This article appears in the February 2003 edition of the Catholic Medical Quarterly

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The Limitations of Counselling

Pravin Thevathasan

Counselling is a vitally important aspect of medical practice; many an experienced GP has commented on the fact that a patient�s wellbeing may respond more through the art of counselling than through the science of medicine. Perhaps this art is in danger of being downgraded in an ever growing culture of evidence-based practice.

However, experienced counsellors recognise that counselling has its limitations. It is useful in only certain given circumstances. Their view compares to a widely held belief that any sort of counselling is bound to do some good. "If you have been affected by any part of this programme, you may wish to ring this number for some confidential counselling". As long as someone is seeing or listening to a counsellor, it is said, things are bound to get better.

How many counsellors does it take to change a light bulb? Only one, but the light bulb must wish to change. This joke is now a little over-mature but it does contain a grain of truth. There are certain personalities who simply do not have the built in mechanism to learn from the counselling experience. The histrionic person may be delighted to be told that he has been referred to a counsellor after several visits to his local hospital with various instruments attached to his person. He may proceed to wear down many a counsellor with detailed descriptions of his past medical �career�; but he is unlikely to gain insight from his counselling experience. The dependent person may indeed make great strides during the counselling process. But when the counsellor starts talking of ending the sessions, he becomes distressed. For him, the counsellor has become a sort of human benzodiazepine. The sociopath does not have the built in mechanism to learn from his past experiences. The classic paedophile, for example, has a pathological need to control others and little insight into his problem behaviours. He has a limited desire to change. Counselling by itself may prove a disaster as others around him may feel that "at least something is being done". The less experienced counsellors may not be able to offer an adequate screening process prior to the counselling sessions.

Assuming that counselling is deemed to be of help, ought a Catholic see a Catholic counsellor? If she needs to see a counsellor because of a fear of spiders, it really does not matter. If she wishes to discuss feelings of guilt after an abortion it would surely help her to see someone who understands her spiritual perspective. In this latter case, seeing a non-directive counsellor is unlikely to prove beneficial. There needs to be a moral framework to guide the counselling process. She is rather like a passenger on board a plane who is unlikely to have much confidence in a non-directive pilot - even if the said pilot shows lots of empathy.

One hears of counselling in certain schools. This may be entirely appropriate if, for example, a child has been bullied, but what happens when a young person wishes to see a counsellor because he is confused about his sexuality? If you have a facilitator counselling a group of young people, he is likely to impose his own set of beliefs on them either consciously or unconsciously by means of group dynamics. Although the facilitator�s role is supposed to be value free, that in itself introduces a new dogma.

There is no right or wrong. What is good for you may be bad for me. The mature deliberation is never that clear.

The facilitator first creates the appropriate environment for change. His task is to create doubts about previously held perspectives. This may be done by techniques such as role playing, whereby difficult dilemmas are presented. By enhancing a person�s self-esteem, it is possible to make him believe that the old rules are unlikely to work now. "An actualised" person evolves into a more flexible and more "affirming" person.

As has already been stated, self-esteem programmes are entirely appropriate in certain circumstances. However, it needs to be said that they are wholly inappropriate in most circumstances and may promote the values of ethical egoism and a general preoccupation with the self. St Gregory wrote of the "rottenness of wretched self gratitude". Of course he probably never had the benefit of attending a self- esteem seminar.

Counselling has its uses. Like any other therapeutic intervention, it has side-effects and contra-indications. There is a generally held view that improving a person�s self-esteem is bound to promote authentic values. This view needs to be challenged.

Dr. Pravin Thevathasan is Consultant Psychiatrist in Shrewsbury.

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