Introduction

People in distress have always turned to others for support, advice, and other forms of help, traditionally family, friends, community members, doctors, or priests. In many non-Western cultures, traditional healers work with troubled 'clients', incorporating many different methods of healing, including those more akin to Western ideas of counselling, as well as a variety of ritual healing methods. (1,.2) In Western countries, social changes over the past few decades have led to increased social mobility and reduced social cohesion. External sources of support are sought where previously family, neighbours, and community sufficed. At the same time there has been a shift away from the unquestioning acceptance of external authority towards a more egalitarian and collaborative relationship between helper and helped. These social changes have promoted the emergence and growth of counselling; in its turn, the growth of counselling and the spread of its underlying philosophies has promoted a new set of expectations, a new value system.

Counselling as a profession and professional activity has emerged since the Second World War in economically advanced countries, initially within the voluntary sector. As the scope, acceptability, and provision of counselling have increased, its attractions as a career have been enhanced and training programmes in counselling have mushroomed in response to demand. Standards of practice, ethics, and accountability have been established through accrediting organizations. Spinelli(3) indicated that in 1993, there were around 30 000 people earning their living from counselling in the United Kingdom, with a further 270 000 in the voluntary sector. The Department of Employment suggests that over 2.5 million people use counselling as a major component of their work. The continued growth in counselling results, in part, from increased emotional openness and readiness to seek psychological support, which is apparent now in many cultures. At its worst, however, counselling is purveyed indiscriminately as if a panacea for all human suffering. This devalues its purpose and potential benefits, and undermines the commitment and professionalism of trained counsellors. The rapid increase in counselling as an activity and profession, and as a treatment offered for a range of psychological difficulties, requires careful evaluation and attention to standards of training. Much of the counselling literature comments on the lack of specificity and control in studies, the diversity of patient groups who are offered counselling, and variation in the approaches offered. (4)

Counselling skills are integral to the practice of psychiatry, indeed for all the 'helping professions', being basic ingredients of effective patient interviewing, essential for accurate history-taking and diagnosis, and central to the way in which psychiatry manages and helps patients. Counselling as a specific intervention is important in many areas of mental health practice, both in primary care and a range of specialized settings. As therapeutic interventions, the different models of counselling interface with specific psychotherapies, leading to much debate and at times lack of clarity about the distinctions between counselling and psychotherapy.

The aim of this chapter is to examine the place of counselling in mental health services; and to consider the modifications required for its effective application to psychiatric populations. We look at the definitions of counselling, and the role of counselling in medicine and psychiatry. The chapter goes on to define different models of counselling, and its applications to specific problems including common mental health problems, grief and adjustment, trauma, and relationship difficulties. We then consider counselling in different settings, including primary care, mental health settings, student counselling, and the workplace. The chapter concludes by looking at issues of training, quality, and standards, commenting on the need for the control of an ever-developing profession without loss of the growing availability of effective counselling services to those in need.

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