A great deal of counselling is done in general practice and in other settings. It has expanded greatly over the past 20 years or so. It is very popular with patients and GPs, and clearly fulfils a need for patients to talk things over with a trusted adviser.

Probably, this popularity is only partly to be seen in mental health terms. Social factors such as family instability and reduction in involvement in organized religion may have meant that many individuals in distress do not have such ready access to their own means of support as did previous generations. Expectations and values have changed as well, the virtues of reticence (the traditional British 'stiff upper lip') being replaced by a notion that it is intrinsically 'good to talk'.

Counselling forms part of the valuable work done with patients by organizations such as the Citizens Advice Bureau (practical problems such as debt, housing, benefits, etc.), Cruse (bereavement), and Relate (relationship problems).

Primary care counsellors need to be appropriately accredited and qualified, and to have regular supervision. They usually offer a limited number of sessions, typically six to eight, and practice in a non-directive, supportive, 'reflective' way. Most patients probably do well.

From the perspective of secondary care, where patients who have not improved with counselling may be referred, there can be a perception that counsellors do sometimes inappropriately stir up old problems from the past. This can lead to patients becoming more distressed and perhaps requiring referral, when they would not otherwise have done so. Certainly, there is no evidence that provision of counselling and primary care leads to a reduction in workload in secondary care.

As regards effectiveness, in a large, randomized trial in the UK, both counselling and CBT were more effective for depression than usual GP care, with no difference between the two types of talking therapy (Ward et al., 2000).

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