WHAT IS COUNSELLING

& PSYCHOTHERAPY?

Other books in this series

Reflective Practice in Counselling and
Psychotherapy by Sofie Bager-Charleson

ISBN 978 1 84445 360 3

Creating the Therapeutic Relationship in

Counselling and Psychotherapy by Judith Green

ISBN 978 1 84445 463 1

Counselling and Psychotherapy in Organisational

Settings by Ruth Roberts and Judy Moore

ISBN 978 1 84445 614 7

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Parkstone, Poole, BH12 3LL. Telephone 0845 230 9000,
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WHAT IS COUNSELLING
& PSYCHOTHERAPY?
Norman Claringbull

Series editor: Norman Claringbull

First published in 2010 by Learning Matters Ltd

All rights reserved. No part of this publication may be reproduced, stored in
a retrieval system, or transmitted in any form or by any means, electronic,
mechanical, photocopying, recording, or otherwise, without prior
permission in writing from Learning Matters.
Norman Claringbull 2010
British Library Cataloguing in Publication Data
A CIP record for this book is available from the British Library.
ISBN: 978 1 84445 361 0
The right of Norman Claringbull to be identified as the Author of this
Work has been asserted by him in accordance with the Copyright, Designs
and Patents Act 1988.
Cover design by Code 5 Design Associates
Project management by Diana Chambers
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Printed and bound in Great Britain by TJ International Ltd, Padstow, Cornwall
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Contents

Preface and Acknowledgements

Part 1

Where has counselling & psychotherapy come from?

Chapter 1

Part 2

Part 3

Part 4

Counselling & psychotherapy the

opening story

vii
1

What do therapists do?

Introduction

27
28

Chapter 2

Repairing people the tales begin

33

Chapter 3

The psychodynamic story

45

Chapter 4

The cognitive-behavioural story

65

Chapter 5

The humanistic story

86

Chapter 6

Personality and therapy todays story

105

Where do therapists work?

Introduction

119
120

Chapter 7

Working in the commercial sector

123

Chapter 8

Working in the educational sector

137

Chapter 9

Working in the National Health Service

149

Where is counselling & psychotherapy going?

165

Chapter 10 Counselling & psychotherapy the next story

167

References
Index

188
197
v

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Preface and Acknowledgements

It is an exciting time to be a counsellor. It is a great time to be a psychotherapist. Times they are a-changing and never more so than in the talking
therapies. Counselling and psychotherapy in the UK are at a crossroads in
terms of their professional and academic development. Nowhere is this
more evident than in the intense debate that is taking place about the
possible futures of all the talking therapies. No one attending counselling
or psychotherapy seminars or conferences, reading professional journals,
or simply talking to therapist colleagues, can fail to be aware of the passionately advanced arguments and counter-arguments. Much of the debate is
centred on therapist regulation and its likely ongoing impact on
practitioner education and professional practice. It feels like the end of
an era. Counselling and psychotherapys greats are being ruthlessly
reappraised and its long-accepted orthodoxies are being irreverently
challenged. The old certainties of the therapeutic craft are fading and
radical changes in therapist training and practice seem inevitable. All of us
who are in any way involved in the talking therapies are now being
compelled to take a fresh look at our calling and at ourselves. In 1966,
Robert Kennedy famously (and erroneously) claimed that a Chinese curse
condemns enemies to live in interesting times. It seems more likely that,
for all psychological therapists, from trainees to advanced practitioners, our
own interesting times could prove to be a blessing rather than a curse if
we use them to properly shape our professional tomorrow.
So, anyone concerned with the talking therapies, at any level, will
inevitably be affected by these developments and might even want to
contribute towards them. This is especially so in the case of the rapidly
emerging, new genre of graduate and postgraduate trainees and practitioners who will be at the forefront as personal therapy practice increasingly
evolves into being a mainly university-educated profession. It will help the
therapy professions new thinkers to better consider their future if they
first critically and reflectively examine their ideas about counselling and
psychotherapys past (its history). They will then be better placed to examine
what counselling and psychotherapy is currently about (its present), and
then they can productively explore how counselling and psychotherapy

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PREFACE AND ACKNOWLEDGEMENTS

might evolve (its future). Put simply, the overall question is: Therapy
whats the story there then?
The story of the personal therapies is, of course, just that. It is a story; it is
at best an approximation; it is not a matter of absolute fact. All tales are
inevitably dependent on the partialities of their tellers and the preferences
of their listeners. Similarly, therapys tales are also based on an ever-varying
selection of interpreted personal, social and academic histories. Like the
process of personal therapy itself, counselling and psychotherapys various
stories depend on who is doing the telling. Just as therapists try to interpret
their clients stories and make guesses about their future needs, so too must
therapists interpret their own stories about the therapeutic profession and
make some guesses about its future directions. Sensible practitioners will
evaluate the tales told in this book in the same way, it is hoped, that they
evaluate the tales told to them by their trainers, their teachers and their
clients. That is to say, to value these stories as essentially being attempts to
be truthful but always open to critical questioning. At the end of the day,
the best tales that therapists can tell are their own and it might be that some
of their stories are more credible than others. The trick is to find out which
is which. That is what this book is all about.

FOUR CORE QUESTIONS TO THINK ABOUT

1. Where have counselling and psychotherapy come from?
2. What do therapists do?
3. Where do therapists work?
4. Where are counselling and psychotherapy going?

ACKNOWLEDGEMENTS
With thanks to Di Page, Luke Block, Lauren Simpson and all their colleagues
at Learning Matters for all their help, advice and encouragement.
Thanks also to Paula Biles-Garvey, Tina Graham, Barbara Allen and Alex
Bossman for all their contributions to Practitioner Reflections.

viii

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part 1
WHERE HAS COUNSELLING
& PSYCHOTHERAPY
COME FROM?

The story of the talking therapies how they evolved

Madness
(pre-1800)

Psychotherapy emerges
(early 20th century)

Behavioural models
(1930ish2000)

Psychiatry emerges
(18001900)

Psychodynamic
models
(18901990)

Counselling
emerges
(mid-20th century)

Humanistic models
(1950ish1990)

The therapy explosion

Schoolism and Purism
(1950s90s)

Workplace and agency

counsellings influences
Purposeful, brief,
solution-focused,
time-limited models

A multiplicity of
client-centred models
The time of confusion
500+ counselling models
(1970s onwards)

Psychodynamic
humanistic, cognitive,
behavioural, existential,
gestalt, groups, TA,
narrative, Adlerian, etc.

Integrative models +
The therapist or
therapy debate
(1990s onwards)
Government
policy
(current)

Todays therapy
revolution

Tomorrows therapy revolution

Regulated
therapists?

Degree-based
therapists?

Training
standards
under
reconsideration
(ongoing)

Chap ter 1

Counselling & psychotherapy

the opening story

CORE KNOWLEDGE
The explosion in the demand for personal therapy after the Second World
War led to the emergence of many hundreds of therapy types.
Historically, the development of counselling and psychotherapy has
depended on three main theoretical schools:
psychodynamic
behavioural
humanistic.
Modern counselling theories have evolved to include:
cognitive-behavioural ideas
integrative methods.
Counselling and psychotherapy are based on extensive research-based
evidence. The talking therapies are now established professional disciplines.
Counselling and psychotherapy are likely to become statutorily regulated
professions.

