How does Counselling work?
Discuss two approaches, evaluate their theory and practice. Which approach is your preference and why?
Counselling has been defined by the British Association for Counselling and Psychotherapy (BACP, 2009) as "talking therapy," which "involves a contractual arrangement between the therapist and the client where they meet, in privacy and confidence, to explore a difficulty or distress the client may be experiencing" (p. 1). It works through the development of a therapeutic relationship whereby the counsellor actively and attentively listens to the client in order to gain insight and understanding into the difficulties the client is confronted with, from the client's perspective. Using different techniques, the counsellor can try to help the client to work through these difficulties, to understand them, and to solve them or accept them, depending on what the difficulties are. Importantly, counselling does not work by the provision of advice or direction; instead, the counsellor helps the client to gain mastery in directing their own lives.
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Counselling can be short-term or long-term, as well as individual or provided to families, couples, or organisations (Coren, 2001). Counselling techniques and methods will vary according to the approach or theoretical basis from which a counsellor works. Examples of different approaches to counselling include cognitive-behavioural therapy, solution-focused counselling, art therapy, person-centred counselling, psychodynamic counselling, and trauma therapy. A counsellor might adopt one approach within all of their work or take an eclectic approach whereby the theoretical framework adopted depends on the client (e.g. their age) or the problem (e.g. depression, phobia).
The two counselling approaches discussed within this essay are person-centred counselling and cognitive-behavioural therapy. The theory underlying these approaches will be outlined, followed by examples of techniques used, and evidence of efficacy.
Person-centred counselling, also known as 'client-centred' or 'Rogerian' counselling, is a humanistic approach to counselling founded by Carl Rogers in the 1950s (Rogers, 1951). The approach is based on the assumption that human beings are experts of themselves and that they have access to their own innate expert resources of self-understanding and self-direction. The role of the counsellor is thus to provide a facilitative environment and relationship for the client to find these resources within themselves.
In order to provide this facilitative environment and relationship, the counsellor basis their interactions with the client on three key principles:
1) They are congruent (genuine) with the client, which can involve the counsellor showing their own human traits through appropriate and well-timed personal disclosure. This contrasts many other approaches to counselling, which tend to promote a more formal relationship between counsellor and client.
2) They provide unconditional positive regard, even if a client divulges something that the counsellor disagrees with; the counsellor remains accepting and caring of the client. Roger's believed this was important for clients to grow and reach their full potential.
3) They expressÂ empathy (the ability to understand what the client is feeling) andÂ understanding towards the client. By providing empathy, the clients' feelings are validated, which can be an important part of moving through and beyond those feelings.
These three key principles demonstrate how the primary focus in person-centred counselling is the relationship between the counsellor and client. The person-centred counsellor seeks to establish a trusting relationship with the client in whom the client can gradually confront anxieties, confusion and other negative emotions.
Central to person-centred counselling is the notion of 'self-concept,' which refers to the perceptions and beliefs the client holds about themselves. The self-concept is influenced by an individual's experience of the world and comprises three components:
Self-worth (self-esteem) - thoughts about the self, which develop in early childhood and from experiences with parents or guardians.
Self-image - perceptions of the self, including body image, which can influence personality.
Ideal self - the self a person would like to be, including goals and ambitions.
TheÂ self-conceptÂ is not necessarily consistent with how others view the client, as is the case in people with low self-esteem or conditions such as body dysmorphic disorder (characterised by perceived defects in physical appearance). Rogers based person-centred counselling the assumption that all human beings are seeking a positive self-concept (self-actualisation). It is this innate motivation towards self-fulfilment that is nurtured during person-centred counselling, with the emphasis again being on the clients own resources.
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Roger's has been criticised for having an overly optimistic view of human beings (Chantler, 2004), as well as focusing too much on a client's ideal self without considering whether this ideal self is realistic (Wilkins, 2003). However, despite this criticism, there is strong evidence supporting the efficacy of the person-centred approach, including a UK-based meta-analysis of scientific studies (Elliot and Freire, 2008). This meta-analysis demonstrated large pre- and post- changes in therapeutic outcomes that were maintained in the long-term.
