Book Review: Clinical Counselling in Voluntary and Community Settings

As a practitioner in both statutory and voluntary agencies, I enjoyed reading this book. Its aim is to provide theoretical and practical advice to help improve the quality and reliability of voluntary counselling services. In its 133 pages it manages to cover an enormous range of material that will certainly be of interest to students considering a placement in a voluntary counselling organisation. The ten chapters of the book move from the historical development of voluntary sector counselling in Britain, through issues of research and evaluation of "good practice", to some current clinical issues, with a final, thought provoking, four pages on 'Counselling in a Post-modern context' by the editor.

It will also give food for thought to the experienced practitioner as, both implicitly and explicitly, it discusses a range of questions fundamental to counselling practice such as: 'How far is counselling a political practice?'; 'Is practice "difference" oriented?'; 'What are we gaining and losing by professionalisation of voluntary organisations?'; 'Who decides what is "good practice"; 'How can we continually rediscover the amateur's creativity?'; 'How important is theory?'; and, of course, 'Where is the client's voice in the large organisation?'.

The editor says that the contributors come from varied and diverse backgrounds, both in work experience and in clinical theories drawn upon, and that "No attempt has been made to reconcile the different viewpoints presented; rather the tensions between different perspectives are allowed to speak for themselves with the aim of encouraging and stimulating further thought and debate in those who read the text". I quote this in full as I was very aware while reading a large part of the book that, where no model was mentioned, the assumptions often came from a psychodynamic orientation, which readers may think is an accurate reflection of counselling practice today.

In Chapter 1, Christopher Robinson acknowledges a psychodynamic perspective in tracing the birth, growth and development of voluntary and community organisations' responses to social and health needs, with specific reference to the historically recent growth of counselling services. He uses a Kleinian model to describe the inter-dependency of statutory and voluntary provision as a parental one (voluntary being mother, statutory father). An ideal 'maternal' service, he suggests, is provided in an atmosphere of innovation and hope, through proximity and accessibility in a fear free, stigma free environment; whereas 'paternal' state provision can be distant and frightening. Two of the main obstacles that Robinson identifies to achieving this ideal service (and which will strike a chord with most already involved in the field) are the need for funding and the related aspect of maintaining productive relations with external organisations. Nor surprisingly, both of these issues recur throughout the book.

Nicholas Tyndall traces the emergence of counselling as a specific form of voluntary activity growing out of the recognition that, behind the needs met by the early voluntary organisations (many of which were taken on by the welfare state), there was often an equal need for listening i.e. Rogers 'unconditional positive regard.' Counselling (a term originally coined in Britain by the National Marriage Council) thus fast became a widespread response to people experiencing stress and difficulties in relationships; the local voluntary organisation's specific strength has been in undertaking new and sometimes unpopular tasks (e.g. AIDS counselling) with freedom to select 'appropriate clients.' But Tyndall reminds us that, in addition to 'need' other more pragmatic and political issues have driven the growth of counselling; for example the Association of Pastoral Care and Counselling found it easier and cheaper to provide individual counselling than 'care', training for carers and working with groups. Also, volunteers find working one to one more satisfying for their own growth and understanding. Currently we have a wide range of very different voluntary organisations offering counselling, from the large national body (e.g. Barnados) with mainly professionally qualified staff, to the small, local group with volunteers with whatever training can be afforded. Tyndall looks at the wide variety of trainings that have emerged to create the current 'professionalisation' of counselling. These can set unrealistic standards for small or new local groups and lead to the necessity to become attached to a national body for survival. Directly linked to this issue is the disproportionate amount of time and energy being spent on fund raising in small groups and the anguish of charging fees. Tyndall sees the growth of private practice for richer clients as a significant threat to voluntary, virtually free, counselling for the less well off, and questions the current setting of unachievable standards for voluntary counsellors even when they possess the essential personal quality of empathy.

In Chapter 3 Derek Hill takes the professionalism of counselling as a given in looking at clinical work, supervision and management and their essential relationships. He writes that current evidence suggests there is no one uniquely good way to ensure that a counselling service sustains professional standards. Using Skyner's notions of the 'wounded healer' and the 'vicious cycle of deprivation' versus the 'virtual cycle of mutual nurture,' he reminds us that volunteers bring, in addition to altruism, a desire for mutual interaction by which they can learn and change and this can involve projective identification with the client. There is also a parallel process between counsellor and supervisor, right through to managers and trustees (or 'quasi-practitioners'). This places the counsellor/supervisor as 'piggy-in-the-middle'. One outcome of this complexity can be staff displacement activities and denial of where and in whom problems reside, leading to the negative impact of organisational sickness on clients. Therefore, supervisors in voluntary organisations need to be recruited and trained with an awareness of conflicts between the two Cycles in their own organisations.

Linda Machin's approach to research, based on her own case study and other work undertaken by Bereavement Care, may be of more particular interest to existential practitioners. She looks at the parallel development of research and practice, with research no longer being seen as separate from or marginal to practice. She uses her detailed examples to show that research is a way a) of understanding the phenomenon of bereavement and b) of evaluating practice, with clients being the source of expertise. Counsellors are involved in 'action research' she says as they move in an interactive way between their therapeutic and investigative roles, thereby reshaping their practice. Dimensions of new learning to emerge from this work at Bereavement Care include: the various constructions of 'meaning'; gender and culture's influence on emotional expression; medical notions of normality and pathology in grief compared with its actual manifestation in counselling practice; and methods of facilitating learning about grief in professionals at the point of transition and change. A sad footnote: in spite of these interesting developments at Bereavement Care, the reality of extra managerial demands and limited resources has now reduced the emphasis given to research within the organisation.

