Strengths and weaknesses of counselling

There are many varied approaches to counselling in contemporary society to which all have their strengths and limitations. The purpose of this assignment is to discuss the strengths and limitations of Transactional analysis (TA) and Cognitive Behaviour Therapy (CBT). The first section of this assignment will provide a brief overview of TA, then moving on to discuss and analyse its unique strengths and limitations and the research evidence that can demonstrate its capabilities. This discussion is then further developed with a brief overview of CBT, then moving on to discuss and analyse this approaches unique strengths and limitations and the research evidence which suggests this is a successful therapeutic approach.

Eric Berne (1975) defined Transactional Analysis as “a theory of personality and social action, and a clinical method of psychotherapy, based on the analysis of all possible transactions between two or more people, on the basis of specifically defined ego states into a finite number of established types”.

Aaron T Beck (1979, p.3) defined Cognitive Behaviour therapy as “an active, directive and time limited, structured approach used to treat a variety of psychiatric disorders”.

Transactional analysis was first developed by Eric Berne a psychiatrist in the US during the late 1950’s. TA is described as being a theory of personality because it has the ability to show us how people are structured psychologically. It can do this by using what is know as an ego state model which can help us understand a persons expressions within their behaviour. TA is also referred to as a theory of communication because is can analyse relationships between individuals and the transactions which occur. This particular theory also links very neatly with Freudian explanations of child development because it links with the development stages – oral, anal etc. TA has been recognised for its introduction of a “Life (or Childhood) Scripts”, which is, a story we can perceive about our own life. TA is well known for it uses in the diagnosis and treatment of many types of psychological disorders, and provides a method of therapy for individuals, couples, families and groups. Lastly TA has been used in education, to help teachers remain in clear communication at an appropriate level, in counselling and consultancy, in management and communications training and by other bodies (Harper, 2009).

TA is considered an extremely flexible approach for therapists to utilise Dusay (1986) believed TA as a therapeutic system had two major advantages the first being that there is a complete and simply communicated theory of personality, and second, because of this, the therapist is free to develop their own innovative style of treatment which utilises their own strengths. He adds, if we observed a trained transactional analyst in action therapeutic styles ranging from a more “intellectual” cognitive approach to a “feeling” emotive approach” would be apparent.

TA is considered simple and easy to understand due to its terminology making it easy for clients to understand Dale (2009, p.3) states

“The theory is easily understandable, and it appears to make sense across cultures. In my own practice I have taught the basics to Mauritians, Asian, Black and Afro Caribbean clients, and a variety of European clients.”

However some think that although the terminology used in TA is different from that used in other counselling approaches it is considered both a strength and a weakness of the model Hough (2006, p.172) states

“although the language is memorable and accessible, it is also regarded by some critics as simplistic and superficial”

Paradoxically, again the strengths of the approach are also its weaknesses. Because TA is considered to be easily understandable and accessible to therapists they often use it without having an in depth understanding of the complexities of it. Dale (2009) states therapists are at risk when asking a client to shift ego states and separate a part of their personality without being certain that the client can reintegrate can cause serious damage. However Davis & Meier (2001) believe that TA can be modified to brief, structured, problem focussed therapy, which is considered a great strength in many settings. Practitioners who work within structured care frameworks have less time to gather client information, make a formal assessment, provide orientation to the therapeutic process, establish rapport and intervene.

Another significant strength of TA which could also be considered a weakness of the approach is that it emphasizes on individualism Corey (no date, p.36) states

“Many people are restricted by their early decisions: they cling to parental messages, live their lives by unexamined injunctions, and frequently are not even aware that they are living in a psychological straitjacket. Conceptually, re-decision therapy offers tools members can use to free themselves from an archaic life script and achieve a successful and meaningful life”.

However clients who come from collective cultures may not fit in as easily into the paradigm of scripts described by Berne and others (Hough, 2006).

A further strength of TA is that it allows a variety of possibilities for both preventative and remedial work by providing for both an educational and therapeutic structure. It is vital that the information divulged in the therapy sessions are balanced by experimental work which involves the client both emotionally and cognitively Greenberg, Korman, & Paivio (2002) suggested that interventions in therapy are more likely to succeed and produce lasting changes if they involve the emotional domain rather than focussing purely on the cognitive realm.

A critical limitation of TA is that there is a lack of empirical evidence capable of validating its theory and process due to the fact many of Bern’s concepts were presented in such a manner that it would be unachievable to design a research study to test them. Clinical observations and testimonials are the only records of success. Corey (no date, p.37) states

“Conducting well-designed research studies to evaluate the process and outcome of therapy has surely not been one of the strengths of TA”.

As mentioned above there has been limited research into either the outcomes or processes of TA counselling and psychotherapy. However within the domain of process components, there have been several studies that have attempted to measure ego state functioning and its influence on therapy.

Emerson et al (1994) demonstrated that psychological disturbance which had been measured with a standard symptom checklist, was connected with a higher than average concordance rate of Critical parent and adapted Child ego states. It was believed that successful Transactional analysis could significantly reduce the prominence of these ego states in clients. Research such as this suggests that Transactional analysis can be used to address and reduce the significance of psychological disturbance which is clearly related to the frequent use of these two ego states.

