Counselling in medicine and psychiatry

Burnard(7) begins his text on counselling skills for health professionals with the statement, 'We are all counsellors'. He goes on to say:

Anyone who works in one of the health professions and comes into regular contact with people who are distressed in any way, whether psychologically, physically, spiritually or practically, offers counselling help. Counselling is something familiar to everyone: there need be no mystique about it. Nor should it be something that is reserved for a particular group of professionals who call themselves counsellors.

We would argue that this statement, whilst enthusiastically promoting the role of counselling in good medical practice, is misleading in that it fails to distinguish between counselling skills and specialized counselling.

Counselling skills are a learned extension to those interpersonal skills fundamental to interviewing and treating patients in all branches of medicine, but perhaps particularly in general medical practice and psychiatry. The skills of listening, summarizing, reflecting, and checking understanding enable the patient to feel understood. They are essential for engaging the patient and eliciting information, especially when the patient is afraid, in pain, or mistrustful; so these skills contribute to effective history taking, diagnosis, and general clinical management. The health worker's counselling skills may influence the patient's compliance, or 'concordance' as the more collaborative approach to treatment planning is now termed, and thereby the outcome of a wide range of medical and even surgical treatments.

Counselling as a specific planned intervention in psychiatry can be differentiated into two broad and overlapping categories, defined by aims into decision-making and treatment. It is evident that decision-making is an important ingredient in many forms of therapeutic counselling but, conversely, some forms of decision-oriented counselling (e.g. genetic counselling) embody no explicit therapeutic intention. More specifically therapeutic applications of counselling are employed in the management of a range of psychiatric conditions as an adjunct to other interventions including medication, as an integral component of a multimodal treatment method (e.g. crisis intervention), or as a specific treatment in its own right (e.g. for postnatal depression).

Counselling has a close, complex, and often unclear relationship to psychotherapy, or more accurately the psychotherapies. There are several models of counselling, which are related both in underlying theory and in clinical practice to specific models of psychotherapy, for example psychodynamic counselling, cognitive-behavioural counselling, and interpersonal counselling. Critics might suggest that counselling is just a diluted form of psychotherapy, or psychotherapy practised at a more informal level, but this is erroneous. Counselling has its own history, philosophy, and rationale. While there is within each model an area of indistinct overlap, counselling and psychotherapy can and should be differentiated.

The choice for a particular patient of counselling or psychotherapy is determined by a number of factors, which should have more to do with the attributes and needs of the patient than the training, experience, and interests of the professional. Within the psychodynamic domain, for example, this choice may be determined by the degree of deprivation in the patient's early life, or the identified stage of developmental failure. (li> The application of evidence-based treatments to specific problems requires careful matching between the patient's difficulties and known, effective treatments. As evaluation and research in counselling develops, more careful targeting of specific counselling approaches to specific problems will become more precise.

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