Defining and delivering effective counselling and psychotherapy

CFCA Paper No. 38 – March 2016

Counselling and psychotherapy in a contemporary context: What is it?

All the (healing) precursors to psychotherapy … bear a resemblance to each other and to later forms of healing like psychotherapy. (Duncan, 2014, p. 15)

Federal, state and local governments throughout Australia support a large range of counselling services in the belief that they provide an effective means of improving the lives of individuals, couples and families. It will be seen that broadly speaking, this belief is justified. But what gives counselling its potency? Impressive effect sizes demonstrated by research need to be reconciled with the fact that since its development in Western countries at least 400 intervention models and at least 145 manualised treatments have been developed, while more than 10,000 "how to" books on the "talking cure"1 have been published (Beutler et al., 2005, cited in Miller, 2013). Not surprisingly, this plethora of options has been accompanied by much ongoing debate about the true nature of counselling and psychotherapy.

Mainstream developments of counselling and psychotherapy during the first half of the 20th century are provided in Box 1. After demonstrating that differences between counselling and psychotherapy are largely in the eye of the beholder, the paper provides a comprehensive definition of counselling, the word used as the default descriptor in the remainder of the paper.

Box 1: Origins of the "talking cure"

The seeds of contemporary approaches to counselling were probably sown in the wake of the Industrial Revolution. Giddens (1991) has described how within the larger more urbanised societies emerging at that time, traditional rules of living were increasingly challenged, whilst norms governing personal relationships became less constrained. As power, responsibilities and protections supported by local knowledge and recognised reference points began to diminish, the capacity of traditional healers to influence individual and group behaviour also waned.

According to Albee (1977), the gradual shift from life in villages and small towns to life within larger more anonymous societies prompted increased attempts to seek direction from within. The focus on inner direction, accompanied by the weakening of old certainties hitherto buttressed by religion and a sense of social and geographical belonging, created a need for more personalised help, guidance and support.

Clients with personal problems: the counsellor as expert

In the culture that followed the science-led Industrial Revolution, it is perhaps not surprising that science-informed alternatives to traditional morally and religiously based responses to "problems of living" began to gain acceptance. Scull (1975) for example, has demonstrated how the medical model, resting on taxonomies of physical illnesses and diagnostic criteria, was recruited into also creating categories of psychological disturbance (see also Foucault, 1967).

Experiments with hypnosis in the late 19th century, famously elaborated upon and eventually reinterpreted by Freud, represented an early departure from physically focused treatments. Though still firmly located within the medical profession,2 Freud's development of psychoanalysis contained two foundational insights that continue to inform much (though not all) contemporary counselling and psychotherapy. They are firstly, the importance of the relationship between therapists and their patients; and secondly, the idea that the origins of some psychological difficulties are not fully accessible to conscious rational thought.

At about this time, behaviourism, an overtly rational approach to counselling, grew out of Pavlov's experiments with classical conditioning. In the United States, Watson (1919) applied Pavlov's stimulus-response work with dogs to learning in human beings, while Skinner (1938) extended Watson's work by introducing the broader concept of operant conditioning.

Though behaviourists continue to argue that psychological interventions must be based on observable and measurable learning principles, most have accepted the limitations of attempting to explain complex behaviours (such as language) via linear chains of stimuli and responses (see for example Lashley, 1951). Most contemporary behaviourists acknowledge that the processing of emotions and/or cognitions must also be part of the learning equation. Hybrid models such as rational emotive therapy (Ellis, 1962) and cognitive behavioural therapy (e.g., Westbrook, Kennerley, & Kirk, 2011) have largely replaced earlier "purer" expressions of behaviourism.

The self-healing client: the counsellor as facilitator

Both psychoanalytic and behaviourist approaches to alleviating psychological distress have tended to support top-down, expert-driven interventions. Limitations of this presumed expertise began to reveal themselves towards the middle of the 20th century, especially in the context of attempts to make sense of the Holocaust and other ravages of war.

In the United States, the need to offer practical and emotional assistance to so many returned service men and women coincided with the development of new forms of counselling that were focused on paying close and empathic attention to the client.3 In developing a "person centred" approach, Rogers (1957) did not rely on diagnostic categories or expert-based interpretations of possible reasons behind clients' behaviour or distress. Rather, the self-actualising underpinnings of Rogers' philosophy of human development led him to suggest that being deeply heard and accepted by the counsellor would provide space for clients to discover their own understandings about their distress and their own solutions to their problems. Later research (described below) suggests that while "deep listening" may not be enough, Rogers was quite prescient in his analysis of how counselling and psychotherapy work.

The paper then summarises the evidence regarding whether or not individual, couple and family counselling "works" and how it works. Evidence about how counselling works leads to a brief discussion of the critical question of how counsellors develop and maintain expertise and how, as an essentially private process, counselling can nonetheless provide appropriate levels of accountability for clients, employers, funding bodies and of course for counsellors themselves. The paper concludes with a number of observations regarding future practice options.

1 This description of the "talking cure" process was coined by Bertha Pappenheim, an early recipient of contemporary psychotherapy. A patient of Josef Breuer (more widely known as "Anna O"; see Breurer & Freud, 1895), Bertha was cured of a range of symptoms through a process of talking and hypnosis.

2 In its early days for example, the American Psychoanalytic Association spent considerable time debating whether non-medically qualified individuals were eligible for admission (see Gifford & Thomson, 2011).

3 Australian Indigenous people refer to this process as "Dadirri" or "deep listening" (Brearly, 2010).