1 What is Counselling and Counselling Psychology?

“Psychotherapy is a cyclical process from isolation into relationship.” – Irvin D. Yalom

Introduction

It can be quite challenging to distinguish between the similarities and differences of the mental health professions as often there is significant overlap in the type of services provided by each. This is reflected in a common confusion over distinguishing between, a psychiatrist, a psychologist or a psychotherapist, as each term sounds very similar. To add further to the muddle, there are differences between clinical psychologists, counselling psychologists and other types of psychologists. The word ‘counselling’ is problematic as well because many professions such as social workers, occupational therapists, mental health nurses, psychologists, and counsellors all provide counselling. This raises the question, ‘Is the counselling that each profession provides the same thing or are there differences?’

Another important issue is the regulation of these various professions. Do practitioners from each profession go through the same regulatory processes? What do governments understand to be the differences between these professions and what does this mean in terms of such issues as cost and remuneration? Some of these questions we will not answer here as the answers vary depending on country and jurisdiction. However, we will aim to provide some sense of the mental health landscape.

Well before the modern era of health care, people were supported in their mental health by a range of social networks ranging from family members, community elders, teachers, priests, rabbis, imams and pastors. These forms of community support are generally referred to as pastoral care. By the beginning of the twentieth century the natural sciences had begun to influence the mental health field, introducing new ideas and roles. Before the emergence of the natural sciences, the dominant theoretical foundations of the helping professions were from philosophy and theology. Psychology for example, largely emerged from philosophy and has progressively drawn on other disciplines such as medicine, education, neurobiology, developmental studies, and sociology, combining in a synthesis of what we understand as the discipline of psychology today. Counselling similarly draws on these academic disciplines and adds other fields such as career guidance, and relationship counselling. There has always been a large overlap between the various mental health professions which has contributed to the professional potpourri described above.

Famous names from early in the development of the mental health field include such people as Sigmund Freud, Carl Jung, Willaim James, John B. Watson, and B. F. Skinner with these theorists representing just a small portion of notable contributors. These early twentieth century developers were either psychiatrists (medical doctors) or psychologists. The twentieth century was a boom period for the development of psychological theories and by the mid twentieth century the field had begun to diversify its range of theories. By this time, the dominance of Freudian psychoanalytic theory and the behaviourism of Watson and Skinner had begun to be challenged by the humanistic theories of Abraham Maslow, Carl Rogers, and others.

The world wars of the twentieth century also had an important impact on the development of the mental health field. The returning soldiers from both wars presented with a range of mental health conditions that challenged existing theories and treatment approaches. The famous case of soldiers returning from the First World War with what was then called ‘shell shock’ captured the attention of clinicians just as did the problem of marriage breakdown, addictions, and career malaise after the Second World War. Up until the Second World War and apart from the wider field of pastoral care, most of the professional titles in mental health were linked to either medicine or psychology. After the Second World War the demand on mental health services increased enormously and to help meet the demand, the services of educational and guidance counsellors were enlisted. It was this demand that saw the emergence of counselling psychology and counselling as professions in their own right (Dryden, 1996).

One of the notable differences between mental health professionals is their different philosophical foundations. These different philosophical foundations can be identified in a variety of ways, but one such designation relates to the relative emphasis placed on the natural sciences. Medicine and clinical psychology rely principally on the natural sciences and on what is referred to as the scientist-practitioner model.  Counselling psychology and counselling draw on a combination of humanistic philosophy and the natural sciences, and this combination of influences is sometimes referred to as the reflective-practitioner model. Both scientist-practitioners and reflective-practitioners draw on knowledge from the natural sciences and from reflection on knowledge gained from clinical practice. The difference, it might be argued, is the relative emphasis placed on these knowledge sources (Blair, 2010; Douglas et al., 2016; O’Hara & O’Hara, 2015).

Counselling as Art and Science

One way of capturing the idea that counselling draws on both science and clinical experience is to say that counselling is a combination of art and science. In other words, to be an effective therapist working with a wide range of clients and presenting issues requires the practitioner to apply their scientific knowledge in a way that respects their own style and personality, and respects the needs and personality of the client and the specific contexts in which therapy is conducted. As human beings are so complex it is not uncommon to notice in clinical practice that a therapeutic strategy or intervention that was effective for one client is not effective for another even though the individual clients presented with the same ‘problem’ or symptoms. In fact, interventions used with one client for a defined problem may be effective one day and not another. In other words, while we know from research a great deal about neurobiology, personality, emotions, and human behaviour, the application of such knowledge requires a deep appreciation of the person in the moment, and in context. The awareness required here is an appreciation of variability. Counselling is as much about knowing what and knowing how as it is about knowing when. To put it simply, as counsellors we might know a lot about human functioning and psychological strategies but knowing how and when to apply them is quite another thing. The problem of what, how and when can only be adequately addressed when we appreciate the fact that counselling is really a combination of art and science. Albert Einstein well understood the combined significance of art and science when he stated,

“After a certain high level of technical skill is achieved, science and art tend to coalesce in aesthetics, plasticity, and form. The greatest scientists are artists as well” (Einstein Archives, 33, 257).