TO BEGIN AT THE BEGINNING

The tale of personal or psychological therapy, which is also the tale of
psychotherapy and the tale of counselling, is as old as the story of the
human race (Cushman, 1990; Hollanders, 2000a). Humans have long tried
to make sense of themselves and their worlds (Bettleheim, 1983). That is
why people have always used therapists, be they priests, gurus, wise ones,
philosophers, doctors, good friends, or in fact just about anybody prepared
to listen, as sounding boards and as guides to help to try to bring some
order into their inner and outer worlds. In other words, the role of the
talking therapist goes back to the dawn of humanity (Ehrenwald, 1976).
However, in terms of what we today would recognise as the discrete discipline (or disciplines) of counselling and psychotherapy, it is probably
the professions developmental history over the last 100 years or so that
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COUNSELLING & PSYCHOTHERAPY THE OPENING STORY

interests us most (Freedheim, 1992). Of course, personal therapy has come

a long way since its early days.
However, before we get too far into exploring therapys story, let us clear up
one important source of confusion. There are many terms used to describe
professionals who get involved with helping people who have emotional,
psychological or mental health problems. Titles such as counsellor, psychotherapist, psychological therapist, psychoanalyst, psychologist and so on
are all used, sometimes apparently at random. Naturally, people are often
puzzled about how to understand the differences between all these
professionals. The practical reality is that, historically, these different titles
have probably owed more to the inbuilt prejudices learned during early
therapeutic training than they do to actual differences in professional
practice. After all, many authors (Duncan et al., 1992; Fiedler, 1950; Wosket,
1999, etc.) give us reason to suppose that experienced therapists are far less
worried about therapeutic style-boundaries than are the less experienced
practitioners. Therefore, the answer to the whats in a name puzzle (as far
as this book is concerned anyway) is simple: there are NO differences. If you
are a professional and that includes all the personal therapists who is
trying to help somebody with emotional, personal or mental health
problems, then you are a psychological therapist and practising what today
are often called the talking therapies. Of course, in these more enlightened
times these therapies increasingly include a lot more treatment methods
than just talking the talk. Todays psychological therapists work with
action therapies, treatment plans, practical activities, psycho-education and
many other interventions; they walk the walk as well. In other words,
today at least, the choice of which professional therapist title to use to
describe your practice is yours to make. However, it is very important to
note that the current (July 2009) proposals to officially regulate counsellors
and psychotherapists may result in these two callings becoming separately
registered. This might happen perhaps from about 201415 onwards and
may possibly even involve different levels of training. Nevertheless, in this
book, all the talking therapy titles will still be used interchangeably.
There is one important exemption to the blanket definition of psychological therapist (or any other title that you prefer) that was given above.
It is an iron-clad rule that all psychiatrists must be qualified medical
practitioners. Psychiatrists are doctors who sometimes prescribe medical
treatment for those suffering from mental distress. Therefore, their professional title is legally protected. It is theirs alone. However, having said
that, wise counsellors and psychotherapists will not allow the high-level
professional status enjoyed by psychiatrists to lead them into automatically
awarding superior professional status to the medically qualified. Psychiatrists are our respected colleagues and valued co-workers at the psychological coalface; they are not the mine owners.

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COUNSELLING & PSYCHOTHERAPY THE OPENING STORY

Whatever we call them (counsellors, psychotherapists or any name you

like), what we really need to know is: What is it that they actually do? Well,
that is a tale that is long in the telling. This book will give you one take on
the therapy story. Perhaps by the end of this book you might have some
stories of your own to tell about the psychological therapies.
So, let us think again about the core question that this book will be
exploring. What indeed are counsellors and psychotherapists for? What do
they do? Do they really sort out peoples minds? Surely treating the mad is
a job for doctors? Well, historically that might have often been true (except,
of course, when the priests claimed their share of the action!). However,
we will begin our exploration of counsellings story by considering how
madness has been viewed throughout history.

HISTORICAL EXPLANATIONS OF MADNESS

From the earliest of times, humans have struggled to understand mental
distress. A brief history of some of these earlier explanations is shown in
Table 1.1.

When/who

Cause

Treatment

Prehistoric

Evil spirits/ pressures in

the brain

Trepanning

Early Egypt

Loss of status or money

Talking it out; religion or suicide

Old Testament

Despair/incorrect thinking

Faith

Aeschylus

Demons

Exorcism

Socrates

Heaven sent

None its a blessing!

Aristotle

Melancholia

Music

Hippocrates

Natural medical causes

Abstain from excesses; diet and

exercise

Celsus

Madness is madness

Entertaining stories, diversions,

persuasion

Galen

Functions of the brain

Confrontation, humour, exercise

Table 1.1: Historical explanations of madness.

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COUNSELLING & PSYCHOTHERAPY THE OPENING STORY

As time progressed, however, the idea that the mind was the source of
madness began to predominate and with it the conviction that the sufferer
was to blame. Possession by evil spirits, moral weakness and similar blame
the patient explanations placed the responsibility for both the disease and
its cure on the resulting outcast victims themselves. They were locked away
and shut off from society so that decent people could forget all about
them. That way the mad were not a problem as they no longer existed.
In these institutions, the mad were cruelly treated. They were whipped,
beaten, starved and treated like animals. No differentiation was made
between the mentally ill, the criminally insane or the socially disruptive.
For example, women were committed for wanting to leave their husbands;
men were committed for sedition; and children were committed for being
deformed. The mentally ill were accused of having abandoned themselves
to the devil and to evil sorcerers and they were considered to be wilfully
sinful. They were persecuted without mercy.

REFLECTION POINT
Have our views about either the cause of mental dysfunction or the treatment of
the mentally disturbed really altered so much since those early days?

During the eighteenth century, conditions for the insane started to improve,
and hospitals and asylums began to care properly for the mentally ill. In
1752, the Quakers opened the first ever hospital that tried to treat the
insane kindly, even constructively. By the mid-1800s many institutions
were genuinely trying to cure the mentally afflicted. It is important to note
that, by the end of the nineteenth century, the medical profession had
attained a monopoly in the treatment of the mad. This meant that all
psychological disturbances were believed to have medical or biological
explanations and so discovering a sufficiency of correct biological cures was
the ultimate goal of the doctor-therapists.

PSYCHOTHERAPY IN THE NINETEENTH CENTURY

Medicines monopoly quickly led to the emergence of specialist doctors
(eventually known as psychiatrists) to treat these new illnesses. In the late
nineteenth century, the term psychotherapy began to be used to describe
a new psychiatric subdivision one that was based on attempts to cure
the body by the mind, aided by the impulse of one mind to another
(Van Eeden, 1887, cited in Ellenburger, 1970, p765).
Of course, it is acknowledged today that the great psychotherapist of that
period was Sigmund Freud. This greatness is certainly true in terms of his
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COUNSELLING & PSYCHOTHERAPY THE OPENING STORY

overwhelming and long-lasting influence on the psychotherapy profession.

Whether it is true in terms of scientific rigour and honesty, or practitioner
integrity, is quite another matter and we will look further into these issues in
Chapter 3. However, Freuds ideas were not his alone. Like all trendsetters, his
work was very dependent on a number of widely held, pre-existing theoretical concepts and attitudinal beliefs. For example, as McLeod (2003) tells us:
Early nineteenth-century biological theories already included the
concept of a unitary life-force or libido.
Many nineteenth-century theorists were already debating the
possibility that emotions and psychological disturbances had (at least
in part) sexual origins.
By the early eighteenth century, the possibility that humans had both
conscious and unconscious minds had already begun to be
investigated. During the nineteenth century, psychiatrists such as
Charcot or Janet began exploring how to tap into the assumed
curative powers of the unconscious. Interestingly, even at this very
early stage in its development, psychotherapists were aware of the
importance of establishing a good rapport between doctors and their
patients. In other words, good working alliances were essential.
Then along came Freud. Although he did not invent psychological therapy,
what he did do, and did very well, was to bring all the already existing
ideas together and take them forward into an innovative, even pioneering, and certainly extremely well-organised theoretical model of human
personality development. The heuristic value of Freuds model has so far
stood the test of time. However, its true curative powers remain a matter of
intense debate. Freuds model underpins what is generally known in todays
psychotherapeutic world as the psychodynamic tradition and, even today,
psychodynamic modelling provides useful metaphors to help us understand what makes someone tick. It offers us a comprehensive theory of
human development. This is because the Freudians claim that all of us
the mad, the bad, the sad and the glad are the products of our inner
psychological conflicts and our instinctual drives.

PSYCHOTHERAPY IN THE TWENTIETH CENTURY

Real changes in how we viewed the mad, and started to wonder more
about the sad, began to occur as the twentieth century dawned and progressed. Looking back, we can now see the importance of Freuds theories
to the evolution of the counselling and psychotherapy trade. However,
it took time for his ideas to permeate society to the point where today
they are prevalent, even inherent, in everyday language and activities,
even when people are unaware that they are being Freudian. It took much
of the first third or so of the twentieth century for Freuds ideas about the
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COUNSELLING & PSYCHOTHERAPY THE OPENING STORY

origins of psychological disturbance to permeate the Eurocentric world.

