Book: Psychotherapy: A Very Short Introduction (Very Short Introductions)

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Many more of us will see a counsellor than ever be treated by a psychotherapist. Family doctor surgeries, colleges and schools, and many workplaces now employ counsellors. How is counselling different from psychotherapy? The word has several meanings—from a careers counsellor who advises on jobs, to being ‘counselled’ (told off) about work performance. In this book counselling refers to a confidential relationship between a client (the term preferred by counsellors, rather than patient) and an individual who is trained to listen attentively and who will try and help you improve things through support and understanding. What is the difference, then, between counselling and psychotherapy? This is a good question, but one that is not easy to answer. The boundaries are blurred and no definition pleases everyone. However, there are some recognizable and useful differences.

Overall, counselling is less formal than psychotherapy, and the relationship between counsellor and client more equal. The word counselling itself is a bit less ‘threatening’ and therapists working in schools or colleges are often referred to as counsellors to reduce anxiety about going to see them. Counselling also tends to be shorter, often just half a dozen sessions. It is rarely more than once a week and is usually less expensive. Most counselling training focuses predominantly on the use of counselling skills and on building the therapeutic relationship rather than on any complex model of mental functioning. It is generally less theory-laden. This does not mean there are no guiding principle, or that counsellors make it up as they go along, but you are unlikely to have a sense that a specific interpretation of your problems is imposed on you or on the process. As with psychotherapy, counselling can focus on specific symptoms or on more general problems of living. There are times when counselling is preferable to more formal psychotherapies, as in coping with acute and overwhelming events such as a bereavement or a relationship break-up.

Initially there was no training requirement for counsellors. Individuals with a wide experience of human life and with a warm and tolerant personality simply ‘became’ counsellors. Although still very variable in length and intensity, training requirements are becoming more formalized. Many counsellors in the UK are registered with the British Association of Counselling and Psychotherapy (BACP), although they are not required to be. To be registered they need to have completed a recognized training course, many of which require them to have spent some time in counselling themselves. They must have a supervisor with whom to discuss practice and keep up to date with their subject. The BACP was originally the British Association of Counselling, but it added Psychotherapy in 2000 as counselling training became more sophisticated. The name in itself is emblematic of the overlap between counselling and psychotherapy, which we have outlined. Let us start with the fundamentals of counselling practice, before describing some approaches in more detail.

Rogerian or client-centred counselling

Whatever they are called (existential, rational emotive, problem-based) most counselling draws on the core tenets of Carl Rogers’ client-centred approach. Carl Rogers (1902–1987) was an American psychologist and psychotherapist who reacted against the pessimistic view of human nature that dominated psychotherapy during his training. He rejected its excessive focus on symptoms and disorders, basing his approach on humanism and existentialism. Humanism emphasizes the basic goodness and positive striving of all individuals, while existentialism teaches that the meaning of our lives lies in what we do with them. To be what he called fully functioning we continually have to make choices, and making choices is inherently stressful. Rogers concluded that the only one who could know what was right for an individual was that person himself. In client-centred counselling, the client is always the real expert whose judgement should be trusted when things are unclear.

The titles of Rogers’ most influential books (On Becoming a Person and A Way of Being) demonstrate his outlook and underscore his fundamental principle of counselling. Counsellors have to embody the counselling process; it is not a technique to be learned but a philosophy to be embraced and lived. Counsellors must accept the basic value and goodness of everyone (including themselves) and recognize the healing power of self-awareness and human relationships in the conduct of their daily lives. Without this their counselling would be a hollow sham. Rogerian counsellors disapprove of technique and explanations, relying instead on their style of relating and on clarification.

