Counselling
Diana Sanders
Introduction
People seek counselling for many reasons. Sometimes those who have had no previous need for mental health services are literally stopped in their tracks by life events—illness, family breakdown, intolerable stresses. People with long-term difficulties may turn to counselling when they feel the statutory services are not able to meet their needs, or as an adjunct to health care provision. With greater social mobility and the separation of family members, counselling increasingly provides the care and support previously offered within local communities. The provision and acceptability of counselling is on the increase. Counselling is possibly the most commonly delivered form of psychological therapy(1,2) and the British Association for Counsellors and Psychotherapists have over 30 000 members, with equivalent numbers in other countries. Professional training programmes in counselling have mushroomed in response to demand. Counsellors are found in many statutory and voluntary settings—mental health, primary care and medical settings, workplaces, drug and alcohol services, voluntary and charitable organizations, trauma services, and educational settings—as well as in private practice.
But what exactly is counselling? What do counsellors do? Is counselling the same as psychotherapy? And, is it an effective form of treatment? Although counselling is a major growth area within mental health, it can be difficult for consumers and purchasers of counselling services to know what kind of counselling and counsellor to use, with lack of clarity about what works for whom. There are many different models of counselling, types of counsellor and many different training courses. It is difficult to make clear distinctions between counselling and psychotherapy. Much of the work of counsellors has not historically been amenable to standard methods of evaluation, and research is relatively new. Currently there is no statutory regulation for the term ‘counsellor’, which means that people are able to practise as counsellors without registration or accreditation. By definition, people who seek counselling are likely to be vulnerable, and the issue of public protection is paramount.
The aim of this chapter is to clarify these issues and examine the place of counselling in psychiatry. The chapter begins by looking at the definition of counselling, and how counselling is both similar to, and distinct from, psychotherapy. The chapter goes on to look at the key features of counselling, and different models of counselling. Although counselling can and is used for many psychological difficulties, the chapter selects specific problems where there is evidence that it is an effective intervention: mild to moderate depression, adjustment difficulties, bereavement, trauma, and relationship problems. I then consider counselling in different settings, again selecting a few which illustrate the work of counsellors—primary care, mental health settings, student counselling, and the workplace—looking at the way counselling can be adapted according to the needs of the service. 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.
Defining counselling
No single definition of either counselling or psychotherapy exists in spite of many attempts in Britain, North America, and elsewhere to arrive at one.(3) Currently, neither the British Association of Counselling and Psychotherapy (BACP) nor the American Counseling Association has either proprietary rights of the terms or even official definitions, although, as discussed below, the move towards statutory regulation for counselling and psychotherapy may ensure greater clarity for practitioners and consumers.
At its broadest, counselling is conceptualized as a way of helping or assisting others to make their own adjustment and decisions in the face of life problems. Counselling aims to offer a safe relationship within which the individual can explore personal difficulties and, through developing a deeper understanding of themselves, move towards change. The Department of Health defines counselling as … a form of psychological therapy that gives individuals an opportunity to explore, discover, and clarify ways of living more resourcefully, with a greater sense of well being. Counselling may be concerned with addressing and resolving specific problems, making decisions, coping with crises, working through conflict, or improving relationships with others.(4)
In contrast with other forms of psychological therapy, where the focus may be on treating specific problems, many counselling models give equal if not more weight to the process of change. The journey through which a client goes—to greater understanding, awareness, and resolution—is as important as the outcome. Counsellors practise within all therapeutic approaches, strongly influenced by humanistic, experiential, and psychodynamic principles. They tend not to link their work to diagnostic categories, preferring to see each client as an individual, and using an approach matching the client’s needs rather than diagnosis. Counsellors may define themselves by the model they practise—for example, humanistic or psychodynamic—and/or by the type of problems they work with, such as bereavement or relationship counsellors.
Counselling may also be defined in terms of key elements and goals,(5) as shown in Table 6.3.1.1. Again, the key elements and goals illustrate the variation within counselling. For example, what is meant by counselling ranges from providing a safe arena for people to gain understanding and insight, to offering more direction and guidance leading to decision-making and problem-solving.
