Which Counsellor & Which Therapy? - The Client's Choice

This article considers the challenges facing clients who may be deciding the form of therapy to work with and which counsellor to approach.

The decision by a client to take up counselling is rarely taken lightly.  It usually emerges after much internal reflection on a sensitive personal issue; or alternatively as the immediate reaction to a specific disruptive event.  Whatever the cause, the act of walking into the counselling room is a courageous one. Yet it can also bring into play some challenging questions – including not just which counsellor to contact but also the type of counselling to opt for.

There are many different kinds of therapy and varied descriptions tumble from each counsellor’s web page or advertisement. The titles of the different approaches can occasionally seem complex and off-putting. The descriptions of each technique and the benefits claimed may also sometimes confuse the apprehensive reader.  The challenge for the potential client is to be able to understand enough about the different approaches to   enable a balanced decision to be made. That can be a demanding task especially if it has to be completed at a time when the client is already under stress.

The variations between some counselling modalities can be seen as substantial but other differences are more nuanced. In those circumstances the process of discrimination and selection is particularly challenging. Some consolation can be found in the suggestion that the actual choice of counselling approach may be less important in terms of successful outcome than the selection of the right counsellor. Proponents of this view argue that if the relationship is right the client will find the support they need within the counselling room irrespective of the approach.  The evidence on this is however ambivalent and critics will point to the very major differences which do exist between some groups of therapies. 

It is certainly true for example, that for two classic approaches, that of Cognitive Behaviour Therapy (CBT) and Psychodynamic Counselling, there are very distinctive variations and individual clients may well react differently to each discipline.  One of these approaches has an emphasis on unhurried reflection whilst the second proposes a more focussed approach often within a time limited setting. It can be argued that clients should ideally go for that modality which best reflects their preferred way of working.

CBT is the newer of these two schools although there is also an impressive lineage to this approach. CBT emerges from work which evolved around the middle of the last century and represents a coming together of Behavioural Psychotherapy and Cognitive Therapy.  Influential pioneers such as Albert Ellis and Aron Beck contributed towards the evolution of an approach which now has many enthusiastic supporters.  Some of these can be found within health services. 

CBT is certainly seen as the favoured approach for some health professionals and much was made of NICE’s initial declaration of approval, indicating CBT as a preferred choice. This approach can be seen to reflect a medical model with a structured procedure maintaining a focus on achieving a cure.  That in turn presupposes the presence of some form of illness and that is where CBT may invoke criticism. This can come particularly from those potential clients who regard themselves as seeking improvement and who come into the counselling room for developmental reasons rather than because of some latent psychopathology.

Cognitive Behaviour Therapy (CBT) is often seen as a preferred approach where there is a concern to resolve a specific issue.  With an emphasis on addressing present thinking rather than just past experiences, CBT encourages critical reflections on those thoughts beliefs and attitudes which have had an adverse impact on the client’s well-being.  There is a search for new ways of thinking, often carried out in a structured way aided by modelling and recording techniques.  That cognitive process is also supported by a change in behavioural strategies which will encourage the client to experiment with and to then live a new reality.  There is an overall emphasis within CBT on promoting rationality which will then drive forward change.

That structured process is in marked contrast to psychodynamic counselling.  This approach places much importance on recognising, identifying and acknowledging the power of that which has occurred.  The purpose of this retrospection is to gradually take away from the past, the power to adversely impact and distort both the present and our future.  This work is usually reflective with a focus on relationships which may in part be reflected back to the client by experiences within the counselling room. It can be seen by some as providing for the exposure of, and then the gradual removal of those layers of misunderstanding,hurt and confusion which may have been laid down in earlier years.

This approach owes much to the founding fathers of psychotherapy such as Freud, Jung and Klein; and is the oldest of the mainstream psychotherapies. Of those names, perhaps Freud is the one which has the greatest resonance and invites the greatest controversy. Different views will be held on psychodynamic theories. Despite a recent and pronounced emphasis on research, much has been made of the fact that a number of these more abstract theories are not easily verifiable, which means that the overall effectiveness cannot be scientifically proved.  Nevertheless an important and lasting contribution has been the introduction of the unconscious as a powerful force within us. The wide acceptance of the notion of a Freudian slip would appear to suggest that these theories do continue to hold much relevance today. 

This type of reflective therapy may prove to be particularly useful to those clients who wish to develop a deeper understanding of their internal world and their personality.  For some it is important not just to change behaviours but to have an understanding of why and how we have reached our present stage of emotional development.  It is argued that this type of counselling can provide a deeper understanding of our motivations and desires. It can assist us to establish a more robust emotional base line from which to then introduce changes to our current way of interacting with the world.

These two models appear to stand at opposite ends of a counselling spectrum. Yet there may in practice be much potential synergy between the two modalities. As with many professional disciplines, counselling can be accused of using terminology which is at best pompous and at worst destined to confuse.  Once however this confusing terminology is stripped away, the world within the counselling room may become a little clearer.

That can in turn highlight the two relatively simple drivers at work which propel many clients into the counselling room. The first is a wish for the individual to understand why she or he thinks and acts as she or he does and the second is to then bring about some form of personal change.  It can be argued that the more reflective form of therapy has the potential to be very effective in achieving understanding whilst the CBT approach can be particularly helpful in introducing change, at least in the short term.

It follows that if CBT and Psychodynamic Therapy can be worked in combination, a joint approach could help the client to meet both needs of comprehension and of change. If synergy can be achieved with a coming together of these two modalities, this may allow the client to emerge from the counselling room better equipped to meet and respond to the demands of the world.

Given the extent of the differences it is clear that the bringing together of such varied approaches is not an easy task.  It requires a willingness to embrace flexibility which is a competency counsellors in some disciplines may be very uncomfortable with. It also requires a sound theoretical and practical appreciation of each modality.  That in turn suggests that therapists need to be professionally trained in both approaches and for that overall training to be ideally reinforced by recognition through formal accreditation by at least one approved body.  If that can be achieved, the counsellor may be in a good position to assist the client who comes searching for a form of support which defies easy description.

This technical response may however not be sufficient for the client. We have already acknowledged that familiarity with various counselling strategies per se and a willingness to embrace a new approach is not enough. There is another key set of competences which has to fit alongside that counselling continuum.  To allow the process of understanding and change to take place, the client must also feel secure and held within the counselling room.   

It will be important for the client to feel able to sit with the counsellor within the therapy room and to regard it as a place of safety.   The recognition of that feeling of safety is likely to be an intuitive call by the client. It can certainly be regarded as a crucial prerequisite to the process of choice of both technique and therapist.

Perhaps this serves as a powerful reminder to us as counsellors that although we will attach much importance to matters of modality and approach, the client’s first concerns are likely to reflect those very basic constituents of the counselling contract.  If client needs around approachability and empathy are not met during any initial assessment it is unlikely that the counselling work would be effective irrespective of the merits of the different strategies.

This paper is intended to acknowledge the challenge that clients are faced with when seeking counselling support. There are very different approaches offered by therapists and this paper has referred to two classic models.  In practice the client may be best served by working with a mix of strategies although such an integrated approach will place much demand upon the therapist. 

Care should be taken to ensure that the need to meet those technical demands should not overshadow the importance of the therapist continuing to provide support within an environment in a way which is sensitive to the basic needs of the client. This includes empathy and consideration. In seeking counselling, clients will rightly expect much from therapists with regard to both technique and personal sensitivities.