The core conditions

Rogers believed that certain core features of the counselling relationship were responsible for healing. Of the original conditions, he described three that have become accepted as the basis of all psychotherapies. Two of the others are so self-evident they are hardly mentioned. One of these is that there has to be a psychological contact, a real relationship, which fully engages both counsellor and client—one that they are both aware of. Counsellors allow a greater degree of self-disclosure, acknowledging the feelings in the room, and may sometimes share aspects of their own experience, such as a bereavement. In drug and alcohol counselling services an openly acknowledged history of addiction is often a requirement. The second ‘self-evident’ condition is to communicate this engagement and understanding to the client. It is no use having all this commitment if the client remains blissfully ignorant of it. What, then, are the three core conditions for successful counselling and psychotherapy?

Congruence or genuineness

This means that the counsellor is fully engaged both in himself and in the relationship. Rogers originally used ‘congruence’ to convey that the counsellor’s personality matched (was ‘congruent with’) her behaviour in the session. She is not putting on a professional front, so can legitimately draw on her own experiences in the therapy. The declared aims of the counselling—those agreed by counsellor and client—then really are shared objectives. Congruence is now more often described as genuineness or authenticity. The three core conditions will vary in intensity over time, but genuineness is a precondition for the other two. A counsellor who denies that she is anxious in a session, while her body language clearly demonstrates she is, will find it hard to help a client to be honest.

Empathy

The counsellor has to gain an understanding of what the client is going through, emotionally as well as intellectually. Empathy means being able to feel what the other person is experiencing. It is not the same as sympathy, which is to feel for their plight. Accurate empathy is a core skill in all therapy. We need to be able to ‘get under the skin’ of our patients and to see the world through their eyes. Empathizing with a client means acquiring an ‘as if’ experience of what they are going through, not sharing it directly. The therapist does not have to be personally anguished to empathize—in fact this could be most unhelpful.

Establishing empathy often requires clarifying emotions. Rogerian counsellors frequently repeat the clients’ comments (mirroring), often with a questioning tone to encourage them to tease out what exactly they are experiencing. What matters is that the client, not the counsellor, understands. This mirroring of the client’s utterances has at times led to a cruel and dismissive caricature of Rogerian counselling, in which such repetition is presented as purely reflex:

CLIENT: I feel awful.

COUNSELLOR: You feel awful.

CLIENT: It’s hopeless. I’m going to end it all.

COUNSELLOR: You feel hopeless. You’re thinking of ending it all.

CLIENT: I’m jumping out of the window!

COUNSELLOR: You’re jumping out of the window!

Of course it is not at all like this. Mirroring and clarification are active processes to deepen understanding, without which change cannot take place or freer and healthier choices be made.

Unconditional positive regard (respect)

It is difficult to imagine helping someone in counselling or psychotherapy if you actively dislike them. Rogers believed that you have to have a real desire for your client to do well, and to genuinely respect their struggle. At the very least you should not find yourself disapproving of them, and certainly not express such disapproval. This may seem a counsel of perfection, as we all have our prejudices. The need to believe in people’s fundamental goodness does not mean that counsellors are always ‘warm and cuddly’. The clarification employed to deepen empathy often requires asking hard questions and making uncomfortable observations.

Unconditional positive regard sounds very daunting so is now usually called respect. You can have a positive regard for someone despite finding some of their behaviour off-putting. Most therapists have strategies for maintaining this distinction, just as clergymen profess to ‘love the sinner but hate the sin’. Counsellors who really cannot warm to a client may refer them on to a colleague, whereas a psychoanalyst is more likely to see such feelings as important counter-transference clues to be worked with.

As in the later psychotherapies, the relationship itself has a central importance in counselling. It is not simply a framework for exploring the patient’s internal life, but a curative force in its own right. Many counsellors distrust theories and concepts such as the Oedipus complex, archetypes, or maladaptive schemas. The client is the only one who can answer the ‘why’, and remains the final expert.