Table 6.3.1.1 The key elements and goals of counselling (Reproduced from Feltham, C. What are counselling and psychotherapy? In The Sage Handbook of Counselling and Psychotherapy, (eds. C. Feltham and I. Horton), pp. 3-10, copyright 2006, Sage Publications.) | ||||
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Counselling and psychotherapy
Much of the above can also be applied to psychotherapy and parts of this chapter do indeed overlap significantly with psychotherapy. There may well be variation between countries in what is defined as counselling or psychotherapy. Counselling and psychotherapy each have distinct features including different historical roots. Psychotherapy arose from the seminal works of Freud in the late nineteenth and twentieth centuries, and in the past, psychotherapists tended to offer a long-term psychodynamic approach. Now, however, psychotherapy also includes interpersonal, humanistic, and cognitive models. In the United States, counselling was originally linked with vocational guidance, personnel management, and the workplace,(5) and as such was much more advisory and directive than the analytic processes of psychotherapy. Carl Rogers, the founder of non-directive counselling in the 1940s, initiated the movement away from practical guidance and problem-solving towards collaborative and person-centred models, forming the basis of counselling today.
Differences between psychotherapy and counselling tend to relate more to the individual psychotherapist’s or counsellor’s training and interests and to the setting in which they work, rather than to any intrinsic difference in the two activities. In medical and mental health settings, psychotherapists are more likely to work with patients with severe psychological disorders, offering longterm therapy, whereas counsellors may concentrate on difficulties amenable to short-term work—mild to moderate psychological disorders, relationship difficulties, or bereavement. Counsellors who work for voluntary agencies or in educational settings such as schools and colleges usually concentrate more on the ‘everyday’ problems and difficulties of life than on severe psychological disorders, although agencies such as MIND, Alcoholics Anonymous, or
Narcotics Anonymous offer counselling to people with serious mental illnesses. In private practice, however, a counsellor’s work will overlap with that of a psychotherapist.
Narcotics Anonymous offer counselling to people with serious mental illnesses. In private practice, however, a counsellor’s work will overlap with that of a psychotherapist.
In a pragmatic vein, Feltham states that practitioners and the public stand to gain much more from the assumption of commonality than from spurious or infinitesimal distinctions … little is to be gained practically from further controversy about professional titles and distinctions.(5) In 2000, the British Association for Counselling lent weight to greater rapprochement by becoming the British Association for Counselling and Psychotherapy. On a practical level, it is interesting that many recipients of ‘talking therapies’ other than counselling, such as psychotherapies, cognitive-behaviour therapy and problem-focused discussions with GPs, psychiatrists, or nurses, say that they have received counselling, reinforcing Feltham’s plea that the issue of definition and distinction is academic rather than of practical value.
Counselling skills and counselling practice
Counselling skills are integral to the practice of psychiatry and all the ‘helping professions’, as basic ingredients of effective interviewing, accurate history-taking, diagnosis, and treatment-planning.(6) The skills of listening, summarizing, reflecting, checking, understanding, gaining rapport, and communicating enable other people to feel understood. They are essential for engagement and eliciting information, especially when the person is afraid, in pain, or mistrustful. The health worker’s counselling skills may influence the patient’s collaboration with an active participation in treatment, and thereby the outcome of a wide range of medical and even surgical treatments. Many helping and health professionals such as social workers, occupational therapists, probation officers, and speech and communication therapists use counselling skills as an integral part of their work but would not be seen as primarily counsellors.
In contrast, counsellors as professionals, who use counselling as a specific intervention, work in many areas of mental health practice alongside psychotherapists, clinical and counselling psychologists, psychiatrists, psychiatric nurses, and social workers.(7) For professional counsellors, counselling skills are central to their work.
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:
Decision-making is an important ingredient in many forms of therapeutic counselling but, conversely, some forms of decisionoriented counselling (e.g. genetic counselling) embody no explicit therapeutic intention.
Counselling as a primary treatment for problems is used in the management of a range of 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 psychology
As well as professional counsellors, counselling psychologists have a particular role to play within counselling provision in mental health. The area of counselling psychology, now developing in the United Kingdom in line with other parts of the world, is a distinctive profession within applied psychology, which aims to foster the psychological development of the individual and help people develop more effective and fulfilled lives. It is based on the fundamental tenets of counselling, but in addition aims to integrate the application of psychological theory and research into its practice.(8) Counselling psychologists use a variety of therapeutic models, including person-centred, psychodynamic, and cognitive. Although the training of counsellors can be varied, as discussed below, counselling psychologists undergo standardized post-graduate doctorate training leading to chartered status within the British Psychological Society, or equivalent in other countries.