Loffredo et al (TAJ, April 2004) reviewed reliability research and updated their own research in a study which measured the reliability of a questionnaire designed to pinpoint the five ego states. This demonstrates that their questionnaire reliably identifies these five ego states in individuals. In addition to this Loffredo et al determined significant construct validity, the five ego states were defined by his questionnaire which represented five specific forms of thought, feeling and behaviour. Research such as this suggests that the ego states are in existence and can be accurately identified by those with knowledge of Transactional analysis theory.

Cognitive behaviour therapy was developed by a psychoanalytically trained psychiatrist in America known as Aaron Beck in the 1960’s. CBT functions by integrating both cognitive and behavioural strategies. CBT relies on both the client and therapist working collaboratively within a therapeutic alliance. The aim of CBT is to help the client overcome their difficulties by identifying and modifying negative automatic thoughts (NAT’s), behaviours and emotions. CBT therapy is a structured process which is goal orientated and measurable. This model focuses on present emotions that act as a primary guide to core beliefs and meanings. CBT is a structured model of therapy with a specific agenda and focus for each therapy session. Homework is also given which is an essential element of treatment (Harper,2008).

CBT in comparison to TA is considered to have a substantial amount of empirical evidence to support its effectiveness when treating a variety of disorders. Essentially CBT is the most likely therapy to be offered within the National Health Service (NHS) Judith Beck (1995, p.1) claims that cognitive therapy

“is unique in that it is a system of psychotherapy with a unified theory of personality and psychopathology supported by substantial empirical evidence”

CBT is also believed to be a directive approach which utilises structured plans and sequenced therapy sessions set out by the therapist. However it has been critiqued for making the assumption that the therapist has expert knowledge surrounding how the client should tackle the problem, which may not be appropriate for every individual (Bandersnatch,2007). This statement cannot be generalized to all clients however as most clients find its commonsense method very appealing as it allows them to see that the issues they face are part of their past experience and learning history which has attributed to success and failings within their life. It also aids them in their discovery of new behaviours and more productive ways of thinking for the future (Lehman & Coady, 2001).

Case formulation with CBT has also been commended for being simple and easy for clients to be able to understand and utilise Stephens (no date, p.8) states

“In practice, cognitive formulations are generally understandable, non-esoteric, and easy to share with clients”.

However this suggestion is subject to criticism for possible over simplification of ‘complex psychological dynamics’ (Person et al, 1996). Specifically it is debatable whether all of a client’s issues can be dealt with by a single case formulation. CBT therapists do not claim that this can always be done but the temptation to attempt to deal with multiple issues can be strong (Willis & Sanders, 1997).

CBT is also believed to be incredibly open to falsifiability in regards to case formulation unlike other approaches in counselling Person (1989, p.55) states

“The therapist can never be certain her hypothesis about the underlying mechanism is correct and must always be prepared to revise or change in the face of evidence. This is a continuous process; in fact, assessment and treatment are a continuous process of proposing, testing, re-evaluating, revising, rejecting and creating new formulations”.

However these case formulations are considered to be open to the prejudices and biases of the therapist and may be imposed despite obvious flaws as Willis & sanders (1997, p.52) stated

“We may develop a perfect, sophisticated and theoretically sound conceptualisation which has little empirical or practical value to the client, and, because of our own cognitive distortions, start to see everything in those terms”.

CBT’s case formulation can also be critiqued for its acceptance of the client’s judgement as to the accuracy of the formulation regarding when considering its clients attitude towards change and the therapy being used. Weishaar (1993, p.108) states

“Critics from both the psychodynamic and cognitive science camps … accuse Cognitive Therapy of ignoring the role of unconscious processes.”

This suggests that the more credit which has been attached to the role of unconscious processes, the less that can be given to a client’s judgement in regards to the appropriateness of a case formulation (Stephens, no date).

Lastly CBT has also been criticised for relying on simplistic entities within its theory such as schemas that face controversy and debate in relation to their existence. Skinner (1971) a radical behaviourist within psychology believed that these so called inner constructs could not proved and are not a vital necessity within the theory or practice of psychotherapy.

The efficacy of CBT has been established in controlled research studies, and its effectiveness documented in a variety of clinical studies DeRubeis et al (2005) carried out a study whereby 240 people where hospitalised with clinical depression. Their depression was measured by a Hamilton depression scale. After 16 week of either modern drug therapy or CBT their levels of depression where measured again using the same scale at the end of therapy and after 2 years. They found that the short term effects of both CBT and drug therapy where equally as effective as 58% in both groups recovered. Researchers also found that after 2 years 75% of the people that received CBT and recovered where still free of depression compared with 60% of the people who received drug therapy. Research such as this suggests that CBT is potentially better than drug therapy in the long term, altered thinking and better self awareness allows the client to make long term changes reducing the likelihood of relapse.