However, the nature of the counselling relationship carries some specific risks. Because it is less structured and theory-bound, and because the training is usually shorter, things can go wrong. A naïve counsellor may blur professional boundaries too much and risk becoming overinvolved with their client, or become swept up in the suffering. Self-disclosure (‘I recognize how this feels, my own brother died suddenly when I was young’) can be very powerful, but it can also derail the treatment. It could overburden clients who may feel they then have to care for their counsellor. Regular supervision is necessary to manage this tricky balance, particularly if the counsellor has no other professional background (nurse, social worker, psychologist) where supervision is an established practice. The BACP has been at the forefront of developing codes of ethics and practice to address these risks. We will now describe some specific counselling approaches.

Existential therapy

Person-centred counselling derives its thinking in great part from existential philosophy. Existentialists believe that what matters is what we do, rather than who or what we are. It is our own actions (our existence) rather than some preconceived view of human nature (an essence) that is important. We constantly create our identity rather than being determined by it, and our lives are driven by motives rather than causes. Every choice we make defines us, and we have no option but to continually make choices. Existentialists emphasize that we are active agents in the world, not objects, so therapists strive strenuously to avoid objectifying or categorizing the patient. They emphasize a mutually interacting relationship, focused on the here-and-now and an immediate relationship with the world.

The American existentialist-humanistic approach

The first form of existential therapy was developed by Ludwig Binswanger in the 1930s and is now mainly of historical interest. The existentialist approach lives on in humanistic counselling and psychotherapy. Rollo May and his enormously influential pupil Irving Yalom shifted the focus to a consideration of the individual’s subjective reality; that is, how the client experiences his own world. This deviates from the hard-line existentialist’s insistent focus on interaction with the outside world. Their approach focuses back on to the client’s inner life and emotions.

In contrast to Freud’s rather dour pessimism, Yalom brings a sunny Californian positivity and optimism. He encourages the client to stay with their emotions and confront the defences they have erected to protect against life’s complexity: ‘feel the fear and carry on’. Like Rogers, Yalom encourages therapists to be open to the client, and he repeatedly insists that ‘it is the relationship that heals’. Increased self-understanding may be helpful, but it is not enough, nor is it the crucial ingredient. The vital ingredient is the relationship itself.

This existential-humanistic approach re-engages with the unconscious, but it is warmer and more directive than psychodynamic counselling. It is concerned with the present and the future, rather than with the past.

Therapy focuses on four core existential concerns: death, freedom, isolation, and meaninglessness. Counselling approaches for the physically and even terminally ill have been extensively developed. Despite this apparently morbid preoccupation, the tone of existentialist-humanistic counselling is inexorably upbeat. Complaints of ‘can’t’ are reframed as ‘won’t’. In his 1980 book Existential Therapy, Yalom exhorts the client to repeat regularly to himself or herself the following statements:

Only I can change the world I have created

There is no danger in change

To get what I want I must change

I have the power to change

The British existential school

In contrast to the sunny, Californian optimism of the American existentialist-humanists, the British existential therapy school assumes that ‘life is an endless struggle’. Developed and popularized by the Dutch psychotherapist Emmy van Deurzen, this approach links back to traditional existentialism. It focuses on the immediate relationship with current reality rather than the intrapsychic, subjective world of the patient. It continues to emphasize the importance of an ‘authentic’ relationship, and rejects the trappings of formal psychotherapy and of diagnoses and classification. It construes patients’ problems in terms of being ‘clumsy at living’. True to its existentialist roots it is relentlessly descriptive rather than explanatory. The aim of therapy is to form a clearer awareness of experience rather than try to explain it. In this it takes from Rogerian therapy, and in practice it is very non-directive and democratic. It re-emphasizes ‘being with the patient’. Its radical and anti-authoritarian (anti-expert) stance makes it very attractive to those who might have difficulty tolerating a more paternalistic or establishment approach.

Transactional analysis (TA)

TA is a very accessible theory of human interaction that is used by many integrative or eclectic counsellors. It was introduced in 1964 by Eric Berne in his bestselling book Games People Play. TA focuses on how we communicate with others, and it replaces the three familiar Freudian levels of super-ego, ego, and id with the mental states parent, adult, and child. Berne shared Rogers’ and Yalom’s broadly optimistic view of human nature and of our capacity to find success and happiness. Well-balanced individuals behave as adults and treat those around them as adults. This was captured in the title of one of the most successful TA books, I’m OK, You’re OK.

