly wrong with the book’s index: many index entries point to the wrong page, while many terms, including many authors’ names, do not appear at all.)
Colin Feltham’s introduction positions the book as presenting a “responsibly positive case for psychotherapy and counselling as beneficial” (p. 1) and suggests that a defence of the benefits of psychological therapy would tackle questions such as:
- What questions and problems do psychotherapy and counselling claim to address?
- What are the components of effective therapy and how do we know?
- How do we go about evaluating whether therapists’ claims have reliable evidence to support them?
- Which endeavours compete with therapy (e.g., religion, philosophy, medicine, education) and how can comparative effectiveness be assessed?
- Who are the ‘stakeholders’ and how can we address their respective voices and needs equitably?
- What problems exist in the conceptualisation and delivery of therapy?
- What exactly are the complaints of the critics and how are they to be addressed?
- Do therapists have something distinctive and useful to say about the kind of society that produces the levels of distress they have witnessed? (p. 2)
After such a well set out map of the territory, I was disappointed to find that, for the most part, the book’s contributors have chosen paths through slightly different patches of territory, addressing most of these areas only obliquely or not at all. I’d like to emphasize at the start that I have specifically reviewed each chapter as a contribution to the job which the book sets out for itself — and I have been fairly critical in this — rather than reviewing them as individual papers independently of the context of the book. As I suggest below, many chapters in the book’s three separate sections make fine papers in their own right — but without necessarily being very good contributions to the book as a whole.
Section 1: Addressing Human Suffering
After an initial chapter on ‘The Epidemiology of Mental Distress’ (Janis Abernathy and Mick Power), which usefully quantifies the prevalence and correlates of various types of psychiatric morbidity, the first section of the book continues with five more chapters addressing work with children and adolescents, with adults who were abused as children, with suicide reduction and prevention, with relationship difficulties, and with borderline personality disorder. But a reader hoping to find five straightforward discussions of ‘the good of counselling and psychotherapy’ in each of these areas may be disappointed to discover that each reads largely as a stand-alone introduction to the field and the authors’ preferred theoretical approaches and/or developmental models. This structure becomes particularly glaring in the last three chapters of the section, which, while making admirable introductions to their respective fields, are less noteworthy in terms of their contributions to the stated aims of the book.
Section 2: Enhancing Personal Effectiveness and Social Cohesion
The second section kicks off with a chapter from the book’s editor himself, a chapter which is more in line with what I had initially expected to find throughout the book. At the start of ‘Consumers’ Views of the Benefits of Counselling and Psychotherapy’, Feltham writes that “Surely the single most crucial focus of therapy and reflection on therapy is the client or consumer…it is ultimately in the changed or changing experience and behaviour of consumers…where the most important effects of this work are found” (p. 114). The chapter recounts both positive and negative reports on the benefits consumers have received, and I was disappointed only to find that two-thirds of the chapter’s length has been devoted to three individual case studies. Although each of these is worthwhile for what it is individually, these case studies serve an illustrative purpose rather than enabling any kind of extrapolation or generalization to the broader questions which lie at the heart of the book.
There follows a chapter on the human potential movement (Juliana Brown and Richard Mowbray) and one on the benefits of psychotherapy (specifically psychoanalysis) to spirituality (specifically Buddhist spirituality) by Shahid Najeeb. While both are less examples of ‘the good of counselling and psychotherapy’ than they are examples of individual perspectives on the development of the human spirit, they are still interesting in their own right. The second particularly intrigued me, as it offers a rare opportunity to glimpse a positive perspective on spirituality from an author who makes no apologies for writing from an unabashedly psychoanalytical perspective. Some of the author’s early comments about religion (as distinct from spirituality) might illustrate why I found this juxtaposition so fascinating:
Since psychoanalysis is about exposing delusions and hypocrisies, it must necessarily expose the delusional and hypocritical aspects of religion. It must show us that God is not an external and supernatural figure, but actually an internal and perfectly natural figure. It must demonstrate our irrational and infantile dependence on this figure and show how, when we are in this frame of mind, we regress to magical and primitive modes of thinking that are qualitatively different from our usual adult modes of thinking. This is the business of psychoanalysis. (p. 144)
So, no controversial stuff here, then!
Chapter 10 addresses the potential contribution of psychotherapy in enhancing citizenship and strikes me as primarily a philosophical exploration of the underlying ideas relating psychotherapy to citizenship; indeed, I believe it is fair to characterize it as part psychotherapy, part political philosophy. Chapter 11, on ‘Fostering Emotional Intelligence’ (Hilde Rapp), explores the meaning of the term and generally plumps for its importance. Regrettably, Rapp’s penchant for drawing references from the popular press perpetuates the myth that Daniel Goleman had anything to do with the scientific emergence of a concept of ’emotional intelligence’ — as distinct from the popularization of the term and its subsequent hard sell into the business community via Goleman’s business consulting and ‘EI Consortium’ activities. One incomplete and misspelled reference to Salovey and Mayer appears in the chapter’s references but receives no attention in the body of the paper; authors such as Caruso, Cobb, Hein, Paul and Payne don’t appear at all.