The fact that both CBT and drug therapy can be equally effective treatments can be seen in the following clinical study. Goldapple et at (2004) conducted a study to examine biological changes within the brain associated with the use of CBT. 17 un-medicated unipolar depression patients had their brain changes in response to CBT examined before and after 15 to 20 week course of CBT. Results showed a full course of CBT resulted in substantial clinical improvement in the 14 patients that completed the course of CBT. It was concluded that like antidepressant treatments CBT affects clinical recovery by modifying the functioning of specific sites in the brain. This research shows that although both CBT and drug therapy’s influence specific parts of the brain differently CBT alone is capable of inducing significant improvement in the treatment of unipolar depression.

In conclusion to this assignment both TA and CBT have varied strengths and limitations in regards their success. After the completion of further research there is a substantial difference in the amount of empirical evidence that supports TA and CBT. CBT has been identified as being the most prominent and widely offered therapy in regards to the treatment of mental health issues and therefore has copious amounts of research to substantiate these claims. However although CBT has been identified as a well established and effective therapy in the treatment of depression, anxiety, eating disorders etc there is little evidence to suggest that it can be considered the most effective therapy in the treatment of all atypical behaviours within contemporary society.

Reference List

Books

1. Beck, J. (1995) Cognitive therapy: Basics and Beyond. New York: Guilford Press
2. Berne, E (1975) What do you say after you say hello? London: Corgi. (Original work published 1972)
3. Davis, S. R., & Meier, S. T. (2001). The elements of managed care: A guide for helping professionals. Pacific Grove, CA: Brooks/Cole.
4. Hough, M. (2006) Counselling skills and theory. 2nd Ed. England. Hodder Education
5. McLeod, J. (2009) An introduction to counselling. 4th Ed. England. Open University Press
6. Person, J.B. (1989) Cognitive Therapy in Practice: A case formulation approach. New York: W.W. Norton
7. Skinner, B.F. (1971) Beyond Freedom and Dignity. Harmondsworth: Penguin.
8. Whitfield, G. & Davidson, A. (2007) Cognitive Behavioural Therapy explained. United Kingdom: Radcliffe publishing LTD
9. Weishaar, M.E. (1993) Aaron T. Beck. London: Sage.
10. Willis, F. & Sanders, D. (1997) Cognitive Therapy: Transforming the Image. London: Sage

Electronic books

1. Lehman, P. & Coady, N. (2001) Theoretical perspectives fir direct social work: a generalist eclectic approach. Google books [online] Available at http://books.google.co.uk/books?id=Lbtv3SsrLdEC&pg=PA176&dq=cbt+strengths&cd=1#v=onepage&q=cbt%20strengths&f=false Accessed [29 December 2009]

Journals

1. DeRubeis et al (2005) ‘ Cognitive therapy vs Medications in the Treatment of Moderate to Severe Depression’. Archives of General Psychiatry, 62: 409-416
2. Dusay, J. M. (1986). Transactional analysis. In I. L. Kutash & A. Wolf (Eds.), Psychotherapist’s casebook (pp. 413-423). San Francisco: Jossey-Bass.
3. Goldapple, K., Segal, Z., Garson, C., Lau, M., Bieling, P.,Kennedy, S., Mayberg, H. (2004). Arch Gen Psychiatry, Modulation of Cortical-Limbic Pathways in Major Depression: Treatment-Specific Effects of Cognitive Behavior Therapy, 61:34-41.
4. Greenberg, L. S., Korman, L. M., & Paivio, S. C. (2002). Emotion in humanistic psychotherapy. In D. J. Cain, & J. Seeman, (Eds.), Humanistic psychotherapies: Handbook of research and practice (pp. 499-530). Washington, DC: American Psychological Association.
5. Loffredo et all. (2004) The Ego State Questionnaire Revised.Transactional Analysis Journal, 34
6. Persons et al (1996) Psychodynamic therapists’ reservations about Cognitive-Behavioural therapy. Journal of Psychotherapy Practice and Research, 5: 202-212
7. Stephens, E. (no date) A case formation approach to Cognitive Behaviour Therapy: PCI college & centre for sexual addictions

Websites

1. Bandersnatch. (2007) Strengths and weakness of CBT and REBT. [online] Available at http://psyclick.org.uk/ [01 January 2010]
2. Australian institute of professional counsellors (2007) Aipic’s five therapies Ebook. Behaviour, Cognitive Behaviour, Person Centred, Solution Focussed, Gestalt. [online] Available at http://www.counsellingconnection.com/wp-content/uploads/2007/10/aipcs-five-therapies.pdf Accessed [28 December 2009]
3. Bream, V. (no date) What is CBT? – A beginners guide. [online] Available at www.ocduk.org/10/greenwich05/VB.pps Accessed [03 January 2010]

Lectures

1. Dale, H. (2009) Transactional Analysis Overview. [Introduction to Transactional analysis]
2. Harper, P. (2008) Transactional analysis lecture notes. [Transactional analysis theory and application]
3. Palmer, D. (2009) Cognitive- Behavioural therapy. [Introduction to theoretical approaches to counselling]