Berne’s approach achieved instant popularity, not only through his easily grasped structure of the parent, adult, and child roles, but via his description of a series of ‘games’ with catchy titles. The ‘games people play’ are based on the various permutations of the three roles (I act like a child that forces you to act as a parent, I act as a parent forcing you to respond as a child, and so on). Our tendency to fall into these roles in different situations will depend on our own issues (see ). We may feel driven to exploit the child role when we feel particularly insecure, or perhaps the parent role when we want to avoid the intimacy that can come from adult sharing.

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9. The three possible roles or ‘ego-states’

The most famous of these games is the ‘yes, but’ gambit, which is very familiar not only to counsellors and therapists but surely to us all. The client describes a problem that is troubling her, but when the counsellor points to an obvious solution this is countered with an explanation of why it will not work:

CLIENT: People dismiss me, even when they know I’m right, because I’m a scruffy dresser and they are all snobs.

COUNSELLOR: What would it be like for you to ensure that when you are going to those sorts of meetings you put on a suit? You don’t have to wear one all the time.

CLIENT: If I weren’t myself, if I had to put on a show, then it would all be a waste of time and I wouldn’t care if they agreed.

On the face of it this is a reasonable adult-to-adult discussion about identity and integrity. However, the counsellor might note that the patient is using a victim-child state to engage the therapist’s parent role. The conversations people engage in are built up of transactions which can be analysed in this way. The most complex transactions occur when there is a deliberate or unconscious difference between the overt social exchange (what is said) and the covert psychological intent (what is meant). These are referred to as ulterior transactions and need careful unpicking.

The most obvious strength of the TA approach is its common-sense quality. We can all grasp the three roles, and once the games are pointed out they are very easy to recognize. Counselling, of course, goes beyond simply ‘spotting’ games or the roles being used. It is the task of understanding why and how the client uses them with certain individuals and in specific circumstances that matters.

Drug and alcohol counselling

There is no recognized model for drug and alcohol counselling, but counselling is used extensively throughout such services. The practice is very widespread indeed, which should come as no surprise. It takes real commitment and energy to get off and to stay off drugs or alcohol—to ‘kick the habit’. The initial phase of getting off drugs or alcohol under medical supervision is now fairly straightforward, but staying off is anything but. This is where counselling comes in. Staying off requires radical changes in lifestyle, giving up something that used to provide the pattern for your existence, moving away from a familiar social circle of other drinkers and addicts, with few other supports.

Alcoholics Anonymous (AA) is the most widespread system worldwide to support sobriety in alcoholics, and its offspring Narcotics Anonymous (NA) helps drug users stay ‘clean’. Its twelve steps approach is not, in itself, a model of counselling but a structure, both social and psychological, to help the addict embark on a new life. AA insists that with no ‘cure’ for addiction, you have to renew a commitment to abstain ‘one day at a time’. AA has quite a religious feel to it, with regular meetings where members ritually acknowledge their problems: ‘My name is Janet and I am an alcoholic’.

Most services for addicted individuals go beyond supervised withdrawal and support from AA or NA meetings, and they also offer counselling. This aims to help the recovering addict understand the personal issues that may have driven them to drugs or alcohol and, just as importantly, those that keep them stuck in their habit. What emotional pain was the drug blunting? What failed relationships did the intoxication obscure? What made sobriety unbearable? In addiction circles the language is often quite dramatic: ‘demons’ rather than complexes, ‘self-destruction’ rather than risk-taking. But the issues are the same. Unresolved feelings, painful memories, low self-esteem, and disturbing ruminations make it harder to get off and stay off drink or drugs and to build new relationships.