Two big developments in particular influenced peoples thinking:
During the First World War it was noticed that large numbers of
soldiers were incapacitated by emotional problems and it was plain to
see that not just the few, but the many, developed apparently
abnormal thinking and behaviour. It was argued that, if extremely
traumatic situations such as combat could cause such widespread
mental distress, then it was reasonable to assume that lesser traumas,
although perhaps occurring more frequently throughout society,
could produce similar effects. Further, if trauma could be seen as often
merely being the impact of some of lifes ordinary events, then
psychological dysfunctions could be identified in the apparently
normal population and, it was hoped, eventually treated.
Another big change came about as it became generally realised that
Freuds ideas also apparently applied to people engaged in everyday,
routine human activity and not just to the interestingly neurotic.
For example, the psychodynamic explanation of interpersonal dislike
in the everyday world suggests that it is not simply a rational response
to an apparently unlikeable person. It is, some Freudians claim, an
unconscious, unregulated, negative response to an unfortunate whose
apparent behaviours or appearance remind someones unconscious of
an earlier problematic relationship.
Of course, Freud was not a lone theorist; he was not the only psychotherapist of his era. Other practitioner-theorists were investigating ways of
responding to a new and growing demand for treatments for the mentally
dysfunctional. The dying nineteenth century and the first half of the
twentieth century was the time of some of psychotherapys supposedly
great thinkers: Jung, Adler, Klein, Bowlby, Fairburn and many, many other
famous names. However, it would generally be true to say that, at least up
until the end of the Second World War, much of the psychotherapeutic
world was dominated by the psychodynamicists, many of whose adherents were also medically trained. This was particularly the case in the USA,
where analysis was exclusively the province of doctors (Mulhauser, 2008).
Interestingly, Freud himself believed that medicine and psychoanalysis
were two different topics (Freud, 1986) and argued that training programmes should include non-medical analysts, prominent among whom
was his own daughter, Anna. When Ernest Jones brought Freuds ideas to
England in 1913, he too promoted the value of lay analysts (Jones, 1959/
1990). However, all these practitioners, medical and non-medical alike,
were required to undergo extensive and costly training. Therefore, psychotherapy was inevitably an expensive process and, inevitably, it was largely
restricted to the privileged few who alone had the time or the money to be
neurotic. The poor just got on with life the best they could.
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COUNSELLING & PSYCHOTHERAPY THE OPENING STORY

It seems that, up to the mid-twentieth century at least, psychotherapy was

not for the masses. However, two major insurrections were unfolding,
quietly and slowly at first and then gradually gathering momentum.

INSURRECTION NUMBER ONE THE BEHAVIOURISTS

At the same time that psychodynamic theory was becoming increasingly
accepted as an explanation of human personality and development, some
very important alternative theories were being developed by pioneering psychologists. Two such theories are of significant interest to todays
therapists. Both are concerned with deliberately imposed (or obviously
overt) learning and its effects on human development. In both cases,
human personality is considered to be, at least in part, more or less
dependent on automated or routine reactions. Such theorists argue that
personality is derived from learned, often automatic, responses to stimuli
the trumpet blows; the old soldier holds himself erect!

The behaviourist explanation

The first of the personality comes from learning models is the behaviourist
explanation of human activity, which originated with the work of Pavlov
(1927). Pavlov proposed the concept of the classically conditioned response.
He believed that someones reactions to certain stimuli are first learned
and then become automated. For example, think about how you react
to the smell of your favourite food or the mention of your greatest fear.
The behaviourists would say that your reactive behaviours actually come
from a learned, automatic set of responses. Behaviourism assumed a more
modern, more sophisticated form with Skinner (1971), who proposed that
even very complex behaviours could be learnt and, much more importantly, deliberately changed, by operant or instrumental conditioning. To
illustrate this, think about a child finding out how to talk to some adults.
Suppose the child says something rude but something thats also unintentionally amusing. The adults laugh and the child is pleased and will
probably say the rude word again and then go on to say similarly naughty
words. As long as the adults show their approval by laughing, the child will
carry on. However, as soon as the adults start to disapprove and stop
laughing, the behaviour will slow down and eventually probably stop.
Every time the adults reverse their approval response, the child will reverse
its naughty-to-good behaviours. This type of behaviour/response modification is also known as behaviour shaping. It is interesting to note that,
although the behaviourists usually decried Freuds concept of the unconscious and its impact on personality, in effect behaviourism too relies on
a sort of unconscious, as it depends on the individual being unaware of
the psychologically manipulated influences on personal actions and
thoughts.
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COUNSELLING & PSYCHOTHERAPY THE OPENING STORY

The cognitive explanation

The second of the personality comes from learning models is the cognitive
explanation of human activity. This, in part, originated with the work of
Ellis (1962), who proposed that irrational beliefs interposed themselves
between stimulus and reaction, and Bandura (1977), who proposed that
thinking (cognition) plays an important part in learned behaviour. For
example, Beck (1963, 1964) argued that depression arose in people whose
thinking processes had, in part, become dysfunctional. These, and similar,
developments have culminated in a general viewpoint that considers
emotionally or psychologically dysfunctional people as being the victims
of their own incorrect or negative thinking. However, at base this dysfunctional thinking is learned behaviour. Therefore, a cure will come about if
the sufferers can learn how to correct such unhelpful thinking and to
replace it with more constructive belief systems. However, in this case,
incorrect or negative are not judgemental terms measured against proper
thinking, but merely describe maladaptive thoughts (cognitions) that have
an adverse effect on the patients psychological well-being.
Various therapists have experimented with various combinations of the
overall ranges of the behavioural and cognitive approaches to therapy
(Freeman and Simon, 1989; Persons, 1993, etc.). These usually preplanned
and personalised individual treatment programmes underpin the currently
increasingly popular cognitive-behavioural therapy (CBT) approach to
counselling. CBT is usually a quick therapy, often taking fewer than six sessions (in other words, it is cheap). It is also claimed to have easily identifiable
and very measurable outcomes. Therefore, it has naturally become extremely
popular with healthcare providers both in the UK and in America (McLeod,
2003). CBTs official popularity, at least in the UK National Health Service
(NHS), is now enshrined in official governmental policy (Layard, 2005).
Unsurprisingly, now that the Government plans to invest 170 million in the
provision of CBT, the traditional antipathy that many counsellors have
routinely felt for CBT and its practitioners is rapidly fading away.

INSURRECTION NUMBER TWO THE HUMANISTS

Although the humanist tradition includes many great thinkers (Moreno,
Spinelli, Maslow and Perls, to name but a few), for most modern psychotherapists and counsellors the name that stands above all others is that of Carl
Rogers. Rogerian (or person-centred counselling) was very much the child of
its time. The Rogerian ethic of limitless self-development, together with its
emphasis on respect and freedom for the individual, very much resonated
with the social ethos of the latter half of the twentieth century. It was seen as
a self-liberation therapy for the freedom-conscious, baby-boomer generation.
Person-centred therapy offered a sort of cheaply provided mass-production
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COUNSELLING & PSYCHOTHERAPY THE OPENING STORY

counselling therapy one that was essentially simple to understand and

simple to apply to an increasingly emotionally troubled post-Second World
War population (McLeod, 2003). Expensive psychiatrists or psychoanalysts
were no longer needed. The therapy had another great appeal it was
apparently testable and quantifiable (Gendlin, 1981; Truax and Carkhuff,
1967, among many others). In other words, customers knew what to expect
and what it was likely to cost (essential requirements for any mass-produced
product, from baked beans to luxury cars).
The core of the humanistic approach is based on the notion that the
therapists task is to help patients find their own solutions to their own
problems. It differs from the psychodynamic approach in a number of
significant ways, but the most vital one is this:
The psychodynamicists view their clients current relationships as being
effectively unconsciously driven repetitions of previous events and
reactions to previous experiences. Their clients are relating to the therapists
and to their own worlds as if certain emotional constructs are really true; as
if their memories of previous events are accurate or factual. For example, a
client perceiving the therapist as a disapproving or judgemental figure may
be seeing the therapist as if he resembled a disapproving parent. However,
the therapist is not that parent and so the client/therapist relationship is
UNREAL.
However, the person-centred therapist works with the client on the basis
that both the client and the therapist are real figures who exist in the reality
of the immediate situation. The therapeutic relationship is therefore not
imaginary or as if, but immediate and actually happening in the here and
now. Therefore, the client/therapist relationship is REAL.
Of course, it follows, at least for the Rogerians, that clients are effectively
the true experts on their own inner selves. Therefore, the therapists role
must be respectful and not judgemental or directive, and the therapy must
be client-led. This is because the therapist is trying to enter the clients
world and not trying to coax the troubled client into the psychological
haven of any given therapy schools concept of the psychological ideal. Or
so they tell us.
Person-centred counselling, often claimed to have originated with a speech
given by Rogers to the University of Minnesota in 1940, crystallised into
its modern form during the 1950s and 1960s (see Rogers, 1961, 1980 and
many others). It certainly met the needs, in terms of availability anyway, of
the emotionally troubled members of society in the 1950s, 1960s and
onwards. Person-centred therapy, with its emphasis on promoting the
needs of the individual over the demands of the established society, can
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COUNSELLING & PSYCHOTHERAPY THE OPENING STORY

