A Layman’s Guide to Counselling.

A number of people have requested I write this, as they have found navigating the types of counselling on offer extremely difficult. This is no surprise, for various, largely historical, reasons, the profession has been poor at empowerment of client choice. However this is of course, all simply my views and opinions, and I am aware will probably show my biases, even as I attempt to be as unprejudiced as possible.

What’s the difference between therapy and counselling?

This comes up quite a lot, with length of engagement, topics covered, some mysterious “depth” all given as reasons to distinguish between the two. In fact there is no difference. The words are interchangeable, whilst counselling may in some minds create a picture of short-term, focused on one issue, interventions, this is a misapprehension. Partially I believe this comes from the fact  counselling is added to other words for people who offer this kind of shorter intervention i.e debt counselling. Another thing which adds to the confusion is that many charities and third sector organisations can only offer time limited sessions, often as few as six sessions for financial reasons. There is no reason issues cannot be addressed in a limited number of sessions, a hundred variables come into play, and each therapeutic relationship is unique. However it does mean that the only experience many people have of counselling is of something time and content limited.

Hang on, does that mean I can just book 6 sessions and sort everything out?

Annoying therapist answer; It depends

Slightly more useful answer; It depends on your expectations, what you want to work on, and your honesty with your therapist.

          Ann is 45, going through a divorce, she approaches me for counselling, saying she has just set aside the money for 6 sessions. She wants to work on “what now” feeling like she has wasted the best part of her life. During the course of the second session she reveals she was abused by a family member as a child, and has never talked to anyone about this before. (This is a hypothetical client)

Part of my role, any ethical therapist’s role, is to put the client first. It’s unlikely that we will be able to explore the full impact of childhood abuse in 6 sessions. By telling Ann this, it doesn’t mean we cannot work on other issues, on some of the impact, on how she wants to move forward.

Ann decides to continue the 6 sessions with me, then take up a referral to a local Rape Crisis center who provide free therapy. Over the course of our work we look at patterns in her life, she leaves feeling stronger, with clear plans for the future and new goals. 

What’s the difference between a counsellor and a psychotherapist? And is a psychotherapist the same as a psychoanalyst?

This is one of those questions where the answer depends on who you ask, which is why I think a lot of people end up disheartened and confused. So to start with the easiest, a psychoanalyst is probably what you think of when you think of therapy. Meeting several times a week (usually) they will use free association to explore how the client’s childhood experiences impact on their current self. Psychotherapy is sometimes used interchangeably, again taking a more traditional approach, rooted in the works of Jung and Freud, but also newer theorists. Both are perhaps more directive than person centered counselling, but less so than CBT. This is where it can all come down to personal experience though. It would be a rare psychotherapist/analysts who did not believe in the core conditions and active listening. Almost every other difference is around the attitude of the speaker towards other forms of talking therapies. As a counsellor I have been told I have not studied Freud, dont know about repression, transference, the ego, or a whole host of other things. By the same token I have heard counsellors say psychotherapists are cold, or unfeeling towards their clients. Usually this is about protecting someone’s own image rather than giving a fair judgement.

To sum up something that may have left you more confused than when you started, a counsellor (usually) is willing to work shorter term, on specific issues, whereas a psychotherapist/analyst usually wants to work longer term, and on every issue. However counselling does not have to be short term.

But counselling is all about the here and now, don’t you need a psychotherapist to work on the past?

The phrase “the here and now” is used by counsellors, and has unfortunately been misunderstood. It refers directly to the therapeutic experience, to the emotions, transference (more about that piece of jargon later) and experience of the client, and counsellor in the counselling space. It came about because classic Psychoanalysis (and we are going back to the middle of last century) concentrated on the childhood of the client. The Grandfathers of counselling, and in particular Carl Rogers, Fritz Perls and Albert Ellis wanted to work with clients where they were at. If the here and now for you is grief at a loved one who died 50 years earlier, that’s where a counsellor will go. Its part of why Rogers believed that counselling must be non directive, and why he coined the term person centered.

What are the different types of counselling out there, how do I know which is the best for me?

There are, in the UK, three main schools of counselling. Psychodynamic, Person Centered, and CBT. Other common ones are transactional analysis, existential therapy and Family therapy.  The one most people will have heard of, for all the wrong reasons, is CBT.

Yes! my sister did CBT, it was useless, the nurse did a workbook with her for depression, she said she felt worse than when she started.

Your sister didn’t have cognitive behavioral therapy.

One of the greatest harms done to the perception of counseling in this country, and a huge waste of resources, was the NHS decision to provide something it called CBT for stress, depression and anxiety. NICE sited research showing that CBT was effective in treating these conditions. However the research was with qualified therapists, who were not limited to six sessions. To be blunter than people might expect from a counsellor, a practice nurse with a week’s training and a workbook is not a cognitive behavioural therapist.

Articles like this one in the Guardian don’t help either.

