by James T. Hansen
Over the past several decades, counselling has been increasingly defined as a healthcare profession. Signs of this reconceptualisation have emerged from various realms, including an increased emphasis on diagnostic training in counselling curricula1; legislative efforts for counselling to have parity with healthcare professions; the emergence of health or wellness counselling as a distinct specialisation2; and the prolific use of the words health or healthy to describe personal fulfillment in various counselling realms, including the marriage3, family4,5, individual emotional6, multicultural7,8 and spiritual9 subspecialties. The counselling profession is now linguistically saturated with healthcare definitions, metaphors, and models. Remarkably, however, the consequences of, and justifications for, this transition into healthcare have gone relatively unexamined. That is, the underlying logical structure of the healthcare movement has not been critically appraised. This lack of critical appraisal is particularly disconcerting given that 20th-century developments in philosophy suggest that the ways in which the world is languaged have a determinative effect upon perception and action10,11. However, the consequential implications of adopting the language of healthcare to describe counselling activities have not been systematically appraised. The purpose of this article, therefore, is twofold: (a) to deconstruct and analyse the logical structure that underlies and supports the counselling profession's movement into healthcare and (b) to consider some of the consequences of that move.
This is accomplished within the following organisational structure: (a) deconstructing the logic of the move to a healthcare model, (b) ideological and practical consequences of the move to a healthcare model, and (c) discussion and conclusion.
The move of the counselling profession to a healthcare model is not simply a cultural accident. There is a logic that underlies this transition. In order to critically appraise the relanguaging of counselling as a healthcare activity, this underlying reasoning must be critically examined. Three of the possible, logical arguments that can be used to justify the transition of counselling to a healthcare profession are discussed: (a) critiques of dualism, (b) adoption of the logic of psychiatry, and (c) argument from etiological advances.
Cartesian dualism has been a foundation of Enlightenment ideology and, by extension, the Western mind-set12. Specifically, Descartes proposed that the mind and body are separate realms. Consciousness and mental events are in the intangible, spiritual realm. The body and other physical entities that populate the universe
are in a spatial, tangible domain. This philosophical division opened the conceptual door for objective, scientific investigation of the body/physical realm, which is characteristic of Enlightenment thought12. Although dualistic conceptualisations have paved the way for numerous scientific advances, dualism has its own set of philosophical problems. Chief among them is the question of how an intangible consciousness and a physical body are linked13. For example, how can an intangible conscious thought, such as a directive to move one's hand, result in a tangible, bodily response? If the mind and body are distinctly different entities with incompatible properties, why is there so much apparent connectivity and communication between them?
Over the centuries, there have been various philosophical solutions proposed to resolve this problem inherent in dualism13. More recently, however, holistic models have emerged that do not reductively partition humans into Cartesian sections14. Holism has productively spawned other movements, such as relational epistemologies15, intersubjective approaches12, and the wellness counselling movement2. Notably, however, the logic of holism can be used to justify the utilisation of the healthcare metaphor for the counselling profession. The reasoning behind the utilisation of holism to support counselling as a healthcare profession might be as follows: If the mind and body are considered separate entities (ie dualism), professions that focus on the body, such as medicine, should be considered entirely separate from those professions that focus on the mind, such as counselling. In short, body professions are healthcare and mind professions are something else altogether. However, from the vantage point of holism, the mind-body distinction is no longer tenable. By extension, therefore, it also becomes untenable to separate the body professions from the mind professions. Therefore, mind professions, such as counselling, are also healthcare, given that, because of the collapse of dualism, emotional wellbeing can no longer be logically separated from physical wellbeing.