very much be seen as being dependent on the socio-political era from

which it originated. It clearly echoed the deconstructivist liberation philosophies that permeated the Western world during the latter half of the
twentieth century. This psychotherapeutic child of post-war America was
brought to Britain in the early 1960s (Thorne, 2007), mainly through the
auspices of the National Marriage Guidance Council (now Relate) and
the Facilitator Development Institute (later renamed as Person-Centred
Therapy: Britain). From the 1970s onwards, person-centred therapy became
the primary intervention method taught to most trainee counsellors and
social workers in the UK. If cognitive-behavioural models can be loosely
seen as the psychologists approach to psychotherapy, then humanistic
therapeutic models, including the person-centred approaches, could loosely
be described as the counsellors approach. However, at least in academic
circles and at training college level, humanistic counselling approaches are
beginning to lose some of their primacy (Aldridge and Pollard survey, 2005).

THE THERAPY EXPLOSION A TIME OF CONFUSION

Although it is true to say that the three main models of counselling and
psychotherapy discussed so far (psychodynamic, CBT, person-centred) have
dominated the UK therapy scene, it is also the case that they are far from
being the only styles of therapy available. Todays therapy customers face
an overwhelming choice menu, including gestalt, existential, psychodrama, cognitive-analytic, systems theory, brief intervention, solutionfocused, feminist, transpersonal, narrative, etc. the list appears endless.
Each competing therapy model, or school, has its own fierce defenders
who try to ensure that their own brand of therapy remains purist and
unadulterated by allegedly non-counselling contaminants, such as having pre-set targets or commercial limitations. In fact, although it is not
generally known, probably the most widespread approach to psychotherapy (at least in terms of its total client numbers and worldwide
availability) is to be found in the various 12-step models as practised by
Alcoholics Anonymous and its many spin-offs. This form of mass psychotherapy is likely to be seen by many purists as being so contaminated that
it is often even provided by non-counsellors. This may well be the reason
why the existence of the 12-step approaches is rarely acknowledged in
therapy circles and they are rarely taught and rarely researched, even within
the specialist addictions market. In effect, for many counsellors, 12-step
therapy is an elephant in the room we all know it is there but nobody talks
about it; somehow it is one of our unacknowledged open secrets.
Since the 1960s there has been an explosion in the types and numbers of
therapy models being made available. In 1986, Karasu found over 400
allegedly distinct models and so it is reasonable to assume that, by the end
of the last century, there were probably 450 to 500 or more on the market.
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Doubtless there are even more today. Clearly such a proliferation of personality theories, therapeutic models and treatment delivery systems has
served to create a time of confusion for practitioners and clients. This
confusion is deepened by the enthusiastic evangelism that each counselling
schools adherents exhibit for their own models, the level of which is usually
only matched by the deep antipathy that they express towards all the other
schools.
If, as Evans and Gilbert (2005) suggest, there are almost as many therapy
models as there are practitioners, the therapy trade must answer two vital
questions:
1. What sort of therapy should clients be looking for?
2. What sort of training should student therapists elect to undertake?
Finding sensible answers to these two questions is essential if counselling
in particular wants to emerge as a profession that is taken seriously in
society. What sort of responses can the talking therapies offer?
It would seem to be a commonsensical way forward to simply test out
the various therapies on offer, find out which one is best, and then to
concentrate the professions efforts on promoting therapys latest best buy.
Of course, some practitioners have fundamental objections to the notion
of testing therapies, seeing therapy as an art form that cannot be analysed
against criteria such as effectiveness, usefulness and value for money.
Despite these objections, research into all these areas has long been
undertaken and it is worth spending a little time looking at the specific
history of counselling research because, unsurprisingly, that too is a vital
part of the story of the talking therapies.

THE HISTORY OF COUNSELLING RESEARCH

If counselling is to mature into a socially desirable, politically supported
and academically respected profession, it has to justify itself as being a
worthwhile activity that society should support. There are three core
questions that those advocating counselling as a serious response to a
number of personal and social issues must have ready answers for:
1. Does it work?
2. How does it work?
3. Is it cost-effective and how can we best provide it?
The history of counselling research is essentially the history of attempts to
answer these questions. It can be helpful if we view this narrative as having
evolved over four phases.
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COUNSELLING & PSYCHOTHERAPY THE OPENING STORY

Phase one research 1940s to 1960s

Does counselling work?
Can we measure some worthwhile benefits that the clients have received as
a result of coming to counselling? If we cant identify and quantify such
benefits, why are we offering people psychotherapy? The core question for
the phase one researcher was: Does psychotherapy work?
Eysenck (1952, 1992b) famously claimed that about 65 per cent of all
neurotics who were treated by non-behavioural psychotherapy improved
substantially over a two-year period. The problem for counsellors and
psychotherapists is that he also found that untreated control groups
apparently recovered equally well. This suggests that time was actually the
primary curative factor and not the psychotherapeutic interventions. As
with all psychological research, argument rages over whether or not
Eysencks studies really did show what Eysenck claims they showed.
Eysenck claimed (with apparently good reason) that psychotherapy doesnt
work.
However, many modern-day researchers believe that they have answered
Eysencks devastating attack. More modern researchers (see Lambert, 2004)
have concluded that spontaneous remission rates in Eysencks control
groups were greatly overstated and that his therapy-based recovery rates
were understated. This controversy rages on.

Phase two research 1960s to 1980s

How does counselling and psychotherapy work?
Phase one research was largely characterised by the uniformity myth. This
myth supposed that all the clients treated with a particular therapy would
respond in the same way. In other words, the treatment method was more
important than who delivered it or to whom it was delivered. No attention
was paid to differences in clients or therapists qualities. So, as Paul (1967)
phrased it, the core question for phase two researchers was: What treatment, by whom, is most effective for this individual with that specific
problem, and under which set of circumstances?
Is one kind of counselling more effective than another? The evidence is that
most therapies delivered by most therapists to most clients have similar
outcomes (Lambert, 2004). In a well-known early study, Luborsky et al.
(1975) found no differences between the various therapies in terms of their
outcomes or effectiveness. They famously called this finding the Dodo
Effect Everybody has won and all shall have prizes.
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Phase three research 1980s to date

Is counselling and psychotherapy cost-effective? How can we best provide it?
In todays managerial climate (Inglis, 1989), society usually demands that
these two questions should be answered authoritatively. Put simply, if we
as therapists want society to allocate a share of its limited resources to our
cause, the core question is: Are we are giving value for money?
On the surface, it would appear to be a sensible quantitative approach to
investigating these two questions if we simply measured the effectiveness
of some super-therapies that allegedly integrate the core beneficial qualities of all the apparently useful therapy methods. This has been done largely
on a trial-and-error basis with quantitative researchers measuring change
against baselines see Evans and Gilbert (2005) for a useful review of such
investigations.
Taken overall, these studies suggest that psychological therapies are
generally beneficial (Lambert, 2004). There is also evidence that counselling
by any method, even when provided by means of a limited number of
sessions, is cost-effective (Department of Health, 2001b). However, these
sorts of findings are very much based on bean-counter research into
quantitative changes in behaviour, prescription take-up, sick time and so
on. Studies of long-term versus short-term therapies seem to show that
much of the benefit occurs in the first few sessions. This is usually demonstrated by measuring quantitative behaviour changes, such as reduced
alcohol usage or a lessening of offending behaviour. However, in cases
where clearly the clients have benefited from long-term therapy, it may be
that the change processes are too slowly achieved to be noted by researchers
using quantitative approaches. In such cases, maybe a qualitative investigation might be a better way of finding out whats really going on.

