Counselling: Theory and Process

The conviction has been gaining ground that there are as many theoretical orientations in counselling as there are individual counsellors or, put in a slightly different way, therapists from varied theoretical orientations and backgrounds are reportedly very similar in their conceptualization of the best therapeutic practice and outcomes (Fiedler 1951). There is evidence to conclude that common features shared by all psychotherapies underlie and override differences in their use of specific technical features (Stiles, Shapiro and Elliott 1986). Historically, counselling and psychotherapy have drawn from several identifiable theoretical orientations which are briefly discussed before dealing at some length with two of the currently more influential ones.

             Traditionally, people suffering from abnormalities in thought or behaviour, if extreme, more often than not, are treated by psychiatrists using psychotropic drugs. The biochemical model of mental disorder has helped alleviate symptoms of conditions identified as schizophrenia, bipolar affective disorder, depression, panic attacks, anxiety and phobias. However, drug therapies almost always result in unwelcome side effects and are therefore best restricted to the treatment of only the most intractable psychotic conditions. The drug regime almost always has to continue for a lifetime. Beyond this, the vast majority of people with mild symptoms who are able to function in the everyday world at some level without hospitalization still need the help of psychotherapists or counsellors to overcome their perceived handicaps to leading a 'normal' life. Often described as 'talking cures' they require no biochemical treatment. Broadly speaking, psychoses are treated by medically qualified psychiatrists and neuroses are the province of non-medical specialists with a background in psychology and counselling.

            The two words psychotherapy and counselling appear to be used together and at times interchangeably. Psychotherapy antedated counselling and draws upon medical and psychoanalytical roots whereas counselling is a much broader concept developed by psychologists and others from humanistic and existential backgrounds. A recent analysis of the relationship between counselling interventions and theory refers to 'more than 130 extant theories of counselling’ (http://www.ericdigests.org/1992-3/theory.htm).

 Most reviewers of the literature agree with three or four basic, yet overarching formulations as the main approaches to counselling and therapy such as Behavioural, Cognitive (usually in combination referred to as Cognitive-Behavioural), Psychodynamic,  and Humanistic therapies.

             Behavioural models of psychotherapy are based on learning theory, derived from the two strands of Pavlovian classical conditioning and Skinnerian operant conditioning. All our behaviours, whether positive and useful, or negative and hindering our development, are learnt either through association or through being reinforced. Aaron Beck (1976) identified the cognitive component in human learning.  He stressed 'that behaviour is influenced by far more than just a direct relationship between environment and response. What a person thinks, believes, and expects influences how he or she behaves. Therapy consists in changing negative thoughts'. Rational Emotive Therapy (RET) founded by Albert Ellis (1971) is a therapy based on the above principles which later became Rational Emotive Behavioural Therapy (REBT).

Cognitive therapists believe that distorted thinking causes disordered behaviour and that correcting the distorted thinking will alleviate or cure the disordered behaviour. Behaviour therapists, in contrast, view distorted behaviour as learned from past experience and attempt to alleviate the disorders by learning new, more adaptive ones. However many therapists combine both techniques which is called cognitive behavioural therapy.

            As to the psychodynamic model, Sigmund Freud developed a comprehensive theory of personality divided into the processes of Id, Ego and the Superego. He also postulated three levels of consciousness, composed of the conscious, subconscious and the unconscious. He developed a method of psychotherapy, psychoanalysis, which has increasingly become unfashionable due to its high cost, inordinate length, and non-verifiability as to its efficacy. Freud’s theories are deemed unscientific in that they cannot be tested empirically and are not falsifiable. However, there are many derivative therapies which utilize psychodynamic ideas such as coping defence-mechanisms like denial, repression, rationalization etc. that are effective with some individuals.

            Humanistic therapies developed as a reaction against the mechanical and negative view of human motivation advanced by behavioural and psychodynamic practitioners. It was also a move to detach counselling and therapy from the grip of medical domination of the field. It has its roots in existential philosophy. Humanistic psychology stresses a phenomenological view and prefers qualitative research methods to quantitative models. This makes it easy for critics to label it unscientific, but the claim may be refuted in the light of changing concepts of science (e.g. chaos theory) while its benefits have been extensively studied and acknowledged.