On the surface, this might seem to be a reasonable and civilised argument. That is - as many have humanely and holistically asserted - overall healthcare should not ignore mental health16. This reasoning is regularly used to support the idea that mental health providers should have reimbursement parity with physical health providers. However, when the underlying logic is further examined, several problems are revealed. Specifically, if dualism is no longer tenable, why should mind issues be relegated to health issues? Indeed, from a holistic philosophical base, it would be just as reasonable to reconceptualise all bodily matters as mental. That is, logically, holism does not necessitate that all mental matters be subsumed by bodily metaphors any more than it would presume that all bodily irregularities should be recategorised as mental events. Thus, under holism, the assumption that an 'adjustment disorder' is a health problem is no more defensible than the assertion that influenza is a mental problem. The subsumption of the mental as a component of the bodily (ie health) is an arbitrary arrangement that cannot reasonably use the logic of holism as a defence. One might argue, however, that 'health' has now been redefined to straddle both mind and body. That is, health formerly referred exclusively to bodily processes. Contemporarily, however, health has been holistically redefined to include mental phenomena. If counselling were to be subsumed under the old definition of health, it would certainly be illogical and dualistic, the proponents of this argument might maintain. However, under a holistic definition of health, which, by definition, includes the mind, it is only appropriate for counselling to be considered a healthcare profession. This position is also logically problematic. One problem with this reasoning is that if health is used holistically to signify both mind and body problems (ie the totality of human problems), then it logically follows that any human service activity must be redefined as healthcare. Accountants, educators, and lawyers, for example, under a holistic vision of human problems, could no longer maintain that their form of helping only affects a particular aspect of their clientele. Holism does not allow for the partitioning of humans into discrete mind-body, or other, compartments. Thus, if the collapse of dualism is used as an argument for counselling to be considered a healthcare activity, it logically follows that all other forms of helping would also have to be positioned in the healthcare domain. This would, of course, be absurd on many levels.
Another problem with this argument is that the healthcare realm has a pre-established, long-standing linguistic structure that uses terminology such as disease, illness, and disorder. Thus, even if the broad concept of healthcare is holistically redefined to include the mental, as counsellors, we are forced to rely on the antiquated dualistic language of the healthcare system. It is this underlying linguistic system that determines our perceptions and ways of conceptualising phenomena. Thus, even if we enter the conceptual realm of healthcare with laudable holistic intentions, we are forced to use the pre-existing dualistic linguistic system of that realm, which then determines that we language dualistically, and therefore conceptualise, phenomena as diseased, disordered or unhealthy, despite our original holistic intentions. In short, a holistic redefinition of health cannot serve as justification for the subsumption of mental phenomena as healthcare, given that the language of healthcare continues to be structured by the logic of dualism.
Upon careful examination, then, the rejection of dualism does not provide logical justification for counselling to be considered a healthcare profession. First, there is nothing inherent to the logic of holism that would suggest that the mind be subsumed by the body. Second, the definition of healthcare as inherently holistic would logically demand that all human service professions, not just counselling, be redefined as healthcare. Last, conceptually positioning counselling as healthcare by reconceptualising health as holistic simply transforms counsellors from outright dualists to closet dualists, because the underlying language of healthcare that counsellors are forced to use if they operate in this realm continues to be blatantly dualistic, even if the over arching concept of healthcare is redefined holistically.
Another implicit justification for counselling to be considered healthcare is the adoption of the logic of psychiatry. The logical syllogism might be as follows: Psychiatry is a branch of medicine (ie healthcare). Counsellors help clients that have psychiatric diagnoses. Therefore, counselling, like psychiatry, should be considered a healthcare profession. In order to examine the soundness of this reasoning, the historical development of the psychiatric profession must be considered.
When psychiatry first emerged as a distinct medical specialty in the mid-1800s, psychiatrists typically served as administrators of mental asylums that housed people with extreme disturbances17. To use modern terminology, residents of asylums suffered from psychosis, extreme forms of bipolar disorder, and other severe functional impairments18. Although there are contemporary theorists who reject a medical view of these conditions19, 20, many consider it reasonable to regard these states as health issues, given that certain severe symptom constellations typically occur in stereotypic patterns, often run in families, are responsive to modern pharmaceutical (ie healthcare) interventions, and cause severe problems of adaptation. In short, for a century and a half, mainstream thinking has considered psychosis, for instance, a healthcare issue, and this would seem to be a logically defensible position.
As the psychiatric profession evolved, however, it did not continue to confine its treatment jurisdiction to severe, stereotypic conditions. There are at least two fundamental, historical reasons for the incredible expansion of the psychiatric domain. First, the psychiatric identification with psychoanalysis in the early part of the 20th century expanded the definition of what constituted a psychiatric problem16,17. Before psychoanalysis, a psychiatric patient was generally someone who had severe functional impairments and resided in an asylum. By using psychoanalytic justifications, however, psychiatrists redefined their patient population to include a much wider variety of people, including those who were highly functional but had an underlying neurosis that, naturally, only psychiatrists could detect and treat.