Is counselling an effective method of treatment?
Despite the proliferation of counsellors in many areas of medicine and psychiatry, counselling has tended to lag behind medicine and other health care professions in engaging in and promoting research to establish its effectiveness and efficacy.(9) The nature of counselling can mean that standard methods such as RCTs are not appropriate means of evaluation, whereas qualitative research methodology is better able to assess meaningful changes.(10) However, counselling as a profession is now engaging in better quality research, concentrating on outcomes in routine practice as well as qualitative analysis. New practice-based methods of evaluation, such as CORE (Clinical Outcomes in Routine Evaluation), and the aggregation of data across UK NHS counselling services can lead to national benchmarks. Methods of case-study research, and the development of measures of the client’s perspective on psychological distress, PSYCHLOPS,(11) enable more client-focused research. Such emphasis on evidence-based practice will lead to more careful targeting of specific counselling approaches to specific problems,(3) clearer information for the public and will improve counselling’s parity with other health care professions.
Currently, counselling has an image that it is more appropriate for people with mild to moderate difficulties. The Department of Health(4) recommends that counselling should not be the main intervention for people with severe and complex mental health problems or personality disorders. Patients who are adjusting to life events, illnesses, disabilities, or losses may benefit from brief therapies such as counselling. However, counsellors such as those in primary care and the voluntary sector are already offering an important and valued service. Although people with more serious and enduring mental health difficulties require primarily psychiatric and pharmacological intervention, offering emotional support, advice, and problem-solving can form an important, although under-researched, part of their care.
The core conditions of counselling and the therapeutic relationship
Counselling depends primarily on the interaction between the counsellor and client, what goes on in that interaction and the qualities of both client and counsellor. Carl Rogers'(12) definition of the conditions necessary for therapeutic change was a radical departure from traditional psychotherapeutic practice, in emphasizing the qualities and attitudes of the counsellor rather than specifying what the counsellor must do. His work led to the following as necessary and sufficient conditions for therapeutic change:
The client is in a state of incongruence, being vulnerable or anxious.
The therapist is congruent and genuine in the relationship with the client.
The therapist experiences unconditional positive regard for the client.
The therapist experiences an empathic understanding of the client’s frame of reference or way of seeing things.
The therapist feels non-possessive warmth towards the client.
The client perceives the therapist’s unconditional positive regard and empathic understanding.
These core conditions have been used and developed in many models of counselling and therapy; even therapies traditionally seen as more technical have always maintained their importance.(13) Empathy, for example, a core condition which is central to all good therapeutic relationships, enables clients to know that they are heard and understood. At its simplest, empathy is a simple restatement of someone else’s words. At its richest, it involves … a fearless exploration of another’s inner world, a sensing of meanings unspoken, a compassionate naming of pain … the fullest empathy does not censor or discriminate. It sees the world as the other person sees it.(14)
While Rogers took the view that such core conditions are both necessary and sufficient for therapeutic change to occur, other models of counselling have defined such conditions as necessary but not in themselves sufficient for change. However, the core conditions remain the bedrock upon which counselling is practised.
The therapeutic relationship
Across very diverse treatments, including cognitive and psychopharmacological,(15) measures of the strength of the relationship, or alliance, have been the strongest and most consistent process correlates of treatment outcome.(3,16) Clients who have strong alliances with their therapists tend to have better outcomes.
Although recognized as an essential component of change, different models have different conceptual and practical approaches to the relationship. Three examples illustrate the differences:
Person-centred models take a here-and-now perspective, looking at the immediate interaction between client and counsellor. The client’s perception of the therapist’s empathy, unconditional positive regard, and congruence enables therapeutic change.
Cognitive models regard the relationship as necessary but not sufficient for therapeutic change. The relationship is primarily collaborative, with an active, working bond formed between client and counsellor to facilitate the tasks of therapy.
Psychodynamic models distinguish the real relationship between client and counsellor, and the transference relationship, consisting of both client transference and therapist counter transference. The working alliance therefore is only partly based in reality, also containing aspects of both parties’ histories.