As we have mentioned, there is no unique theoretical model of counselling for addictions—person-centred counselling is the most common approach. It often comes with strict rules on abstinence as a condition of attendance. Blunt confrontations are common, which can seem quite brutal to outsiders, although addicts often welcome them. They are only too familiar with their evasions and have extensive experience of ‘fooling’ previous counsellors. Many services insist that the counsellors are themselves recovered addicts who are familiar with such self-deception and so don’t pull their punches when pointing it out.

Psychodynamic counselling

Distinguishing psychodynamic counselling from client-centred counselling is fairly easy, but distinguishing it from psychodynamic psychotherapy is not so straightforward. This is probably where the boundary between counselling and psychotherapy is the least clear. Many counsellors describe themselves as psychodynamic, so being clear what it is, and the difference between them, is worth some effort. While retaining many of the core features of counselling outlined at the beginning of this chapter, psychodynamic counsellors base their practice on traditional psychodynamic or psychoanalytic theory. They focus on helping the client become aware of unconscious conflicts and making sense of them, often using interpretations (see ). The aim in psychodynamic counselling is ‘to make the unconscious conscious’—Freud’s ‘where id was, ego shall be’. Once the client is properly aware of the unconscious forces shaping their experiences and behaviour, they can start to sort themselves out.

Psychodynamic counsellors are much more likely than client-centred counsellors to respond to a question with another question or an interpretation. Their aim is to uncover underlying issues. For instance, if a client comments that their counsellor looks under the weather, the Rogerian is likely to encourage them to explore in more detail their experience of that concern. The psychodynamic counsellor, however, may seek out underlying anxieties or hostilities: ‘perhaps you think that the problems you have been sharing are too much for me and I am not coping?’

Psychodynamic counsellors pay particular attention to containing clients’ distressing experiences, often rephrasing them so the client can confront them safely. The active emotional engagement buffers the pain of these experiences so that they can be carefully examined. This is often referred to as holding, a concept described by the analyst Donald Winnicott. It implies that the strength of the relationship is such that it can contain intense experiences that would otherwise be overwhelming.

By holding, and reflecting back a somewhat more manageable version of the client’s conflicts, the counsellor provides the opportunity to find an alternative way forward. The experience itself is partly curative. The presence of a trained person who is able to withstand such stresses can be used to explore and replay old conflicts and find new solutions. Unlike most other counsellors, psychodynamic counsellors allow a degree of regression and for clients to become more dependent so that they can explore their more child-like feelings and impulses.

In practice, psychodynamic counselling can be quite long term—many months or even a year or two. It is also rather more formal, being strict about times and self-disclosure. The client is no longer the sole expert on their inner life, although clarifying it is very much a collaborative exercise.

Telephone counselling

The Samaritans in the UK and their sister organizations across the world have long demonstrated the value of fast access by telephone, and now often by e-mail, to a sympathetic listener. They provide an opportunity to express and share acute distress rather than simply soldiering on or resorting to drastic acts such as self-harm or suicide attempts. The telephone service Child Line in the UK offers similar opportunities to children who experience neglect or abuse. In our age of the Internet and Skype the lessons learned from these services have been taken on board by counsellors and psychotherapists. In very dispersed communities such as rural Australia it is now possible to have quite extensive tele-counselling or tele-psychotherapy.

The relationship between counselling and psychotherapy

The outline of the counselling approaches in this chapter demonstrates how complex the relationship is between counselling and psychotherapy. Counselling is not just some watered down or cheap alternative to psychotherapy. From Rogers on it has forged its own theoretically coherent and individual path. While it has learned from the more established psychotherapies, we have also highlighted some of its own unique contributions. These arose out of its more equal relationship and more obviously shared experience. In turn these insights have fed back into the practice of the formal therapies. Perhaps more importantly, it has made a supportive space for self-reflection a realistic proposition for the majority of us.

Previous: Chapter 4: Time-limited psychotherapy
Next: Chapter 6: Cognitive behaviour therapy