Second, the discovery of effective pharmaceutical agents in the mid-20th century also expanded thepsychiatric domain16,17. During that period, the effects of these drugs, such as Thorazine and lithium were nothing short of miraculous, given that persons with severe, intractable conditions were now able, for the first time to be free from their debilitating symptoms. However, the frenzied excitement surrounding the discovery of these pharmaceutical treatments resulted in a renewed idealisation of the medical model, which, ultimately, resulted in the introduction of a medicalised diagnostic manual in the 1970s1. Over the past 30 years, the force of this initial medical momentum has been strengthened by other trends and motives, such as psychiatric alliances with the pharmaceutical industry21, the continued desire of organised psychiatry to be regarded as equal in status to other medical specialties 18,21 and diagnostic requirements for reimbursement from third-party payers 22.
These trends have resulted in an incredible expansion of who is considered a psychiatric, and by extension healthcare, patient. Consider, for example, that not long ago, alcoholics, juvenile delinquents, child molesters and people who disregarded the rules of society were considered to have moral and legal problems. Now, however, these problems have been redefined as psychiatric healthcare issues, as in 'alcohol use disorders', 'oppositional-defiant disorder', 'paedophilia', and 'antisocial personality disorder' respectively23. The psychiatric net continues to be cast further into the moral realm, as exemplified by the current movement to redefine racism as a diagnosable psychiatric condition24. Even the traditional clients of counsellors, who typically have difficulties with life transitions, now have been psychiatrically redefined as healthcare patients with 'adjustment disorders'23.
This psychiatric expansionism has not occurred without criticism. Psychiatry has been accused of manufacturing madness25, inventing diseases to treat, and medicalising the human condition26. If organised psychiatry had confined its healthcare territory to relatively severe, stereotypic conditions, there would probably be few objections16. However, there is arguably little, if any, clinical logic that would justify the gross recasting of moral, legal, social and transitional problems as healthcare issues.
The argument that counselling should be considered a healthcare profession because counsellors often help clients with healthcare (ie psychiatric) diagnoses, then, rests on a very shaky logical foundation. That is, arguably, the only reason many counselling clients are considered to have psychiatric problems is because of the forces behind psychiatric expansionism, for which there is little clinical justification. Therefore, simply because the psychiatric profession has proffered outrageously self-serving redefinitions of healthcare problems, it does not create a logical imperative for the counselling profession to follow suit and redefine counselling as a healthcare activity.
The rise of the medical model has been accompanied by an increase in the use of biological explanations to account for emotional problems1. This trend can be used to logically justify the consideration of counselling as a healthcare profession. Specifically, the logical argument may go as follows: Researchers have increasingly identified biological etiologies for emotional problems. If a problem ultimately has a biological cause, then the treatment for that problem should be considered healthcare. Therefore, because counsellors treat people who have emotional difficulties, counselling should be considered a healthcare activity. As with the preceding arguments, however, this reasoning is also highly problematic.
First, psychiatry has posited the biological, chemical imbalance
explanation for emotional problems. However, no discrete chemical imbalances have ever been discovered1,21,26. The rationale for the chemical imbalance hypothesis is that particular pharmaceutical agents have proven to alleviate particular mental health symptom constellations16. Therefore, the psychiatric community has generally asserted that there must be underlying chemical imbalances that the psychiatric drugs correct. However, simply because a condition improves because of the introduction of a drug, it does not mean that the drug addresses a specific chemical imbalance16. Caffeine often helps people feel more awake, but no one would assert that lack of alertness is due to a chemical imbalance that is corrected by drinking coffee. Thus, there are various possible alternative explanations for the symptomatic improvements that result from psychiatric drugs, such as the drugs having a gross physiological excitation or sedation effect rather than addressing discrete, as yet unidentified, chemical imbalances18,27. In fairness, perhaps future researchers might identify chemical imbalances. At this point in history, however, the assertion that chemical imbalances cause emotional problems is premature and unsubstantiated.
Second, even if future researchers discover particular chemical imbalances that are associated with certain conditions, it would be inaccurate to suppose that physiology is the sole determinant of mental health problems. Psychopathology is a multiply determined phenomenon that is influenced by psychosocial and biological factors. Thus, biological reductionism is completely unwarranted, even if certain biological correlates of mental health conditions are identified in the future.