By contrast to Machin, Ela O'Farrell discusses a piece of research using the psychoanalytic notion of the 'frame' to look at the impact of third parties when working with children. Starting with the ideal of a secure, contained and stable therapeutic frame to be provided for the child within the counselling session, this small scale qualitative study looks, from the counsellors point of view, at areas where third parties impact on and mitigate against this ideal. These include issues of power and control deriving from fee management, information management, supervision requirements and who makes the 'choice' of counselling and for how long and with what goals. The impact of third parties is both implicit in the sessions and explicit in assessments, reviews and supervision. A particular problem can be the counsellor's identification with the child against the parent, with mirrored ambivalence. The 'perfect frame' can thus be fractured in a wide variety of ways and this study suggests compensating structures by which an agency's procedures and supervisory arrangements can be enhanced to provide a safe holding frame for counsellor, child and carer.

Also using the idea of safety, Eve Stolt looks at how to provide a 'safe' service via the initial appropriate assessment of clients for the service. She points out that assessment is a significant part of the professionalisation of counselling since it is undertaken by paid professionals and derives from practice in psychodynamic psychotherapy. In the voluntary sector the assessor has to take account of the quality of counsellors and try to make a judgement of suitability by matching a client's predominant mode of functioning to the counselling modality. Just because a client can talk about the problem doesn't mean counselling will be 'successful'; Stolt suggests 'good ego function' is a better predictor of 'good prognosis'. However, she also acknowledges the importance in some voluntary agencies of supportive counselling with its implications for client turnover. Thus, assessors will be judging whether a time limited or open-ended service is required, this decision being frequently influenced by funds and the demands and expectations of referrers. Stolt concludes that, since studies have shown that poor assessment is related to poor outcome, the initial identification of goals and issues which can be resolved is vital, and assessors play a crucial role in developing a safe and useful service.

Gertrude Mander covers much of the same material in the most psychoanalytic chapter of the book looking at issues of safety in organisational management through theories of containment and holding developed by Winnicott, Bion and others. She suggests that counselling, after an idealistic and auspicious beginning, has gone through a recognisable cycle of growth, expansion and decline with reference to her own experience of this cycle and the eventual 'parasitic containment' in a small community centre. Again, as in previous chapters there is reference to the negative influence of competition for clients, trainees and funds. She points out the importance of the 'holding frame' for future developments in the growing technologically provided services e.g. the internet.

Cottrell and Elgar examine whether there should be lesbian and gay specific counselling services and how the setting affects the clinical work. Explicit reference is made to Spinelli's idea that the therapist must be able 'to "be" from a framework of flexible self-construct.' Cottrell and Elgar look at the clients needs and expectations and the positive and negative impact of coming to a specific service for help with the 'existential crisis' of coming out in a homophobic society. They explore some pros and cons of generic versus specific provision. For instance in a specific service the counsellor is more likely to understand through personal experience and the client will not need therefore to spend precious time 'educating' the counsellor about lifestyle and experiences, but on the other hand, the counsellor may make unwarranted assumptions about the other's unique experience, may over identify or not be challenging enough. From their own personal experience and an examination of the literature, Cottrell and Elgar conclude that there is no simple yes/no answer to which is most useful; a realistic but perhaps disappointing conclusion.

Following this specific service study, Paul Gordon moves to a more philosophical look at the essence of psychotherapy, by questioning the idea of 'technique'. I have been conversing with people with mental health problems for thirty years in a variety of roles and, over that time have regularly admitted (not often to my immediate superiors) to not yet feeling 'professional' as I am aware that I am 'making it up as I go along'. This chapter by Paul Gordon 'putting "technique" into question' clarifies this sense of 'not being professional' admirably. I have always experienced talking treatments as art rather than as science and frequently found the least effective, most destructive therapists and counsellors to be those attached most rigidly to a specific theoretical model. Gordon's quote from Small that 'it does not make any sense to professionalise what is after all a kind of human relating' is at the core of his argument. He reminds us that Freud suggested that 'technique' should only be about what not to do in the session while the mutual exclusivity of many psychotherapeutic theories make a nonsense of any idea of 'technique' as 'the scientific application of protocols' within psychotherapy. In addition to looking at a fundamental art/science dichotomy, Gordon critiques the idea of prescriptive rules in psychotherapy, which would, for example, seek 'meaning' in the financial transaction, or prescribe the correct length or number of sessions He believes that psychotherapy and counselling are ethical endeavours that cannot be taught as they involve existential openness to the other and relevant self disclosure within the interaction. This idea may be regarded with horror by many therapists and training schools, but Gordon models his belief for us by disclosing personal clinical examples where he followed his own intuition to the benefit of his clients.

Quentin Stimpson's short final chapter puts 'the facts' of the previous nine into a post-modern perspective. He first suggests that psychotherapy and counselling are essentially modernist concepts i.e. driven by the desire to produce better, more competent citizens with control and mastery over themselves and the world, and the belief that science and technology underpin progress; they are set firmly within medicine and a quasi-medical 'treatment' culture. However, he argues, we live in a post-modern age of rapid transition, fragmentation of self and death of 'grand narratives' where we are encouraged to deconstruct such scientific 'truth' and 'knowledge' claims and examine what has been left out, particularly the meaning of change for clients which is frequently ignored in evidence based medicine. Evidence based medicine, he points out, has for instance nothing to say about love which is at the core of human existence. Stimpson hopes that voluntary and community based counselling services can resist being appropriated into this mainstream by reporting practice from grassroots, experience/needs driven settings (of which there have been some examples in this book) which question taken for granted assumptions. As entry requirements for voluntary counselling trainees become ever more unrealistic and 'professional', he requests us to keep a Zen 'Beginner's Mind' or we may soon lose the ability to really listen to the other.

Ann McDonnell