Aaron Beck, one of the founders of CBT, described the therapeutic relationship, the warmth, the feeling of being understood, between client and therapist as “necessary but not sufficient”

The current form of CBT most people in the UK are offered on the NHS ignores completely that all the evidence shows it’s the therapeutic relationship that matters.

So you must be a CBT therapist then the way you are defending it?

Nope, my initial training was person centered. Person Centered counselling is based on the idea that we all tend towards self actualization (reaching our full potential as human beings) but life events can act as barriers. By offering the core conditions (empathy, congruence and unconditional positive regard) the counsellor provides a space where the client can grow towards the light. Carl Rogers, the founder of person centered counselling, believed that most people never really had the experience of being heard, or valued (he called it prizing the client). He also argued that in order to be the best we can be, we needed to move from an external locus of evaluation (getting our validation from others) to an internal locus of evaluation (believing in ourselves) and learn to live in the moment.

That sounds a lot like the Mindfulness which is so trendy now!

It does doesn’t it?

So what is CBT then. and those other ones?

Another history lesson I am afraid. Carl Rogers was not the only psychiatrist/psychoanalyst looking at the therapy offered in his day and thinking there must be another way. The second world was played a part too as service personnel returned with PTSD and trauma that the armed forces wanted treated quickly and without thrice weekly sessions of psychoanalysis for three years.

Cognitive Behavioral Therapy takes a more directive approach than Person centered. Based on the idea most of our negative forms of behaviour come from irrational of negative thoughts, which reason, experiments, and socratic questioning can challenge. It also tends to use scaling, to record mood, and homework is common.

Transactional Analysis was developed by Eric Berne, he wanted to make many of the techniques and insights of psychoanalysis more accessible to the general public. However it is not simply a form of dumbed down psychotherapy, but a distinct school of its own. The excellent counselling for toads gives an idea of how it works, and I discuss some of its ideas here.

The last form of counselling you would commonly come across in the UK is psychodynamic. Perhaps closest to traditional forms of therapy it uses the therapeutic relationship to explore how early memories and experiences impact on the client.

Oh and just to muddy the waters even more, many counsellors like me are integrationist or pluralistic. There are technical differences between the two, but basically they mean we use a variety of techniques from different sources, as the client needs or wants.

How on earth am I meant to chose?

Given that most research says it is the relationship that matters, interview your potential therapist. Regardless of the school they may or may not belong to this is someone you have to feel comfortable trusting, revealing yourself too. I give some suggestions of the kind of questions to ask here.

I have been referred via the NHS, will I have a choice?

People often do have a choice, but lack of knowledge, information and confidence in the face of “experts” means they don’t even know this. CBT lite may be the most common option, and the quickest way to get treatment, but other options are often available. It may mean having to refuse the first type of help offered. Again this can be very difficult if you are in crisis, and having an advocate may help. It is OK to ask what exactly is being offered, the qualification of the person offering, and what other options are available.

You have mentioned evidence a couple of times now, is there actually any that counselling works?

A lot, for all forms of counselling, so much in fact that it would take far too long to list it all here. One way in which counselling has grown apart from psychotherapy over the past 40 years is that research into the why of counselling working has been positively encouraged. These are peer-reviewed research projects,many of which have been repeated in different settings.

OK, time to ask the hard question, how much will it cost?

Seeing a therapist privately usually costs between £30 and £60 an hour for an individual. This will vary according to location, type of counselling (for example online has fewer overheads) and a whole host of other issues. This might sound like quite a lot, but for comparison when I have my nails done its £25 a time. Sadly in the UK we tend to undervalue the emotional side of life, promoting a stiff upper lip attitude. Money spent on therapy is also seen as self indulgent, whereas its often no more self centered than putting on your own life jacket before you go to help others.

Quite a few therapists offer lower costs counselling, as I do, and it is always worth asking. We come into this profession to be there for people, as skilled professionals we may charge for our time, but it does not mean we dont understand income is a huge barrier for many.

Many charities offer free or heavily subsidised counselling, again it is always worth asking.

I started counselling, but I felt worse, thinking about bad stuff, shouldn’t it make me feel better?

I have to be honest here, some members of my profession seem less compassionate than they should be, discussing self-care, being available in emergencies, warning clients that they may feel worse are basics in my opinion. You may indeed feel worse, I compare it to a scab, they aren’t pleasant, but over time they heal, and underneath there is new, unmarked skin. Dropping out of counselling before you have reached that place of healing can mean you remain stuck in a painful place. However sometimes people feel they need to stop because it’s not the right time, or they have not found the right therapist. It’s a situation where trusting your gut really does matter. A professional, ethical, therapist, will never blame you if you say you don’t feel this is working, and if you say it, they may be able to explore what the barriers actually are.

Setting out to write a layman’s guide to counselling may be an impossible task. It’s almost certainly a book that needs to be written, rather than a single blog post. However I hope I have addressed some common questions. Please feel free to ask any more you may have in the comments, or on facebook or twitter.

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