Last, simply because a problem has a physiological etiology, it does not necessarily follow that the problem requires a medical, healthcare orientation to resolve16. For instance, the gradual graying of one's hair with age is a physiologically determined event. However, this fact does not require that graying hair be considered a medical problem, that hair stylists become healthcare professionals, or that medical diagnosis and treatment planning should be an integral part of restoring one's natural colour. Also, consider that different learning styles are mediated, to some extent, by innate genetic and physiological characteristics. Does this mean that educators must use healthcare interventions to be effective? Clearly, physiological determinants do not necessitate healthcare solutions.
To summarise, physiological etiology of client problems is a logically insufficient reason for counselling to be considered a healthcare profession. Indeed, none of the traditional arguments, when deconstructed, create a logical imperative for the medicalisation of the counselling profession. Perhaps, however, one might retort, the logical justification of the transition to healthcare is not as important as the pragmatic consequences of that transition. That is, if the consequences of adopting a healthcare identity have a beneficial effect, the reasons for the identification are unimportant. To address this point, the ideological and practical consequences of the transition of the counselling profession to a healthcare identity are examined.
The counselling profession is fundamentally rooted in humanistic ideologies that emphasise subjectivity, potential for actualisation, and the healing potential of the counselling relationship1,28. Reseating the profession within a healthcare model has enormous ideological implications for these traditional humanistic ideals. Some of these consequences are detailed in the following sections.
There is an inverse conceptual relationship between subjectivity, which is idealised by humanism, and external symptomatology, which is highlighted by healthcare models: The more focus put on one, the less important the other becomes29. For example, a healthcare conceptualisation of a particular client might be that he or she has sad mood, anhedonia and eating and sleeping irregularities. Subjective experience might be given passing consideration, but the healthcare model generally trivialises inner life.
An alternative, humanistic conceptualisation of the same client may be that he or she is a painfully sensitive person whose relationships have suffered because of intense fears of abandonment. This acute awareness of subjectivity, alternatively, would acknowledge external symptoms, but the focus would be on the client's inner experience.
These varying conceptualisations would lead to different types of treatments. The healthcare treatment would emphasise symptom reduction, whereas the focus of the humanistic treatment would be on a greater understanding of the client's experience. Therefore, the move to a healthcare model has the ideological consequence of abandoning the humanistic emphasis on client subjectivity along with the deep empathic contact that is idealised by humanism1.
A fundamental assumption of humanism is that there is an inherent drive toward self-actualisation,10,28,30. This has led the counselling profession to place an emphasis on client strengths, potential for growth, and developmental transitions. The healthcare model, alternatively, is rooted in an ideology of deficiency. As evidence for this point, consider the language system of healthcare, which relies on words such as disorder, sickness, and disease. This language is saturated with the assumption that people coming for help have something wrong with them, as in a deficiency or deviation from normative functioning. Although this may be a useful and appropriate metaphor for physical medicine, which has scientific and relatively culture-free standards for normal, healthy functioning (eg the body should be a certain temperature, bones should not be broken), it is highly questionable whether this deficiency language is appropriate for the counselling profession, whose ideals of normative functioning are necessarily dependent on the ever-shifting values of the society in which the counselling takes place1. When this reasoning is taken to its logical conclusion, it has led some theorists to charge that counsellors actually function as 'secret police'31 who subtly coerce socially deviant clients to conform to the standards of society. Although few would endorse this extreme position, it is obviously a tremendous logical contradiction for the counselling profession to place a high value on human diversity while simultaneously embracing a healthcare ideology that emphasises the correction of deviations from arbitrary, culturally dependent, and ever-fluctuating definitions of human normalcy.
The consequences of the actualisation versus deficiency debate, however, are not restricted to the realm of abstract philosophising. Rather, the choice of either a humanistic or healthcare model has tremendous implications for the concrete helping activities that occur in the consulting room. Specifically, adoption of a healthcare ideology because it emphasises deficiency, automatically means that it is the duty of the counsellor to correct or realign clients to some ideal of normative functioning. Alternatively, if actualisation is adopted as an assumptive mindset for counselling processes, the primary role of the counsellor is to understand clients, not correct them. Thus, the transition of the counselling profession to a health care ideology necessarily entails a shift from an actualisation to a deficiency perspective, which has tremendous implications for the ideals of the profession and the type of help counsellors provide.