Counselling methods and techniques
There have always been many approaches to counselling and psychotherapy, and this diversity grew into a veritable ‘multiverse’ during which some authors estimated that there were over 400 brand therapies in existence. There are also different settings and agencies which offer counselling—clinics, institutes, health centres, or voluntary bodies, each with its own particular features. Within each model and setting, there are different formats of counselling including self-help materials on CD-rom and the Internet, as well as individual, couple, group, family, and organizational. Such a range can be confusing to potential clients and organizations, and the question of what works, for whom, and in which setting, has to be central in matching client, problem, therapy, and therapist.
Specific models of counselling are usually differentiated by a number of factors:
Basic assumptions or philosophy
Formal theory of human personality and development
Clinical theory defining the goals, principles, and processes of change
Therapeutic skills and techniques(17)
One useful distinction exists between schools of counselling and theoretical approaches.(18) A theoretical approach presents a single position regarding the theory and practice of counselling, whereas a school is a grouping of different theoretical approaches with common characteristics(see Table 6.3.1.2).
The three main schools are humanist-existential, psychodynamic, and cognitive behavioural. Humanistic-existential models will be described in detail, with briefer mention of psychodynamic and cognitive behavioural models, which are covered in other chapters. The section on methods also looks at the trend towards integration and eclecticism within counselling, whereby counsellors use a variety of methods and approaches adopted from different models. Although not clearly fitting into any one school, informationgiving and problem-solving are counselling methods widely used in psychiatry, and are therefore described first.
Information-giving and problem-solving
Giving information is an important part of all medical and psychiatric practice, reflecting an open and collaborative approach to treatment, providing patients and their carers with the material necessary for informed decision-making. For example, for people with schizophrenia or those who misuse alcohol, the provision of information about the diagnosis, causes, and potential consequences of their condition is essential for mobilizing motivation and compliance with treatment. Giving information about the actions and potential side-effects of a prescribed medication enables people to
play an active role in pharmacological intervention. Informationgiving is always crucial when communicating a diagnosis and fundamental to counselling for risk, as in genetic counselling, and to any intervention in which the individual is helped to make decisions.
play an active role in pharmacological intervention. Informationgiving is always crucial when communicating a diagnosis and fundamental to counselling for risk, as in genetic counselling, and to any intervention in which the individual is helped to make decisions.
Table 6.3.1.2 Overview of counselling schools and main approaches (Reproduced from Nelson-Jones, R. Theory and practice of counselling and therapy (4th edn.), copyright 2006, Sage Publications.) | |||||||||||||
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Psycho-educative methods have a place in most models of counselling and psychotherapy, but have specific importance in problem-solving and cognitive behavioural models. For example, a psychologist or counsellor may describe to the client a psychological model of a specific condition, such as the cognitive model of panic, to help the client understand their particular symptoms.
Information-giving and psycho-education involves more than just giving information to a passive recipient. Wherever possible the individual’s curiosity about their condition is promoted, encouraging them to ask questions and, when appropriate, to find their own answers. The Socratic method and guided learning are central to cognitive approaches. Information is not provided in a didactic fashion, but in response to the client’s questions, as client and therapist are engaged in collaborative enquiry. Whatever the information given, the practitioner checks whether the client has understood the information and its meaning. Information-giving is rarely the endpoint of an intervention, serving instead as the basis for decision-making or continuing therapeutic work.
Problem-solving has been used and empirically validated as a specific treatment, particularly for depression, and is used by many cognitive behavioural and humanistic counsellors. Problemsolving forms a major part of brief solution-focused therapy.(19) From a problem-solving perspective, depression results from the interaction between negative life events, current problems, and deficient problem-solving abilities, and therefore facilitating solving problems is a means to alleviate depression.(20) Therapist and client work collaboratively to identify and prioritize key problem areas, break them down into specific manageable tasks, solve problems, and develop appropriate coping behaviours. The approach involves several stages:
Identification and formulation of the client’s problem(s)
Setting clear and achievable goals
Generation of alternatives for coping
Selection and operationalization of a preferred solution
Evaluation of progress, with further problem-solving as necessary
Research in the United Kingdom has shown that problemsolving delivered by general practitioners is as effective as pharmacological treatment for moderate and major depression in primary care.(21,22) The intervention can be extremely useful for clients who do not want or cannot tolerate pharmacological treatment and is recommended in NICE guidelines as a treatment for mild depression. It can be offered by counsellors, general practitioners, and nurses, and may be a means to improve treatment adherence for people with psychotic disorders, as part of a psycho-educational intervention including motivational interviewing.(23)
Brief solution-focused therapy developed from its roots in family therapy to applications in counselling, mental health, group work, education, drug and alcohol work, social work, and business. It is the preferred mode of working for counsellors in the workplace, given its brief and focused approach. The model arose from family therapists’ observations that clients made significant changes when focusing on their preferred futures rather than on current problems. By articulating solutions, and building on existing skills and strengths, clients saw their problems in a different light and could effect change.