Phase four research current and future

What sort of help should be provided for the emotionally troubled?
This asks counsellors and psychotherapists two questions:
1. Does modern thinking still agree that counselling and psychotherapy
work?
2. Is counselling and psychotherapy superior to other forms of
treatment, such as general practitioner (GP) care or psychiatric
medication?
Modern studies, such as Stiles et al. (2007), still routinely find that there are
no significant outcome differences that can be found between any of the
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models of psychotherapy. However, another consistent finding is that

psychotherapy is routinely helpful and effective (Wampold, 2001). This has
led to researchers asking a third important question:
3. Can we find a way of treating the emotionally troubled that is cheaper
than psychotherapy?
There seem to be two general findings in this area. First, when compared
to other forms of treatment such as the medical help on offer from GPs,
psychotherapy and medical interventions appear to be equally effective
over the long term (Stiles et al., 2007), although it might be that psychotherapy is more effective in the short term (Ward et al., 2008). Whether
medical treatment is cheaper is an open question, although of course some
patients might find taking pills more convenient than attending psychotherapy sessions. It is worth noting, by the way, that the routine guidelines
issued by all the drug companies in respect of their antidepressant and antianxiety medications nearly always recommend that patients using their
drugs should also be undergoing some form of psychotherapy. So, it seems
even those with a vested interest in promoting the medical model of
emotional dysfunction prefer pills + talk to pills alone.
When comparative therapy studies are carried out, anyone overviewing the
literature will see that CBT is often included as one of the therapy models
being evaluated. The fact is that, although CBT is usually shown as being
very useful, it is also routinely shown as being no more effective than any
other form of therapy. CBT is not a super-therapy. One advantage that it
does have is that it is a rapid form of treatment and so it is very appealing
to the patient. Furthermore, it is allegedly easy to train people to deliver
CBT (they dont even need to be first trained as psychotherapists). In other
words, CBT is cheap.

WORKPLACE COUNSELLING ANOTHER OPEN SECRET

Rather like 12-step addictions counselling, workplace counselling is also
one of the therapy worlds open secrets. This may be because, as Kinder
(2005) suggests, many so-called purist counsellors appear to be distrustful of any therapeutic activity that is dependent on commerce and so
they rather suspect that workplace counselling is not proper counselling.
Nevertheless, workplace counselling in the UK is a high-volume therapeutic activity and its pre-registered client base is extensive. Anyone
enrolled on that client base is entitled to demand free help from an
appropriately allocated workplace counsellor. Exactly how many potential
clients are registered and eligible is difficult to gauge accurately due to
commercial sensitivity. However, what is known is that, by the beginning
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of this century, some five million-plus UK employees and their dependants

were entitled to workplace-provided counselling services (Beer, 2003).
Given the usual likely take-up rate of between 2 and 5 per cent of those
entitled (EAPA, 2008), clearly a very large number of workplace counsellors
were needed to service such a potentially immense client demand. It seems
that workplace counselling is yet another of counsellings elephants in the
room lots of counsellors do it but they dont seem to like to talk about it
very much! However, its importance is such that, by the 1990s, some of its
practitioners were arguing that its prevalence was ensuring that the centre
of gravity of the counselling universe is moving inexorably to the
workplace (Reddy, 1993, p47).
Historically, it appears that the roots of modern workplace counselling
provision can be found in the workplace welfare schemes that began to
emerge in the early years of the twentieth century (Coles, 2003; Grange,
2005; Tehrani, 1997). In the UK, workplace welfarism began with the
industrial philanthropists of the eighteenth and nineteenth centuries
(Ward, 2001) and the first UK dedicated industrial welfare workers were
Clara Heath, who was appointed by the Boots Company in 1893, and Mary
Wood, who was appointed by the Rowntree Company in 1896 (Coles,
2003). In parallel, in North America industrial welfarism first emerged
from early twentieth-century attempts to maximise industrial output by
promoting the social welfare of workers in the newly emerging massproduction industries and later to address the ever-present problem of
alcoholism among employees (Steele, 1989). Like psychotherapy generally,
until the mid-twentieth century, workplace psychological services were
largely the province of the psychiatrists. For example, Carroll (1996) tells
us that the Metropolitan Life Insurance Company appointed an industrial
psychiatrist in 1922, as did the RH Lacey Company in 1924. However, an
early forerunner of what today might be recognised as workplace counselling can be found in the setting up of an Employee Welfare Counselling
Service by the Ford Motor Company in 1914 (Carroll, 1996).
Like counselling therapy generally, workplace counselling began to expand
from the 1950s onwards. This was when the person-centred movement
started to sweep through the workplace welfare services at the same time as
it coursed through local authority social services and similar public and
voluntary welfare agencies. The time of the workplace counsellor had
arrived (Reddy, 1997).

The birth of employee assistance agencies

In the UK, employee welfare provisions have evolved from these early
beginnings and spread throughout the world of employment. For the last
20 years or so, much of this welfarism has been provided in the form of
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workplace counselling services (Claringbull, 2006). By the end of the last

century, workplace counsellings UK provision had grown such that up to 75
per cent of medium and large organisations made some sort of counselling
available to their staff (Carroll and Walton, 1997; Oher, 1999). Workplace
counsellings apparently continuing inexorable rise in the UK was further
charted by Coles (2003), and there is good reason to believe that this
explosion in workplace counselling provision is a worldwide phenomenon
(Australian Bureau of Statistics, 2003; EAPA, 2004). Indeed, it seems that in
recent years workplace counsellings growth has been exponential (Hopkins,
2005). By 2006 in the UK, there were at least some six and a half million
employees and their dependants who were provided with psychotherapeutic
counselling services by employee assistance agencies (Claringbull, 2006).

ACTIVITY 1.1
Make a list of the activities that you think proper counsellors should be
involved with.
Make another list of the activities that you think proper counsellors should
avoid.

Modern employee assistance agencies currently try to offer more than

psychotherapeutic assistance to troubled workers (Grange, 2005). As well as
considering workplace counsellings current status, other investigators
(Carroll, 2002; Grange, 2005; Ryan, 1998; Wright, 2001, etc.) have also
speculated about its future status and have discussed the modern workplace counsellors potential to deliver a much wider range of organisationbased psychological interventions than has hitherto generally been the case.
In recent years a number of workplace counselling practitioner-theorists
(Claringbull, 2003, 2004a, 2004b; Cullup, 2005; Jamieson, 2004; Orlans,
2003) have proposed a series of major expansions of the scope and breadth
of the range of the interventions and help programmes that todays modern
workplace counsellor could, and perhaps should, offer their corporate
clients. These include a wide spectrum of psychological interventions (management consultancy, coaching, mentoring, etc.) and organisational assistance programmes (training, stress surveys, awareness enhancement, etc.),
which can combine into a comprehensive package of service provisions
targeted at enhancing overall employee well-being (Carroll, 2002).
Apart from providing extensive employment for therapists, workplace
counselling has also impacted on counselling generally in another important way. Because it is commercially driven, workplace counselling is goal
oriented and it also has to be seen to be financially worthwhile. Companies
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investing in workplace counselling services want a return for their money

they want added value. This means that workplace counselling has, at
base, two powerful drivers. The first is its underlying purpose of helping employees to recover or retain their employability. The second is
that workplace counsellors are required to work within finite financial
boundaries. The effect of these two forces has been to ensure that workplace
counselling is, by necessity:
solution-focused and goal-oriented;
time-limited usually to some four, five or six sessions.
For many purist counsellors and psychotherapists, the tendency for
workplace counselling to be solution focused and time-limited supports
their belief that, rather than being another arm of psychotherapy, workplace counselling actually conflicts with the supposedly traditional,
non-directional, counselling values. This may be why Kinder suggested that
workplace counselling is often unacknowledged by the counselling community generally because they do not see it as being proper, mainstream
counselling (Kinder, 2005). It may be different, but is it still counselling?
The debate continues. Table 1.2 below explores some possible differences
between mainstream and workplace counselling.