As mentioned earlier, the ideological differences between the humanistic and healthcare models are not merely theoretical but are intimately connected to counselling practice. With regard to practice, these ideologies posit radically different conclusions about the factors that are responsible for healing within the counselling relationship.
The logical conclusion of the healthcare model, with its emphasis on sympton reduction, client deficiency and diagnostics, is that particular technical interventions should be implemented for certain classes of client problems. Therefore, as in physical medicine, the factors responsible for psychological healing are accurate problem identification and the implementation of prescriptive treatments32.
Treatment approaches based on these assumptions have been referred to as 'empirically supported'33 therapies. Recently, within the counselling tradition, they have been called a 'best practices'34,35 approach.
Alternatively, traditional counselling models, which are rooted in humanism, focus on subjectivity, client actualisation, and capacity for growth1,10,28. Given this set of starting assumptions, the logical conclusion of humanism is that the mechanism of healing is the counselling relationship, not a specific set of techniques aimed at reducing particular symptoms32.
Therefore, the shift of the counselling profession to a healthcare model has concrete consequences for counselling practice, namely, whether specific techniques or the counselling relationship itself is used as the vehicle for healing. In order to fully appraise the consequences of the counselling profession's shift to a healthcare ideology, the conclusions of the outcome effectiveness literature regarding the relative contribution of prescriptive techniques versus the counselling relationship to client healing should be considered.
In an exhaustive review of counselling outcome research, Wampold32 concluded that 'decades of psychotherapy research have failed to find a scintilla of evidence that any specific ingredient is necessary for therapeutic change'. More precisely, 'the evidence indicates that, at most, specific ingredients account for only one per cent of the variance in outcomes'. In terms of this discussion, then, there is little evidence to support the conclusion that counsellors should adopt an ideology that recommends specific techniques for particular problems as the primary route to client healing (ie healthcare). Rather, the research evidence demonstrates that the quality of the counselling relationship is the factor that accounts for the majority of the variance in counselling outcomes36,37,38. The move to a healthcare ideology, therefore, necessitates that practising counsellors trade effective relational methods for generally ineffective healthcare techniques.
I have argued that there is no logical justification for counselling to be considered a healthcare profession. Moreover, the switch to a healthcare ideology automatically entails a sacrifice of the humanistic ideals that have guided the counselling profession for decades. This abandonment of humanism has a direct impact on counselling practice, switching it from an effective relational paradigm to a relatively ineffective, technique-oriented emphasis.
However, this argument naturally begs the question, If counselling should not be considered a healthcare profession, then what kind of profession should it be?
I think a logical answer is that counselling should be considered a human service profession, just like law, education, and accounting. These professions have a long history of helping clients without embracing a healthcare ideology. The counselling profession, likewise, is perfectly capable of helping clients without defining itself as a healthcare profession. Indeed, as I have argued, the identification with the healthcare ideology comes with significant conceptual baggage that actually detracts from the ability of counsellors to practise effectively.
Some might argue, however, that despite the philosophical objections, there are compelling practical reasons for counselling to be identified as a healthcare profession. First, the healthcare identity has allowed for third-party reimbursement of counselling services, which has permitted many people to access counselling who might not otherwise have been able to do so. Second, defining counselling as a healthcare activity promotes collaboration among professionals identified as healthcare providers. Ultimately, a collaborative treatment effort may produce better results than a solo one. On the level of practice, I am certainly sympathetic to these objections. However, I have provided the following hypothetical example to illustrate why I am not convinced that these objections provide sufficient justification for counselling to be identified as a healthcare profession.
Imagine that accountants had mounted a campaign to be identified as healthcare providers. This thought is not as bizarre as it might sound. Consider that, in a parallel universe, key members of the accounting profession had aligned themselves with psychiatry; had capitalised on the fact that the Diagnostic and Statistical Manual of Mental Disorders23 recognises multiaxial diagnostics that include 'economic problems' as part of Axis IV; and had persuasively cited the regular research finding that income issues and poverty are inextricably tied to, and undeniably affect, psychiatric disorders. Suppose that this campaign resulted in accountants becoming defined as healthcare providers, with all the accoutrements associated with provider status, such as eligibility for third-party payment. Undoubtedly, this professional redefinition would result in the 'discovery' of new healthcare problems, such as 'self-sabotaging financial disorder', 'chronic tax delinquency syndrome' and 'designer label fetishism'. In this parallel universe, it would come to be accepted, without question, that accountants are healthcare providers and that quality mental health treatment always involves close collaboration with an accountant as part of the treatment team.