The ‘miracle question’ is a classic method of solution-focused therapy which is integrated into other models. The client is asked to think about and describe waking up one day to find that all problems have vanished. The counsellor explores the impact of the miracle on people and situations. The question enables the client to get into a problem-solving cognitive set, enabling identification of what needs to happen for the problems to change. The method has been studied in a range of client groups and settings, including with repeat offenders in the forensic service, and can produce positive outcomes.(19)
Humanistic and existential models
Humanistic and existential approaches include person-centred therapy, gestalt therapy, transactional analysis, and existential approaches. Of these, the person-centred model is the most well known, and the one that comes most readily to mind when describing the philosophy of counselling.
Client-centred, or person-centred as it is more often called, counselling originates from the work of Carl Rogers, whose emphasis on the recognition and empowerment of the help-seeker challenged the perceived authoritarianism of both the medical model and psychoanalysis. The model highlights respect for the person, and adopts the optimistic assumption that each person has an inner potential for healthy development and achievement, or ‘self-actualization’. Person-centred approaches often use the analogy of a plant to describe the concept of growth and change. No one can make a plant grow, but if the plant is provided with the right conditions—water, light, soil, nutrients—then it will become the best plant it can be. Person-centred therapy assumes that people have an inbuilt motivation to change, and also have the skills necessary with which to effect changes. Rogers’ model of counselling is non-directive. The counsellor’s task is to create the core relationship conditions of empathy, warmth, unconditional positive regard, and genuineness, described above, in which the client’s inner resources and potential will be unlocked, leading to the spontaneous resolution of problems and developmental growth.
The central features of person-centred counselling form the bedrock of other models of counselling, including cognitive approaches. Carl Rogers, in initiating the person-centred approach, has also had a wide influence in the helping professions—the term ‘person-centred’ is used frequently in policy documents and guidelines within health care organizations, as one of the standards of service and as a philosophy of health care.
While a non-directive and reflective approach has value, and may be useful for initial data-gathering and supportive work, caution must be applied to the use of Rogerian counselling in psychiatry. Resource constraints require practitioners to impose time limits on counselling, which therefore must be more focused and ‘active’. Furthermore, very disturbed people may be unable to access an inner potential for spontaneous change and growth, implicit within the client-centred model. There are some for whom a reflective non-directive approach may be harmful, risking an overwhelming upsurge of avoided or forgotten memories of traumatic experiences without providing methods for coping with them.
Victims of childhood sexual abuse or other destructive experiences may be re-traumatized by unstructured reflective counselling.
Victims of childhood sexual abuse or other destructive experiences may be re-traumatized by unstructured reflective counselling.
It is likely that the person-centred approach will continue to form the basis of good counselling and psychotherapeutic practice regardless of the model used, with increased emphasis on more ‘skills-based’ approaches such as cognitive behavioural and other models that lend themselves more easily to measurement, structured working, and evidence-based practice.
Gestalt therapy was originated by Fritz Perls, who described his approach as dealing with the total existence of a person, rather than being primarily occupied with symptoms or character structure.(24) Gestalt therapy argues that the past is past and the future unknowable, therefore the focus of counselling should be the present moment—an approach, interestingly, espoused by the development of mindfulness in psychiatry and psychotherapy.(25) The goal of therapy is to put clients in touch with what they are thinking, feeling, and sensing, in the here and now, and how they restrict or limit themselves by continual focus on the past or future. Gestalt therapists regard the therapeutic relationship as a ‘working’ relationship, with client and counsellor taking responsibility for themselves. Attaining awareness is an essential aim within the relationship.
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