Fortnightly features' series: Counselling and Psychotherapy

Counselling and Psychotherapy

 

Introduction

 

Psychotherapy refers to the treatment of mental disorders by psychological (rather than physical or biological) means. The term embraces a variety of techniques, all of which are intended to help emotionally disturbed individuals modify their behaviours, thoughts, and emotions so that they can develop more useful ways of dealing with stress and with other people.

 

Some psychotherapists believe that modification of behaviour is dependent on the individual's understanding of his or her unconscious motives and conflicts (psychoanalysts, for example).

 

Other feels that people can learn to cope with their problems without necessarily exploring the factors that have led to their development (behaviour therapists and cognitive behaviour therapists, for example).

 

Despite differences in techniques, most methods of psychotherapy have certain features in common. They involve a helping relationship between two people: the client and the therapist.

 

The client is encouraged to discuss intimate concerns, emotions and experiences freely without fear of being judged by the therapist or having confidences betrayed.

 

The therapist, in turn, offer sympathy and understanding, engenders trust, and tries to help the client develop more effective ways of handling his or her problems.

 

Psychotherapy by professional therapist vs ‘counselling’ by friends

 

Most of the procedures used by trained professionals to treat people with psychological problems involve understanding, respect and helpfulness, but psychotherapy is unique by virtue of the intentional effort of therapists to communicate their understanding of a client's difficulties and help him share in this understanding.

 

Defining psychotherapy as the communication of person related understanding, respect and a desire to be of help raises the question of whether psychotherapy can be conducted by someone who has not been trained as a psychotherapist.

 

For example, can the special kind of communication that constitutes psychotherapy take place between 'counselling' offered by friends?

 

In everyday usage, the word 'counselling' denotes the giving of advice. Informal psychological help in the form of solace, guidance, advice and the like is frequently sought and received from family members and other intimates. Other sources may sometimes be casual acquaintances and even strangers who appeared to be good listeners.

 

The differences between psychotherapy conducted by professional psychotherapists and the 'helpful friends' can be distinguished by the training received by the professional psychotherapists, the non-mutuality of the therapist-client relationship and the formal arrangements for working on a defined problem.

 

The training received by professional psychotherapists allows them to understand the client's psychological difficulties more fully than any empathic non-professional.

 

 It also provides techniques for communicating this understanding in ways the client can comprehend and accept. Conversely, inherently helpful but untrained people from whom others seek counsel are found to engage primarily in informal conversation and advice giving (Gomes-Schwartz & Schwartz, 1978).

 

The professional psychotherapy relationship is not a mutual relationship (i.e. asymmetrical). In psychotherapy, the interests, needs, and welfare of the patient always come first; the therapist rarely asks for consideration of his interests, needs, and welfare in return.

 

Unlike a friend or acquaintance, therapists do not ordinarily respond to anger and criticism by defending themselves or reciprocating in kind, and do not decide whether to continue the relationship on the basis of how pleasant they find the other person's company.

 

Friends trying to help each other discuss personal problems are found to be much more likely than professional therapists to talk about their own ideas and experiences, and much less likely to express statements of empathic understanding (Reisman, 1986).

 

There are certain formal commitments and constraints in the professional psychotherapy relationship that seldom characterise other interpersonal relationships.

 

Therapists and their clients agree to meet at specifically designated times on a regular basis and to continue meeting as long as doing so serves the client's interests.

 

These meeting times are kept as free from interruption as the therapist is able to make them, and, except for chance encounters, clients and therapist do not interact at other times or concerning matters other than a client's emotional difficulties.

 

Psychotherapy by professional therapist vs counselling by counsellors

 

Strupp (1996b) refers to psychotherapy as "the use of a professional relationship for the relief of suffering and for personal growth".

 

Jeremy Holmes refers to psychotherapy as 'a form of treatment based on systematic use of a relationship between therapist and patient-- as opposed to pharmacological or social methods--to produce changes in cognitions, feelings and behaviour." He makes no distinction between counselling and psychotherapy, which to him is mainly a difference of quantity (counselling being briefer and less) rather than quality.

 

Brian Thorne argued that psychotherapy and counselling are indistinguishable. He commented that the distinction was to do with status, remuneration and power in the marketplace.

 

He went as far as to allege that to differentiate between psychotherapy and counselling was a result of any one or a permutation of the following: muddled thinking; a refusal to accept research evidence; a failure to listen to clients' experiences; a lust for status; needless competitiveness; power mongering; a desire for financial gain; or some other unworthy motive prompted by professional protectionism.