Now, suppose that the accounting profession had been challenged by the philosophical objections raised in this article. In defence of their healthcare identity, accountants might argue that third-party reimbursement enables many to receive accounting services who might not have been eligible to do so otherwise. Also, insights from an accountant on a healthcare treatment team may enhance treatment outcomes. Certainly, both these points may be indisputably true. However, would they be sufficient to justify the identification of accounting as a healthcare profession? I am not convinced that these points are persuasive regarding either the accounting or counselling professions.
A couple of other insights into this issue from a postmodernist vantage point are also worth considering. First, Foucault39 has persuasively argued that all claims to truth and ideology are intimately connected to power. That is, embracing a particular ideology automatically has a suppressive effect on competing ideas. For example, masculine models of psychological wellness that emphasise independence and autonomy have historically suppressed a feminine presence in psychological theorising, which, in direct opposition to masculine ideals, highlights relatedness and engagement as hallmarks of psychological maturity40. As another example, the idea that heterosexuality is the correct expression of sexuality automatically has a suppressive, and discriminatory, effect on alternative ideas about sexual expression. Therefore, the counselling profession cannot have it both ways. That is, the counselling profession cannot simultaneously embrace a healthcare model while retaining humanism. The adoption of a healthcare ideology necessitates the gradual demise of the traditional humanistic ideals upon which the counselling profession was founded1.
Second, postmodernists have also argued that language has a determinative effect on perception 10,11. Language, from this point of view, is not a system of accurate signification. For example, to call something a 'chair' is not to accurately encode the essence of the object into a word. The object itself does not demand that any particular word be used to describe it15. To linguistically signify something as a chair, then, determines that one see this object as something upon which to sit. Alternatively, if the object were named 'art', 'firewood', 'antique' or 'god', the function and perception of the object would change. The way something is languaged, therefore, has a determinative impact on perception and action. To extend these concepts into the current discussion, languaging the counselling profession according to the linguistic signifiers of the healthcare model necessarily 'creates' a particular type of client, dictates particular methods for curing this creation, and actively suppresses competing orientations. Given this supposition that language determines perception, I would like to invite the reader to engage in a hypothetical 'thought experiment'. Suppose that, for a period of one year, all counsellors were forbidden to use any words, or synonyms, from the healthcare language system to describe clients. A guardian to ensure the enforcement of this rule would be assigned to every counsellor. This guardian would sit in on every session, monitor all documentation, and accompany his or her assigned counsellor at all times throughout the work day to ensure that the rule was not violated. Whenever the counsellor used words derived from the healthcare language system, such as diagnosis, disorder, health, treatment or disease, the guardian would immediately force the counsellor to use an alternative word that is not conceptually related to the healthcare word.
It might be interesting to speculate about the possible outcome of this experiment. At first, of course, there would be considerable frustration among counsellors, given that they would no longer be able to use their usual way of languaging their work. Inevitably, though, new words would have to replace the old, forbidden ones. These new words would, in turn, create new perceptions of clients and suggest novel ways of helping. Perhaps this result would have the effect of making the perceptual trap of relying on the healthcare language system more apparent.
Obviously, this experiment is destined to remain in the hypothetical realm. However, I hope that by proposing it, the general assertions of this article have been fortified. Specifically, the counselling profession's increased identification with healthcare ideology has no basis in reason; it is ideologically inconsistent with the type of help that we, as counsellors, provide and it has the effect of shutting down alternative options for conceptualising client problems and solutions. Disavowing our ties to healthcare ideology or at least maintaining a continually reflective posture about the ideologies we endorse, will enable the counselling profession to evolve in ways that provide maximum benefit to the clients we serve.
James T Hanson is Associate Professor and Coordinator of Mental Health Specialisation at Oakland University in Rochester, M1. Email jthansen@oakland.edu This article first appeared in the Journal of Counselling & Development, Summer 2007, Volume 85.
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