Cognitive-behavioural therapy (CBT) was founded in the 1960s by Aaron Beck when he observed that during counselling sessions, his clients tended to have an 'internal dialogue' that was often negative and self-defeating. Furthermore, this internal dialogue was observed to influence behaviour. This led to the hypothesis that changing these internal dialogues would lead to changes in behaviour. Thus, CBT focuses on the thoughts, images, beliefs and attitudes held by the client and how these relate to the clients behaviour or way of dealing with emotional problems.
CBT takes a problem-solving approach to counselling, where the client and counsellor work collaboratively to understand problems and to develop strategies for tackling them. Clients are taught by counsellors, through guidance and modelling, a new set of skills that they can utilise when confronted with a particular problem. These skills are often focused on reframing negative self-talk in an effort to change one's interpretation of the problem. An event is not necessarily the problem, but more so the individuals interpretation of the event.
CBT focuses on the present rather than the past, but does examine how self-defeating thinking patterns might have been formed in early childhood and the impact patterns of thinking might have on how the world is interpreted in the present, as an adult. These patterns of thinking can then be challenged by the counsellor and altered to fit the present.
Taking a problem-solving approach means that CBT can offer effective outcomes in relatively short periods of time, most often 3-6 months. As an example, interpersonal psychotherapy for eating disorders has been found to take 8-12 weeks longer than CBT in order to achieve comparable outcomes (Agras et al., 2000). This is an obvious advantage the CBT approach has over other forms of counselling, making it a popular technique and the leading treatment for some mental health issues, such as bulimia (Wilson, Grilo, and Vitousek, 2007). The technique has even been incorporated into health interventions designed to assist overweight and obese individuals in losing weight (Wylie-Rosett et al., 2001), encourage individuals with chronic illness to increase their physical activity (Atkins et al., 2007), and facilitate smoking cessation initiatives (Sussman, Ping, and Dent, 2006).
CBT differs from other counselling approaches in that sessions have a structure, rather than the person talking freely about whatever comes to mind. At the beginning of counselling, the client meets the counsellor so that they can collaboratively set therapeutic goals to work towards. These goals then become the basis for planning the content of sessions as well as for assigning 'homework' between sessions. The reason for having this structure is that it helps to use the therapeutic time efficiently and ensures that important information is not overlooked. Homework between sessions enables the client to practice and gain mastery in new skills with the opportunity to discuss any problems encountered in the next session. The counsellor takes a more active role at the beginning of counselling and as skills are mastered and the client grasps the principles they find helpful, the client is encouraged to take more responsibility for the content of sessions. The aim is that when the therapeutic relationship comes to an end, the client is sufficiently empowered to continue workingÂ independently.
CBT also differs from other approaches in the nature of the relationship between counsellor and client. Some counselling approaches encourage the client to depend on the counsellor, as part of the treatment process, in an effort to build trust. CBT favours a more equal relationship that is more formal, problem-focused and practical. Such a relationship has been coined by Beck as 'collaborative empiricism,' which emphasises the importance of client and counsellor working together to test out how the ideas behind CBT might apply to the client's individual circumstances (Beck, et al., 1979, Chap. 3).
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As demonstrated, patient-centred counselling and CBT are very different approaches to counselling, both in terms of structure and the role of the counsellor. In terms of preference, it could be argued that both are valuable, effective approaches to counselling. Evidence shows that they both work and thus preference would be better decided with consideration of the client and their individual needs. Whilst person-centred counselling might be preferable for a client with trust issues or who requires extensive examination of past trauma, CBT might be preferable for someone with an immediate problem or phobia to solve or someone whose problems are primarily governed by negative self-talk. Since CBT works with cognitions and behaviour and person-centred counselling works more with affect and emotion, their application needs to be based on individual context.
Agras, W.S., Walsh, T., Fairburn, C.G., Wilson, G.T., & Kraemer, H.C. (2000). A
multicentre comparison of cognitive behavioural therapy and interpersonal psychotherapy for bulimia nervosa. Archives of General Psychiatry, 57, 459-466.
Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979).Â Cognitive therapy of depression. New York: Guilford Press.
Coren, A. (2001) Short- Term Psychotherapy: A Psychodynamic Approach, Palgrave Publishers Ltd
Wilson, G.T., Grilo, C.M., & Vitousek, K.M. (2007). Psychological treatment of eating
disorders. TheÂ American Journal of Psychology, 62, 199-216.