The pervasive influence and persuasive power of CBT as a proven mental health treatment is underscored when Lord Layard, a government spokesman, recently argued for its use ‘as a solution to long-term intransigent unemployment’. In contrast to the interminable length of Freudian analysis, ‘an average of 10 sessions of CBT is (supposedly) sufficient input as a strategy for returning those with a mental health condition on long-term incapacity benefit back into work …’ (The Psychologist, December 2007). 

Behaviour therapy, the earliest of the cognitive and behavioural psychotherapies, is based on the clinical application of extensively researched theories of behaviour, such as learning theory (in which the role of classical and operant conditioning are seen as primary). Early behavioural approaches did not directly investigate the role of cognition and cognitive processes in the development or maintenance of emotional disorders. Cognitive therapy is based on the clinical application of the more recent, but now also extensive research into the prominent role of cognitions in the development of emotional disorders. ... The term 'Cognitive-Behavioural Therapy (CBT) is variously used to refer to behaviour therapy, cognitive therapy, and to therapy based on the pragmatic combination of principles of behavioural and cognitive theories (Roth & Fonagy 2005).

            A Mental Health Information Leaflet posted on the Internet explaining CBT says that  ...'Unlike some of the other talking treatments, it focuses on the "here and now" problems and difficulties. Instead of focusing on the causes of your distress or symptoms in the past, it looks for ways to improve your state of mind now'. The leaflet informs that CBT 'has been found to be helpful in:

* Anxiety, * Depression, *Panic, *Agoraphobia and other phobias, * Social phobia, * Bulimia, * Obsessive compulsive behaviour * Post traumatic stress disorder, and *Schizophrenia' (op. cit.). CBT has been recommended by the National Institute for Health and Clinical Excellence (NICE) as a treatment of choice for most of the above conditions. This is because the ‘effectiveness of CBT is supported by evidence from randomised controlled trials (RCTS), uncontrolled trials, case series and case studies’  CBT works not only with individuals but also with groups displaying common symptoms.     

            'The average number of sessions clients receive (across all types of problems and approaches to CBT) is only 16. ... What enables CBT to be briefer is its highly instructive nature and the fact it makes use of homework assignments.(It) is time-limited (and) clients understand at the very beginning of the therapy process that there will be a point when the formal therapy will end. ... CBT is not an open-ended, never-ending process’. It focuses on a shared model of understanding, using a psycho-educational approach, open sharing of the formulation and teaching of positive behaviours. Two computer-based programmes have been developed entitled ‘Fear Fighter’ for those suffering from phobias and panic attacks, and ‘Beating the Blues’ for those suffering from mild to moderate depression. These are approved by the NHS for use in England and Wales.   

            The therapist and client develop a therapeutic alliance but it is not seen as an essential ingredient and unlike other psychotherapies is not viewed as the main vehicle of change. …Therapeutic relationship – a trusting, safe, therapeutic alliance is essential but not sufficient for successful CBT. Therapists undertake a four stage process of 1) Assessment. 2) Formulation, 3) Intervention, and 4) Evaluation.  They question clients to elicit meanings the latter attribute to their experiences and allow them to reflect on their style of reasoning and thinking, helping them to identify possible alternative meanings that can lead to more positive actions in the light of their insights. This approach is referred to as ‘guided discovery’, since the therapist does not advise or tell the client what to think or do. The clients usually are enabled to discover for themselves unhelpful behaviours such as avoidance of the issues and knee-jerk reactions to situations.

Humanistic therapies developed as a reaction against the mechanical and negative view of human motivation advanced by behavioural and psychodynamic practitioners. It was also a move to detach counselling and therapy from the grip of medical domination of the field. It has its roots in existential philosophy. Humanistic psychology stresses a phenomenological view and prefers qualitative research methods to quantitative models. This makes it easy for critics to label it unscientific, but the claim may be refuted in the light of changing concepts of science (e.g. chaos theory) while its benefits have been extensively studied and acknowledged.

Enough has been said about CBT for the reader to realise that it has been developed in line with the dominant empirical, experimental tradition favoured by academic psychology. Humanistic psychology is a school of psychology that emerged in the 1950s in reaction to both behaviourism and psychoanalysis. Indeed, since the founders of the Human Potential Movement were not psychiatrists but psychologists, they were unable at the time to be licensed to use the term psychotherapist for the work they did with their clients. Counselling was a term originally ascribed to Frank Parsons (1909) at the beginning of the century who initiated help for young people with problems in finding suitable employment, and Carl Rogers adopted the term counsellor to refer to himself. Hitherto all who sought help from psychiatrists or psychoanalysts were referred to as patients and the relationship was in no way equal. Humanistic psychology was to change all that.  