Science and Evidence

A foundational principle of science is that evidence needs to be established to assert a claim about facts or truth. The means by which such facts are established is via the scientific method. Ideas gain the status of facts or even ‘truth’ when they can be verified. This is done by proposing hypotheses and testing to see if they stand up to scrutiny especially via re-test reliability. The scientific method has provided the world with wonderful insights into the workings of the nature and the universe. Having said this, the scientific method is not as straightforward as is often portrayed. One of the reasons for this is that there are so many variables that must be controlled to provide sufficient certainty that what the scientist thinks is causing an event is actually doing so. For example, due to the complexity of life, it is usually the case that there are many factors involved in any phenomenon. Recognising this reality researchers acknowledge the influence of mediating and moderating variables. In other words, while there may be a main or primary cause for a phenomenon, it might not be direct in its effect. For example, if we were exploring the effect of age on job satisfaction, we might find that education level is a mediating variable. So, while we might say that age had a particular general effect on job satisfaction, this might not be as certain due to variability in education levels. Another important point to note about the veracity of evidence is that the scientific method recognises that there is no perfect one-on-one correspondence, that is, there is always the issue of variability. Hence, in statistics we always allow for a degree of error.

Types of Evidence

As science is one of the foundational planks of counselling and psychology, it is worth commenting briefly on the nature of evidence that science provides for the work of therapy. The type of evidence can be divided into two overarching categories, evidence about the outcomes of therapy and evidence about the process of therapy.

Outcome Research

People come to therapy with a wide range of presenting issues and conditions, and these range from what might be referred to as general life problems encountered by people to problems that are very serious, causing significant distress requiring skilful professional care. Presenting issues describing general life problems are usually highly amenable to resolution or at least to positive change. More serious problems usually require a longer process of recovery that is designed to meet the specific needs of the person. Whether the problem is of a more common or general nature or is a disruptive issue or disorder, all require an appropriate applied process of therapeutic engagement.

Outcome research essentially asks, “How effective was the therapy?” and potentially “What are the changes that occurred as a result of therapy?” These two questions can be asked at two levels: at the level of the individual and at the level of the population of people experiencing a similar problem or issue. Understanding the various outcomes of therapy is obviously very important to the profession because we want to know how effective therapy is and what strategies and processes work best for the problem change or resolution. While data from an individual case is valuable in this enterprise of understanding the relative effectiveness of therapy, it is data gained from large samples of the population that provide the most convincing evidence that the processes and strategies of therapy have been effective or not.

There are many different approaches to designing research with approaches reflecting the type of information sought. One way of framing or categorising designs that aim to provide information about outcomes is to divide approaches into two types: correlational and experimental. Correlational designs provide information about how different variables or factors are related to each other. For example, it would be helpful to know if people presenting with depression as opposed to those presenting with an anxiety condition are more or less likely to expect that therapy will provide a positive outcome. Similarly, we know that hope is a good predictor of likely progress in therapy and therefore identifying factors or strategies associated with the installation of hope would presumably support positive change.

An experimental design focuses predominantly on how variables influence each other. The researcher manipulates one variable (the independent variable) and observes the effect on another variable (the dependent variable). For example, for someone presenting with panic disorder is it more effective to provide exposure experiences or to provide cognitive challenges to maladaptive thoughts? By applying different experimental conditions to a large sample of people with panic disorder we are likely to gain insight into the approach that works best.

Process Research

While outcome research does provide information about what is involved in delivering outcomes, it does not provide a detailed account of what is occurring in the specific processes active in producing these outcomes. For example, we may know that exposure therapy can be effective for certain anxiety conditions, but we may not know why exposure therapy is effective – we are largely blind to the actions involved. Process research aims to remedy this knowledge lack by seeking to understand the intricate actions and processes involved in the change process.

Counselling and psychotherapy researchers have developed a range of research methodologies designed to delve into the minute processes involved in human psychological functioning. This type of research is usually very detailed and typically enlists a much smaller number of research participants than outcome research due to the volume of data that results from such data gathering methods as interviews, demonstrations, and in-vivo experiences. The wonderful benefit of process research is that it has the potential to identify and explain why certain outcomes are produced in therapy.