Traditional counselling

Workplace counselling

Client-led

Multiple leaders (client, counsellor,

employer)

Seeks to explore/correct personality

Seeks to explore/correct behaviour

Has undefined aims and goals

Has specific outcome targets

Benefits clients

Benefits clients and other interested

parties

A core client activity

Only part of the clients life

Model-based

Whatever works, works

Table 1.2: Traditional vs. workplace counselling.

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TODAYS COUNSELLING REVOLUTION THE INTEGRATIVE

MOVEMENT
Historically, traditional therapists have associated themselves with the
various individual models of therapy (psychodynamic, humanistic, etc.) and
so have tended to remain purist adherents of their various counselling and psychotherapy schools. However, these allegiances are breaking
down, some say already broken, as the evidence mounts that client cure
rates are consistent across the schools and that it is unlikely that any
particular therapy model is better than its rivals (Elliot et al., 2008; Stiles
et al., 2006; Ward et al., 2008). It is also becoming increasingly clear that the
who of the therapist is just as important (possibly even more important)
as the how of the therapeutic methodology that is being employed (Blow
et al., 2007; Project MATCH, 1997). These developments have underpinned
the emergence of integrative approaches to counselling therapy.
In fact, modern integrationalism is not really so very modern. French was
writing about the claimed therapeutic commonalities between behaviourism and psychoanalysis in 1933, as was Rosenzweig in 1936. In 1950,
Dollard and Miller published an innovative attempt to bring together the
then known psychotherapies. Collectively these, and many other writers,
were starting to explore the idea of a common factors approach to psychotherapy. This is the idea that certain therapeutic factors are common to all
therapeutic treatments and so can be identified in all psychotherapeutic
approaches. Therefore, by isolating these commonalities and by focusing
on providing them, therapists could maximise the help that they can give
their clients. Nevertheless, probably up to the 1990s, single-therapy allegiances remained rife throughout counselling and psychotherapy and they
are far from dead today.

The end of the schoolist approach?

However, the schoolist approach to counselling, prevalent in much of the
last century, was not to remain supreme. By the latter part of the twentieth
century a revolution was already quietly under way. For example, Wolfe and
Goldfried (1988) continued to explore the common factors approach;
Wachtel (1977) began to propose theoretical methods of combining, or
integrating, the therapeutic theories; and Bordin (1979) started to wonder
if the quality of the clientcounsellor relationship was of more importance
in terms of therapeutic outcomes than the supposed benefits of the
particular therapy model being employed. In 1975, Egan published the first
of his still extremely popular Skilled Helper series, which emphasise the need
to assess clients purposes in engaging in counselling encounters and then
go on to prioritise the systemic ways in which counsellors might help their
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clients to achieve these purposes. In 1986, Norcross published his Handbook

of Eclectic Therapy, which by 1992 (in collaboration with Goldfried) had
become the Handbook of Psychotherapy Integration. By 1983, the Society for
the Exploration of Psychotherapy Integration had been established and
today attracts many internationally respected and well-known counsellors,
psychologists and psychotherapists. The age of the integrative counselling
therapist had arrived.

Integrated therapy today

So what is integrative therapys position among todays therapeutic
practitioners and just what is it anyway? Well, it is now the case that
integrative counselling is increasingly becoming the dominant model and
this is demonstrated by noting that, by 2008, it was being taught on over
half of the British Association for Counselling & Psychotherapys accredited
training programmes. However, currently the only real answer to the
second part of the above question what is integrative therapy? is that
there is no answer. What are its most important factors? Is it therapeutic
technique or the person of the therapist that is the dominant agent? As
Barkham (2007) has remarked, it all depends on who you ask!
The integrationists are, of course, trying to find an overarching model of
psychotherapy one that forms a comprehensive umbrella for a theoretical
framework within which all the other therapeutic approaches can be found
a place. Currently, there are a number of integrative models of counselling
therapy that might prove to be useful steps along the road to the ideal of
psychotherapeutic unity. These include the Cognitive-analytic Theory
(Ryle, 1990), the Five Relationships Model (Clarkson, 1995, 2003) and the
Relational-developmental Model (Evans and Gilbert, 2005). These models
are further explored in Chapter 6.
It is probably true to say that, at the end of the day, adopting an integrative
approach to counselling is far more than learning a set of overarching
theories or acquiring techniques for maximising the potential benefits of
the various aspects of the clientcounsellor relationship. As Hollanders
(2000b) puts it:
integrative goes hand in hand with a philosophy of life and work that is
truly pluralistic in its vision.
He goes on to say that it:
means being committed to the whole project of therapy rather than to a
particular approach.
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In other words, in its ideal, it is quite likely that integrative therapy is just
that which each experienced counsellor makes it to be. It is about finding
ways that fit the needs of any particular client at any particular time. It is
even possible that integrative counselling might eventually prove to be
model free.

TOMORROWS COUNSELLING REVOLUTION

As we have already noted, for all talking therapists, times, they are achanging. Statutory regulation of the counselling and psychotherapy
profession seems inevitable and probably due by 2011 or 2012 (Clarke,
2008; Pointon, 2008). In addition, the Governments significant investments in the NHS Improving Access to Psychological Therapies initiative are
likely to accelerate the conquest of the therapeutic world by evidence-based
practice. Therapists outdated single-school allegiances are dying out. As we
know, modern research increasingly tells us that no particular therapy
model works faster, better or cheaper than any other (Elliot et al., 2008;
Stiles et al., 2007, 2008). The impacts of these powerful mega-drivers seem
certain to fuel an unstoppable revolution in the counselling and psychotherapy profession and an inescapable transformation in the educational
needs of its practitioners.

Degree-based counselling
One major revolutionary change, and one that is almost certain, is likely to
be the evolution of counselling into a degree-based profession. The British
Association for Counselling & Psychotherapy (BACP) anticipated this
inevitability and so established a Core Curriculum Consortium to explore
what this change will mean for the future of counsellor education. The
Consortiums 2007 draft report stated:
inspection of the generic core competencies indicates . . . counsellors . . .
need to study to at least at Honours level . . . Need . . . an understanding
of a complex body of knowledge . . . analytic techniques and problemsolving . . . [Need to be] able to evaluate evidence, arguments and
assumptions . . . reach sound judgments.
So, will tomorrows entry-level counsellors eventually need generic counselling degrees?
Such proposals, mainly concentrated on counsellor-training quality assurance issues, have been made before and they certainly have attracted
screams of anguish from some sectors of the counselling community.
Spirited defences of the anti-formal training viewpoint can be found, for
example, in the online Ipnosis journal (Postle, 19992008). There is a
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powerful lobby within the counselling profession (e.g. Musgrave, 2007 and
many others) that has grave doubts about the feasibility of teaching
counselling in any sort of an objective or measurable sense. A quick perusal
of the Readers Letters pages of such professional magazines as Therapy Today,
or attendance at any of the counselling conferences and seminars, will
provide many instances of such viewpoints being powerfully put forward.
Counselling is a highly individualised, personal and special activity, the antieducators claim, and so they say that it is a way-of-being to be acquired or
assimilated; it is not a measurable set of skills that can be adapted to meet
measurable targets. The basic counter-argument to such a purist viewpoint
is to note that, whether or not such noble ideas are actually tenable, this is
just not how the world works. Todays taxpayers and investors want value
for their money. Counsellings clients, too, need to know if their personal
investments in counselling (time and/or fees) are likely to pay off. It seems
that sometimes counsellors forget that clients always have the choice of
alternative strategies for resolving their problems. For example, depression
might be tackled by medication; anxiety might be relieved by meditation.
Should clients with relationship difficulties go to couples therapy or visit an
Ann Summers outlet? At the end of the day, clients are consumers and, if
counsellors and psychotherapists do not provide them with what they want,
they will simply go to the shop next door.