In the late 1950s, psychologists concerned with advancing a more holistic vision of psychology convened two meetings in Detroit, Michigan. These psychologists; including Abraham Maslow, Carl Rogers, and Clark Moustakas, were interested in funding a professional association dedicated to a psychology that focused on uniquely human issues, such as the self, self-actualization, health, hope, love, creativity, nature, being, becoming, individuality, and meaning – in short, the understanding of what it means to be human.

In 1961 they formed the Association of Humanistic Psychology. By 1971, the movement was well recognized as a force in psychology that the American Psychological Association (APA) granted its own Division (Division 32). Humanistic psychotherapy or counselling contributes to a non-pathologizing view of human beings and refers to the users of their services as clients and not patients. Carl Rogers’ 1951 book was called Client-Centred Therapy, which evolved into the even more inclusive ‘person-centred therapy’.    

          The Human Potential Movement already mentioned was influenced by the philosophy of existentialism associated with thinkers such as Kierkegaard, Nietzsche, Heidegger and Sartre. Their credo may be summarised by the sentence ‘Man’s wholeness is to be sought through direct experience rather than analytical reflection’. This was in ‘opposition to the psychoanalytical view that man was at the mercy of his unconscious drives and instincts; and also in opposition to the view of the behaviourists, which suggested that man was at the mercy of his environment and learned behaviours’.

              Although Gestalt Therapy developed by Fritz Perls (1952) is among the better known applications of humanistic psychology to counselling and therapy this discussion concentrates on the even better known and universally acknowledged Rogerian approach to counselling. Carl Rogers ‘… discovered an actualizing tendency that is inherent in all organisms – this is the basic drive towards wholeness of the organism and actualization of its potentialities’. As a farm boy in his youth Rogers found potatoes thrown into a darkened basement to rot. However, there was a chink of light coming through from the outside in one of the corners of the basement where a couple of near-rotten potatoes were thrusting shoots towards the light. This and later research by a biologist, Driesh on sea-urchin cells convinced Rogers that given the right conditions every organism has within it a tendency towards wholeness and growth to realise its potential. In human beings this self-actualizing tendency is a non-conscious organismic functioning which when in conflict with their conscious awareness and the external environment would create conditions for mental and physical distress.

          When such an individual seeks help from the counsellor/therapist, the latter ‘creates an environment, or relationship, hitherto denied to the client, that is conducive to growth: she facilitates change using personal skills, communication and understanding, and by modelling another way of being’. 

Three interrelated attitudes on the part of the therapist are central to the success of person-centred therapy: congruence; unconditional positive regard; and empathy. Congruence refers to the therapist’s openness and genuineness – the willingness to relate to clients without hiding behind a professional facade.   …

Unconditional positive regard means that the therapist accepts the client totally for who he or she is without evaluating or censoring, and without disapproving of particular feelings, actions, or characteristics. The therapist communicates this attitude to the client by a willingness to listen without interrupting, judging, or giving advice. …

The third … component of a therapist’s attitude is empathy. The therapist tries to appreciate the client’s situation from the client’s point of view, showing an emotional understanding of and sensitivity to the client’s feelings … in person-centred therapy it actually constitutes a major portion of the therapeutic work itself. … 

Because of this nondirective approach, clients can explore the issues that are most important to them – not those considered important by the therapist.(Extracted from online literature).  

          Later Carl Rogers added a fourth condition, that of ‘tenderness’ on the part of the therapist. This is almost a spiritual or intuitive way of relating to others, ‘a self-giving mode of love’ known to the Greeks as agape (Rogers 1962; Patterson 1985). ‘Profound healing and growth takes place for the client when the counsellor conveys such a cognitive-affective, non-verbal, transcendent, and spiritual loving/knowing of the client’ (Rogers 1980).

          Although there has been no objective evaluation or comparison of the efficacy between person-centred therapy and CBT, the extant literature attributes success to both orientations in equal measure. The difficulty in such an assessment is the one this essay started with, that of the cross-fertilization of varied theoretical approaches. There is no pure form of CBT and neither is there a humanistic therapy that has not been influenced or altered by the individuality of the therapist. What works in counselling and therapy may not be generalisable and is proving to be a moveable feast.