Considering the Nature of the Self

It would not be surprising to suggest that a central focus of counselling psychology and counselling is ‘the self’ of the client. Our clients/patients come to us with a wide array of problems and issues, generally referred to as ‘problems in living’, and such problems obviously concern their person or self. Of course, at both philosophical and practical levels such a focus assumes we have a clear conception of what is ‘the self’. The notion of the self has intrigued philosophers, theologians, psychologists, and other commentators for centuries. While we don’t propose to solve this age-old question in this course, it is important, if we are going to be working in therapy with ‘the self’ of the other, to have some perspective on this fundamental question. To begin our considerations, it will be helpful to provide a brief overview of different views of the self. Later we will highlight key elements that we think it will be helpful for therapists to pay particular attention to.

One common way of beginning a discussion on the nature of the self is to ask the question, “Are you the same person today as you were ten years ago?” Of course, this is a trickier question than at first it might seem. This is because we can answer both ‘yes’ and ‘no’ to this question. If we say ‘yes’, we might cite an example of meeting a friend who we have not seen for years who immediately recognises us as the same person they knew years before. Equally, we ourselves or a close friend might say that ‘no’, we have actually changed in some way. Maybe we are less inclined to be impatient and now display an increased degree of tolerance not common to us in relationships previously. A key issue here is whether there is a central or cohering self, that is, some dimension or structure that holds our continuity of being over time while still allowing for change. Obviously, our friend still recognises us not just physically but personally even after many years – something about our ‘self’ has stayed constant. Alternatively, if we emphasise the changes in us over time, we might argue that there no such coherent, stable self, rather a miscellany of multiple selves experiencing life as series of perceptions and events (Fonseca & Gonçalves, 2015; Gallagher, 2000; Metzinger, 2009).

In the Western history of ideas there are a range of views on the nature of the self. Ancient Greek philosophers such as Plato suggested that the ‘true self’ is the divine intellect or ‘nous’. This nous or eternal form was thought to be unified in its eternal state but could also be expressed materially. Plato thought that one of the ways to discern or explain the nature of something is to identify its ‘telos’ or goal or final purpose. For the human person this was the full emergence or expression of the divine/innate self. The Judeo-Christian understanding of the self has had a significant influence on Western thought. Such a view is founded on the belief that people are made in God’s image and as such have a divine core or God-given essence. While the person does change and grow over their lifetime, it might be thought of as the progressive budding or flowering of the original essence that provided the potential for the full emergence of the self. Another influential theorist was Immanuel Kant who believed the self was that which provides transcendental (pre-existing) unity of thoughts and perceptions. In Kantian ethics the self is autonomous, consistent and free when it conforms to rational principles inherent in the universe (Kant, 1781). In different ways each of these early thinkers had a conception of the self that, at least in part, reflected the view that there is a soul or pre-existing nous which in some way imbued the life of material form. In other words, common to all of these views is a belief in an essential self of some kind.

With the emergence of the scientific revolution, and a shift from the predominance of rationalism (theoretical explanations) towards empiricism (evidence via measurable data), the focus shifted to exploring and explaining the natural world – matter. Intellectuals such a Descartes and Locke began to consider that rather than a soul or non-material eternal form that enlivens persons, it is consciousness that animates the physical being. Of course, this progressively led to the current focus on neuroscience and its explanations of consciousness.

Other approaches reject the idea of an essential or central self. For example, existentialists have largely taken the view that there is no essential self, rather a freely emerging self, based on our responses to our experiences. Satre was famous for the statement ‘existence precedes essence’, meaning that no foundational nature (essence) exists before experience and that we human beings through consciousness create our own values and meanings (Johnson, 1967). Postmodern thinkers in a somewhat different way reject the notion of essence as well, positing the idea of multiple selves. There are various approaches to understanding multiplicity. Social constructionists like Kenneth Gergen argue that self is really an amalgam of the social and cultural narratives one is surrounded by and integrates into one’s consciousness in varying degrees. Other approaches focus on individual psychology, recognising that as we accumulate experiences we are continually changed. Hence, the self of the past is a different self to the present and different again in the future. Other postmodern variations on this theme agree that, while there are multiple selves, what has been erroneously perceived as a core self is not a substance or essence but a process, a process of organisation of the experiences of the multiple selves (Gergen, 2011; Radden, 2011).

This very brief overview of the notion of ‘the self’ has focused on highlighting different definitions or views of what the self is and less on its function. Whether the self is conceived of as having some pre-existing or given essence or is principally an emergent set of processes, in everyday life we still do make reference to selfhood. While the language we use to refer to the self, such as true self, genuine self, or personality, may vary, we at the very least naturally hold a notion of ’the self’.

Self as Content and Process

People come to see a counsellor for two main reasons, psychological support and the facilitation of therapeutic change. The difference between support and therapeutic change is something we will explore later. However, whether our focus in counselling is support or change, it raises the question “What is being supported or changed”? Given our foregoing discussion, it is obvious that we are referring to the individual’s self. The foci of support or change however, raise the question of not just ‘what’ but ‘how’. How does a person gain support or enable psychological (life) change? Clearly when we consider the issues of support and change, we are interested in the dynamic processes of the self.