Choosing the best therapy

Clients have yet another major difficulty in trying to decide if counselling and psychotherapy is likely to offer a best buy way of resolving their
problems. This arises from their difficulties in choosing between the
multiplicity of therapy types, methods and modalities currently on offer.
A quick glance at any local Yellow Pages will confirm the confusing
cornucopia of practitioners and practices vying for custom. Browne (2008)
tellingly describes the trials and tribulations of five typical clients who
were simply trying to find a therapist who fitted their needs. After all, if
therapists themselves cannot decide which is the best therapy, how on
earth can their customers make informed choices? Therapy is a curious
profession. First, its practitioners dont have to be qualified and it is
arguable that this fact, if widely known, would shock a public that is
accustomed to its high-level professionals having degrees. Second, it is the
only profession wherein its trainees select their career path specialities
before they start training. They often need to choose between humanistic,
person-centred, psychodynamic, relationship therapy, group work or any
other specialist area of practice before they can possibly know enough about
counselling to be able to make anything like informed career choices. All
the other professions teach a basic generic form of their discipline at
undergraduate level to begin with. They then require extensive hands-on
supervised practical training before the first-level practitioner qualifications
are awarded. Postgraduate-level specialist training programmes follow after.
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It is a tried and tested training method; why should counselling training

be any different?

The demographics of the therapy trade

If counselling does eventually become a degree-based profession, apart from
such a developments huge impact on the training needs of counsellors,
there is also likely to be a seismic change in the demographic of the therapy
trade. Currently, counselling is almost exclusively entered by very committed mature students who want to train on a part-time basis. Indeed,
many training courses set a minimum age of 30 years for their recruits.
However, the economics of higher education (HE) in the UK favour fulltime undergraduates who usually come from sixth forms or further
education (FE) colleges. This demand generates undergraduates who are
mainly 1821 years old and who may, or may not, be committed to their
particular fields of study. Todays typical counsellor is probably female, 40
and fully committed. Tomorrows counsellor might well be metro-sexual,
maturity-light and multipurposed another therapeutic revolution?

REFLECTION POINT
Can counselling be taught or is it an attitude to life?
Do counsellors need degrees?
Can young people be effective counsellors for the entire client age range?

CONCLUSION
Counselling and psychotherapy have come a long way over the last 100
years. Counselling started to separate out as an emotional healthenhancement discipline before the First World War with the inclusion of
an early form of counselling into industrial welfarism. Dependent initially
on psychiatry and the psychoanalytic approaches to psychotherapy,
counselling later began to have a major impact on society as it gradually
absorbed the thinking of the humanistic and behavioural psychologists
into its practices. Over the years, therapys theoretical and treatment bases
have changed a great deal from the twentieth-century models that were
(and to a certain extent still are) rigidly dependent on the traditional,
single-school approaches to counselling and psychotherapy. Modern
theorists are exploring how far the integrative paradigm models might help
them to suggest some possible unifying general theories of counselling and
psychotherapy that might better underpin the therapy trade. It seems that
the talking therapies can now claim to be independent, academically
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sound, evidence-based, professional practice one with its own defined

specialist subject area and its own independent discourse. These developments, together with current Government policies, are likely to establish
counselling and psychotherapy as a core profession (or professions) within
the provision of emotional healthcare services in the public domain.
An important outcome of these events has been to cause the therapy
profession to start to reconsider how it should train its practitioners. Given
the widely accepted public expectation that HE plays an essential role in
professional practices, it seems that the argument that counselling is likely
to evolve over time into being a degree-based profession is indeed a very
supportable one. However, in this uncertain, and ever-changing, counselling world, one thing at least seems certain. The typical counsellors and
psychotherapists of tomorrow will be a very different breed from the typical
counsellors and psychotherapists of today.

ACTIVITY 1.2
What sort of a therapist do you want to be?
Make a list of the qualities and knowledge levels to which you would like to
aspire.

SUGGESTED FURTHER READING

Dryden, W (2007) Drydens Handbook of Individual Therapy, 5th edition.
London: Sage.
Very readable and set out in convenient bite-sized chunks. Super chapter
on research methodolgy.
McLeod, J (2003) An Introduction to Counselling, 3rd edition. Maidenhead:
Open University Press.
If you only ever buy one counselling book, buy this one. Essential reading;
comprehensive and set out in an easy-to-follow format. Chapter 1,
Introduction to Counselling, is an excellent point from which to begin
your learning. Its all you need to know.
Woolfe, R, Dryden, W and Strawbridge, S (2003) Handbook of Counselling
Psychology, 2nd edition. London: Sage.
An excellent source book, although perhaps of more interest to those with
a psychology background. Part 5, Different Contexts, helpfully tells you a
lot about various aspects of clinical practice.

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part 2
WHAT DO THERAPISTS DO?

INTRODUCTION

INTRODUCTION
The talking therapies sometimes seem to be rather a funny old game, not
least because often it seems that its practitioners do not do or say anything
very much apart from throwing in the occasional mmmm or I see. Well,
at least that is how it might appear to anyone from outside any of the
psychotherapeutic professions who happened to sneak a peek into a
therapy session. After all, most counsellors and psychotherapists do not
usually do anything to their clients, not at least in any active meaning of
the word (Nelson-Jones, 2008; Sanders, 2002 and many others). They do
not generally give their clients any imposed treatments; they do not often
counsel them in the sense of giving specific advice; they certainly do not
try to take control of their clients lives. Even in the case of the cognitivebehavioural therapists, although they undertake active treatment planning
and management, it is still the client who has to do the work. The usual
thing in most treatment situations is for the therapist to respond to, or work
with, whatever it is that the client brings into the therapy session, rather
than to actively lead or direct the therapeutic process. In other words, on
the surface at least, therapy looks like quite a passive sort of a job and not
one that seems to demand much effort from its workforce. Perhaps this is
a more widespread view than we realise. As one counselling teacher I know
once told her colleagues:
Ill never forget interviewing an applicant for a training place at
my college. Why do you want to be a counsellor? I asked her.
Well, she replied, its a sitting-down job.
Of course, some therapists might claim that actually they are quite active.
For example, counsellors and psychotherapists working with traumatised
clients or substance misusers might sometimes decide to be quite directive
or purposeful. Others, for example many cognitive-behavioural therapists,
would certainly claim to be active in the sense that they assess and diagnose
their clients, and then suggest experimenting with ways to try to resolve
some of their problems. Nevertheless, it remains arguable that, even with
these apparently more action-based psychotherapies, therapy might still
be considered to be more of a passive activity than an active one. After all,
even with the active therapies, the therapeutic task is often really more one
of helping clients to discover for themselves what sorts of new and
advantageous ways of being they might want to adopt. It is not usually the
therapists job to actively direct clients towards allegedly beneficial,
officially therapist approved, lifestyles.
Yet other practitioners might suggest that therapy is at least an active (or
perhaps an activist) profession in the socially aware sense, because they
believe that it inevitably encourages certain attitudes to life, such as
supposedly being non-judgemental and anti-authoritarian. It has even been
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suggested, on the one hand, that counsellors and psychotherapists are

inevitably active agents for serious social change (Bennett, 2005), and some
therapists (feminist practitioners, for instance) might well sympathise with
such an argument. On the other hand, some might claim that the therapy
trade is very much the non-action-dependent sector of the so-called
caring professions. So, if the talking therapies really are such a funny old
game, and their practitioners do not seem to have to do anything very
much, it seems reasonable to wonder why training programmes are so
extensive and demanding. Would therapists perhaps be better employed if
they just got on with doing something useful, such as emotionally repairing
their clients?