 

Jerome Frank (1967) pointed out that all forms of psychotherapy (counselling included) shares certain basic processes. He also suggested that these common factors may be more important in bringing about change than are the factors specific to each treatment.

 

These shared factors are listening and talking, release of emotion, giving information and providing a rationale, restoring morale, prestige suggestion and therapeutic relationships.

 

Similarities and differences of Counselling and Psychotherapy

 

Similarities

 

1.      Listening and talking

 

In psychotherapy and counselling, the client talks and the therapist listens. By listening intently, the therapist signals his concern for the client's problems and begins to develop a helping relationship.

 

He detects common themes and revealing omissions in the client's remarks. When the therapist speaks it is usually to comment on these matters and to clarify ideas that have not been put into words before.

 

Thus client and therapist seek links between aspects of feeling and behaviour that have previously been unrecognised.

 

2.      Release of emotion

 

In the early stages of treatment clients may release much emotion about their problems. This emotional release may be helpful at this stage, but is not generally useful if evoked repeatedly. 

 

3.      Giving information

 

When giving information the therapist should bear in mind that distressed clients may remember little of what they have been told. There are two reasons for such lack of recall.

 

First, therapists may use technical language that is unnecessarily complicated; second, they often underestimate the client's capacity to understand the nature and significance of illness when explained in simple language.

 

4.      Providing a rationale

 

All forms of psychological treatment include a rationale that makes the client's disorder more intelligible. This rationale may be described by the therapist (as in short-term psychotherapy), or it may be discovered by the client with the help of the therapist's interpretations (as in psychoanalytically psychotherapy).

 

Whatever the method of imparting the rationale, the effect is to make problems more understandable to the client and thereby give him more confidence that he can solve the problem.

 

5.      Restoration of morale

 

It is an important part of psychotherapy because clients have mostly become demoralized through repeated failure, and have lost the conviction that they can help themselves. Unless this conviction is restored little progress can be made in psychotherapy.

 

6.      Suggestion

 

All psychotherapy contains an element of suggestion. This process can bring about change, but generally the effects are not lasting. For this reason suggestion is not used in most forms of psychotherapy. Nevertheless in the early stages of treatment suggestion may bring about some temporary improvement until more lasting changes are effected.

 

7.      Guidance and advice

 

There is an element of guidance and advice in all psychotherapies, but in the more intensive methods there is usually a requirement that the client discover the answers for himself.

 

8.      The therapeutic relationship

 

In all psychological treatment the relationship between the client and therapist may help or hinder the client's progress. This relationship is present from the start and grows more intense as treatment lasts longer or is carried out more frequently.

 

Even in the shortest forms of psychotherapy this relationship forms the cornerstone of treatment, helping to sustain the client through his difficulties and motivate him to overcome his problems. 

 

The relationship has a 'realistic' and an 'unrealistic' component. The realistic component is known as the therapeutic alliance; the unrealistic element results from transference. As treatment progresses, the unrealistic elements become increasing strong. The client reveals more about his personal problems and the client transfers to the therapist some of the feelings and attitudes that originated in relation to parents or other intimate relatives.

 

This process is called transference. If the therapist is conceived as a good figure, transference is said to be positive; when the therapist is conceived as a bad figure, it is said to be negative.

 

Similarly the therapists may respond in ways that are not simply a reflection of their clients' personal qualities but also a displacement onto their clients of ideas and feelings related to other figures in the therapists' own lives. This process is called countertransference.

 

Both transference and countertransference can be impediments to treatment. One disadvantage of transference is that it may induce behaviour that distracts from the main plan of treatment.

 

Examples are an attempt to prolong the session or dramatic behaviour demanding urgent attention, such as threats of suicide. Transference may also make it difficult to bring treatment to a termination. Countertransference causes difficulties when therapists become inappropriately involved in the clients' problems.

 

However both the clients and therapists can learn more about themselves from interpretation of the transference and countertransference respectively.

 

A person who comes for counselling or psychotherapy is vulnerable and open to destructive action by the therapist. Therefore the following issues are very relevant during the session:

 

1. Maintain confidentiality.

 

2. Counselling and psychotherapy depend on trust between counsellor/psychotherapist and the client.

 

3. Recognise the limitations and seek consultation.

 

4. It is important to obtain supervision and/or consultation in the treatment process.

 

5. Treat the client as you would like to be treated.

 

6. Put yourself in the place of the client. Every person deserves to be treated with respect, dignity, kindness, and honesty.