One of the first psychologists to delve into the nature and processes of the self was William James (1890). James said that the self was a ‘stream of consciousness’, an ever-flowing stream of experiencing. Experiencing here refers to both thoughts and images as well as subjective feeling states. James saw this flow of consciousness on a continuum between an experiencing self or ‘phenomenal self’ and a ‘reflective self’.

Figure 1. Stream of Consciousness

This is an interesting conception of the nature and functions of the self as it highlights a continual movement between experiencing and awareness. In other words, while we are always in the process of experiencing being, whether that be in terms of bodily processes, emotional states, or nonconscious neurological and chemical processes, we only periodically become aware of some of these processes and thoughts. To only experience without awareness would be just as problematic as only being aware without experiencing.

James’ approach to understanding the nature of self and consciousness also involves the idea of self as both subject and object. This reflects the view that there is a self that is both having an experience and a self that is reflecting on experience. James referred to the experiencing self as ‘me’ (objective self) and the reflecting self as ‘I’ (subjective self). Another way of thinking of this is to consider ‘me’ as the aspect of self that is observed and identified by the outer world while the self as ‘I’ is my inner self or my conscious awareness of self (Wozniak, 2018).

At this point it is important to ask what has this got to do with counselling? The short answer is, quite a lot. To stimulate some early thoughts, consider the proposition that quite disturbed people – those for example, presenting to therapists with overly strong affect or whose thoughts are disturbing them or who cannot seem to control their social behaviour very well – might have a problem regulating the movement between experiencing and awareness. We have all had the experience of speaking with someone who talks non-stop, seemingly never really stopping to reflect on what they say or how it might affect the listener. It feels like they are living a ‘stream of consciousness’. They are in the moment of experiencing without pausing long enough to reflect on their experience. In other words, life is their experience; that is, life is what they feel. If they feel it, it must be real or true. Now this is not to disparage feelings and emotions (we’ll explore these more in later chapters). What we experience or feel, is central to being a human being. However, just as our experiences and feelings can overwhelm us, so too can our thoughts. When there is a lack of balance between the two, we tend to encounter ‘problems in living’.

The Art of Listening

One of the central skills that effective therapists have is the ability to deeply listen. Listening is different from hearing. We may hear what a person says physiologically but not have listened. To hear is relatively automatic but listening is an active process. Research has confirmed that listening is a multidimensional process involving:

1. cognitive
2. affective
3. behavioural/verbal
4. behavioural/non-verbal
5. behavioural/interactive dimensions (Halone, et. al., 1998).

There are at minimum several key elements involved in listening. Barthes and Havas (1985) outline three levels of listening:

• alerting
• deciphering
• understanding.

In alerting, we are responding to cues in the environment like noise, light, and movement.

In deciphering, we are detecting patterns in the environment for the purpose of adding a level of meaning. For example, when we hear a car engine coming up the driveway, we know that a member of the family has returned home.

In understanding we go beyond interpreting to realising that what we say affects the other person. In this respect, genuine listening requires us to suspend judgement on what the other is communicating so that we attend to and grasp what they are saying rather than what we presume they are saying.

Effective listeners have a developed ability to suspend their own need to interject unnecessarily so that the other has room to speak. While in many ways this all seems obvious, effective listening is surprisingly difficult to do.

These dimensions and elements of listening are present in any encounter between people, whether that be in the family, at work or socially. The same elements are present in counselling. One of the differences, though, in counselling is that the counsellor is paid to listen. In other words, they need to be really good at it. Without the ability to listen effectively, it is impossible to understand the nuances of the client’s problem. Not only that, effective listening also involves making space for the other to speak. The ’making space’ part of interpersonal communication is a challenging sub-skill to acquire. For example, when a counselling client comes into the room for the first time, how do we help them feel comfortable enough to begin telling their story? What do we do to support them in continuing the conversation? To what parts of the conversation do we pay particular attention? One way of developing our listening capability is to break down some of the skills of communication into manageable parts. Any communication is made up of sub-components which can be identified. This fact is very helpful for it enables us to practise and develop these sub-skills. There is a danger though, in breaking down communication into component skills. We can be distracted by the sub-skills leaving them separate and atomised without integrating them into a flowing coherent whole. A useful musical analogy is learning scales. Being able to play scales makes us technically proficient but it doesn’t mean we can play a concerto. In the end playing a concerto requires technique joined with interpretation, form and feeling. One of the aims in this book is to help you to develop your communication skills so that you become a deep and active listener. We’ll explore some of the sub-skills of communication but always with the view of integrating them in such a way that your communication and deep listening flows like a concerto.