Section 3: Therapeutic Settings and Arguments for Effectiveness
The final section benefits from a clearer focus on some of the questions the editor set out in the introduction, and the number of pages dedicated to introductions to authors’ preferred fields is noticeably lower.
The section begins with Chapter 12, on ‘Good Money After Bad? The Justification for the Expansion of Counselling Services in Primary Health Care’ (Graham Curtis Jenkins), a chapter which puzzles me. The author begins by positioning the growth of counselling in primary health care within the context of evidence based health care. After carefully reviewing the particular challenges which psychotherapy research faces and briefly alluding to common factors research (although, oddly, not by name; see Hubble et al. 1999), Curtis Jenkins promptly introduces an audit system, the widely-used CORE outcome battery, and begins both drawing conclusions from its data and speculating about what the audit data will ‘likely’ demonstrate, or what ‘might be’ the case (e.g., p. 206). Yet the audit system described no more fulfils the requirements for an RCT (randomized controlled trial) nor escapes myriad other methodological challenges or criticisms which the author himself levels at other pieces of research — especially when it comes to external validity. (And indeed, a few of the author’s favoured conclusions are actually inconsistent with empirical evidence from studies which are widely regarded as having been methodologically sound.) Having warned of the risks posed by basing spending decisions upon incomplete, biased or misleading data, it seems odd that Curtis Jenkins would proceed without offering at least some indication of why the described audit system should be viewed any less circumspectly.
A chapter on ‘The Benefits of Counselling and Employee Assistance Programmes to British Industry’ (Carolyn Marchinton-Yeoman and Cary L. Cooper) reports on the authors’ large-scale research into UK EAPs and counselling programmes. While both this research and the other, largely US-based studies which the authors review, remain relatively rudimentary in comparison to much of the quantitative research available in other areas of the field, nonetheless the initial conclusions are valuable and should be taken into account by every business either running or contemplating the introduction of an EAP or counselling service. For those looking for evidence to support claims about the benefits of counselling and psychotherapy within a business setting, this chapter is great. I was somewhat puzzled by the lack of attention to the fact that for many EAPs, counselling and psychotherapy constitute only around half of the services actually delivered, making it difficult to relate measures of overall EAP impact to the impact of counselling and psychotherapy specifically.
Ian P. Palmer’s chapter on ‘Psychotherapy, the Psychology of Trauma and Army Psychiatry Since 1904’ offers an unusual glimpse into some of the ways mental health is viewed and treated within the military. It also provides some thoughts on the use of psychiatric labels which I found particularly interesting. (Specifically, Palmer suggests that labels such as ‘exhaustion’ or ‘fatigue’ help to normalize psychological distress experienced by soldiers in combat in a way that pejorative terms such as ‘psychoneurosis’ do not.)
Chapter 15, on ‘The Clinical Effectiveness of Psychotherapy’ (Stephen M. Saunders) paints a picture of the scientific method and of progress within psychotherapy research which is both a little too easy and more than a little misleading. Saunders’s main point — that psychotherapy works — has been well-supported by the research literature and widely known within the scientific community for some time. But his worthwhile discussion of randomized controlled trials with manualized treatments completely neglects the host of methodological challenges with testing efficacy of manualized treatments; likewise, his favourable comments on meta-analyses altogether fails to mention the challenges posed by the sometimes wildly differing underlying methodologies for the studies included within meta-analytic studies. The placebo effect receives a welcome paragraph of attention, while common factors receive only a couple of sentences. Although the paper reads somewhat like a summarized and (over?) simplified Bergin and Garfield (see “Handbook of Psychotherapy and Behavior Change, 4th Edition”), remarkably, no references are made either to the ‘Bible’ of psychotherapy research or to Hubble, et al. (see “Hubble, Duncan and Miller on What Works in Therapy”). I want to be very clear about this: I fully support the job Saunders and others are doing! I just don’t believe this chapter does its topic the justice it might have. While the chapter does a good job of introducing the territory if you have only 15 pages of time on your hands, I can’t help but think most readers would be better served by investing the time in a whole book instead (such as Hubble, et al.).
Finally, the book concludes with a lengthy piece by Digby Tantam on ‘The Philosophical and Ethical Basis of Benefit’.
Overall, as noted at the outset, this book is not quite what I expected, and I believe most readers hoping to find straightforward and focused attention to the cluster of questions surrounding the main topic — What’s the Good of Counselling & Psychotherapy? — will be disappointed. While the overall impact of the book as a whole is compromised by the absence of this focus, nonetheless the individual contributions make worthwhile reading in and of themselves.
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