 

7. Be aware of individual and cultural differences

 

8. Review ethnical standards constantly.

 

9. Observe boundaries.

 

Differences

 

Some argued that counselling is concerned with problems which are reality-oriented, environmental, situational, specific and conscious, whereas psychotherapy is reserved for problems which are intra-personal, general, personality disturbances, embedded and unconscious.

 

Einzig, 1989 suggested that counsellors are really only concerned with the relief of immediate mental pain whereas psychotherapist are primarily interested in the total life experience of their clients.

 

Naylor-Smith postulates the 'continuum' theory according to which counselling and psychotherapy overlap for much of the way before one reach the area on the continuum where psychotherapy has the field to itself.

 

He describes this area authoritatively and succinctly: 'With more frequent sessions, more focus on the unconscious, on dreams and phantasy, and on the transference and countertransference; and with the allowance of greater dependence and of regression, the work is, now, in my view, clearly psychotherapy' (Naylor-Smith, 1994).

 

Psychotherapy, according to this definition, requires more frequent sessions, depends on an acceptance of notions of the unconscious, transference and countertransference and sees dependence or regression as likely behaviours.

 

Anthony Yeo described three sets of skills that every counsellor should possess. They are interpersonal, intervention and integration skills.

 

1.      Interpersonal skills form the core skills for counselling. They refer to skills required for building relationship with clients in order to engage them in the counselling process.

2.      In the problem solving process, the counsellor needs to be knowledgeable about the different strategies and techniques to help clients deal with problems. There are some generic intervention skills practised by most counsellors which can be applied to all problems presented. However there are specific types of problems that may be more effectively treated by one particular set of strategies than others. The basic intervention skill is the ability of the counsellor to engage clients in problem solving.

3.      Integration skills refer to the ability of the counsellor to apply strategies to specific situations, bearing in mind the culture and socio-economic context of the clients.   

 

Locally, family members are often very involved with the symptoms and problems of the client (unless the client seeks treatment without the knowledge of his family members). Clients do not have problems alone. Even where there is individual pathology, family and other related members are involved and should be engaged in some way in the management of the clients' problem.

 

Most clients do not see counselling as psychotherapy. Those from the lower socio-economic sector of society appeared to respond better to the problem solving approach when done in a more concrete and directive manner.

 

As psychiatrists, our training tends to focus on a biopsychosocial model, taking into consideration the client's personality, his past experiences, his religion and beliefs, and his family and related social system when prescribing any treatment. We need to be contextual in our work. Some of the clients do not readily accept the Western models and styles.

 

 

 

 

 

 

 

1.       References

 

2. Gomes-Schwartz, B., & Schwartz, J. M.  Psychotherapy process variables distinguishing the "inherently helpful" person from the professional psychotherapist. Journal of Consulting and Clinical Psychology, 1978, 46, 196-197.

 

3. Reisman, J. M. Psychotherapy as a professional relationship. Professional Psychology, 1986, 17, 565-569.

 

4. Strupp, H.H. The tripartite model and the Consumer Reports study. American Psychologist, 1996b, 51, 1017-1024.

 

5. Thorne, B.J. 'Psychotherapy and counselling: the quest for differences', Counselling, 1992, 3 (4): 242-248.

 

6. Einzig, H. Counselling and Psychotherapy: Is it for Me? Rugby: British Association for Counselling, 1989.

 

7. Naylor-Smith, A. 'Counselling and psychotherapy: is there a difference?', Counselling, 1994, 5 (4): 284-286.

 

8. Persuasion and healing by Frank, J.D. 1973 (Revised Edition).John Hopkins Press ,

 

9. Principles of Psychotherapy by Irving B. Weiner. 2^nd Edition, 1998. John Wiley & Sons, Inc.

 

10. An Introduction to the Psychotherapies. 3^rd Edition, 1996. Edited by Sidney Bloch. Oxford Medical Publications.

 

11.  Controversies in Psychotherapy and Counselling. 1999. Edited by Colin Feltham. SAGE Publications.

 

12. A Helping Hand by Anthony Yeo. 1981.Singapore: Times Editions Pte Ltd.

 

13.  Counselling-A Problem Solving Approach by Anthony Yeo. 1993. Armour Publishing Pte Ltd.

 

This article is contributed by Dr Lee Cheng, Consultant Psychiatrist, Institute of Mental Health Singapore.

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