Repairing people
Actually, many counsellors and psychotherapists, from all sorts of
backgrounds, would object strongly to the idea that therapists ought to
repair people. They would argue that it is wrong to assume that, as
psychological counsellors, we know best about how people ought to be;
about how people ought to live their lives; about how peoples lives should
be mended. Indeed, it is likely that most therapists would passionately
declare that it is the clients exclusive privilege to choose the directions
that they want their therapeutic experiences to take. Practitioners such as
these (probably the majority of the profession) might well argue that
psychotherapists and counsellors cannot repair their clients because, quite
simply, they were not broken in the first place. Instead, rather than
describing psychotherapy as being a form of people-repair, many of todays
practitioners (again probably a majority) would most likely describe it as
being an emotional development process that is somehow centred on the
clients personal explorations of their own inner selves. This means that,
for many practitioners, counselling and psychotherapy is essentially a
client-led process. For them, it should not be therapist led; indeed, it must
not be therapist led. Choice, they say, is a matter for clients; it is not a
matter for their therapists. These sorts of apparently non-directional, nonjudgemental views are held by very many practising counsellors and
psychotherapists.
However, it is worth spending a moment to consider if, in fact, what
therapists claim (and probably genuinely believe) is the proper purpose and
value of therapy actually matches the realities of the consulting room. This
is because it is arguable that, when a therapist subscribes to a particular
model of therapy, then that practitioner is, in effect, also subscribing to
some specific ideas about how people develop emotionally over the years.
If this is the case, whether or not counsellors and psychotherapists are
aware of so doing, by adopting a particular therapy model they are also
implicitly giving their support to certain associated beliefs about how
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peoples psychological beings ought to grow, about how they do grow, and
about how this process might go wrong. This inevitably leads to therapists
having ideas (acknowledged or not) about ways in which troubled people
can be helped to become untroubled. In other words, the term counselling
and psychotherapy, as practised, implicitly contains the concept that
therapists have some notions about how to assist their troubled clients to
put things right in their lives. All this strongly suggests that even the most
ardently non-directional practitioners are inherently a lot more directional,
and a lot more dominated by psychological theory, than they either realise
or than they would be prepared to admit.

How do we repair people?

Although many practitioners would disagree, it seems to be potentially
arguable that, whether or not it is their overt or covert intention, therapists
are actually (at least in part) engaged in people-repair. If this is so, it seems
reasonable to propose that, before we can put something right, we need to
know how it went wrong and (if possible) how it ought to have worked in
the first place. Of course, this same pragmatic rule can apply to any of lifes
mishaps. After all, it does not seem very likely that you could mend
anything at all (your lawnmower, your car, your relationship, your life)
until you find out how it came to be broken in the first place. This general,
diagnose first/repair second principle is equally true for counselling and
psychotherapy. As therapist-repairers, we too need to find out what has
gone wrong, only in our case we want to know what it is that has gone
wrong for our clients. In order to do this, we need to know something about
what sort of a person it is that our client has now become and how they
came to be that person. We then need to compare what they are to what
sort of person our client could have been, might have been, or might want
to be.
All this suggests that we might feel a bit more confident in our therapeutic
work if we could achieve an understanding of how it is that people become
people. In other words, we need to find out what it is that makes someone tick. These are really all questions about how it is that someones
personality develops, how someones personality ought to develop, and
how that development can become distorted. If we can answer those
questions, perhaps we can find out how to repair a wrong personality. At
this point we also need to remember that self-reflection is also an important
part of any therapists everyday professional practice. Therefore, as we
wonder about how our clients became who they are, we are also making
some guesses about how we too became who we are.
This means that, in order to be able to at least make a start helping their
clients (and evaluating themselves), it seems clear that:
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Counsellors and psychotherapists need to understand people.

Or to put it another way:
Counsellors and psychotherapists need to understand personality.
Of course, finding out about what makes someone tick (what personality
is and how it grows) is only the first part of the puzzle. Working out the
specifics of what it is that makes a particular client tick is only the
assessment (diagnosis) part of the therapists task. The second part, possibly
the major part of the task, is deciding what to do about what has been
found. What sort of therapeutic methods will we choose to use? What were
the alternatives and why have we rejected them? In order to be able make
sensible choices about treatment methods, it is clearly necessary that:
Counsellors and psychotherapists need to know the people
theories (personality theories) that underpin the various
treatment styles.
The essential point being made here is that practitioners who provide
therapy without appreciating the supporting theoretical backgrounds are,
in effect, fighting with one hand tied behind their backs. That is why all
counsellors and psychotherapists would find it very illuminating to ask
themselves:
What makes people tick? (What is personality?)
Our answers to this question lead on to an even more difficult, but absolutely
vital, question:
When we know what makes people tick, what are we going to do
about it? (What sort of psychotherapy should we offer them?)

REFLECTION POINT
If counsellors do not repair people, what exactly do they do?
Is it always wrong for counsellors to know better than their clients?
Think about one of the therapy models. Can you justify it without referring back
to an underlying theory about what makes people tick?

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Chap ter 2

Repairing people the tales begin

CORE KNOWLEDGE
Counsellors and psychotherapists will be better practitioners if they know
something about:
what personality is;
how personalities develop.
For many practitioners:
counselling and psychotherapy is about change;
counselling and psychotherapy is about choice.
Much of counselling and psychotherapy theory and practice is based on the
psychodynamic, behaviourist and humanistic explanations of how people
become the various sorts of individuals we all are. Modern theories include
the biological, social and genetic explanations of personality development.
Put simply, therapists who want to work with people, who want to try to
help people, need to understand people.

UNDERSTANDING PEOPLE
This story begins with an assumption. Just for now, let us assume that
counsellors and psychotherapists do try to find ways to either repair their
clients or at least help their clients to become their own do-it-yourself
therapists. So, if we feel that something is emotionally or psychologically
wrong with our inner beings (our core personalities), the implication is
that somehow or other there is, or at least in theory there ought to be, an
emotional or psychological right. Clearly, if our personalities do not seem
to be working properly, if they are not right, we want to know if we can
do something about it. Can we mend our defective emotions, put right
incorrect thinking, change our bad behaviours and eliminate our uncomfortable feelings?

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It would be great if we could find an official blueprint that tells us what

sorts of people humans ought to be. Then we could compare the supposed
ideal person with what they actually are. If we could use such a blueprint
to identify any mismatches, we might be able to find out where it is that
we are psychologically broken. Then we could decide on a treatment plan
(select a psychotherapy method?) and we could try to help our clients put
things right. Just as medical doctors and their patients look for physical
cures, so too might counsellors look for emotional cures.
Although there are no officially agreed people blueprints, as psychological
therapists we do need to try to understand what it is that makes our clients
tick. If we do not know that, how can we help them? Sensible therapists will
also want to know what it is that makes themselves tick, too. Therefore, as
practitioners, or indeed as clients, we need to understand ourselves as
people. If we can begin to answer these questions, and especially if we are
not particularly content with what we have found, we really need to find
an answer to the obvious follow-on question, which is: What sort of person
do I want to be? Put another way, we need to understand what our
personalities are and how they developed. In order to explore these sorts of
issues properly we need:
some ideas about what personality is;
some ideas about how personalities develop.
From a therapeutic point of view, having an understanding of human
personality and how it develops is a vital first step in deciding what sort of
treatment method might be the most helpful in any particular case. Clearly,
in practical terms, the way in which you set out to repair something must
depend on your ideas about what has gone wrong. Obviously, a mechanic
has to find out what is wrong with an engine before deciding which
spanners to use to repair it. Similarly, a psychotherapist also needs to find
out what has gone wrong with the psychological engine (someones personality) before choosing the therapeutic spanner (counselling approach)
needed to put things right. Therapists choices about which psychotherapeutic tools to use will depend on their ideas about what human
personality is and what it could be or should be. The problem is that there
are many competing theories about personality and personality development. Which one should therapists choose? What if their choice is wrong?
After all, if counsellors and psychotherapists are wrong in their theories
about how personality develops, it is possible that they are also wrong in
their ideas about how to carry out effective counselling. Clearly, if they are
wrong about what is amiss with the psychological engine, they might
choose the wrong therapeutic repair tools.

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ACTIVITY 2.1
Make some notes about what sort of person you are right now and what sort of
person you would like to become.
Think about some people you know and select just one word to describe each
of them.

WHAT IF WE MISUNDERSTAND PEOPLE?

It is arguable that the various counselling and psychotherapeutic
approaches currently available have all arisen, at least in part, from the
personality theories with which they are associated. Therefore, it is likely
that mistaken ideas about the psychology of personality development will
lead to mistaken ideas about counselling and psychotherapy theory. This
means that there are many ways in which practitioners could make some
fundamental mistakes when they opt for any particular treatment style.
What if their treatment choices actually turn out to be dependent on some
false premises? Would such mistaken therapists be delivering inappropriate,
even harmful, therapeutic inputs? The following are some examples.

A psychodynamic error?
Generally speaking, the psychodynamic theory rests on the idea that
personality develops and exists as an unconscious process. Suppose we
could prove that the concept of a core unconscious is false. Where would
that leave those adherents of the various psychodynamic schools of
counselling who depend on identifying unrealised human emotional
exchanges? Would their work no longer have any therapeutic value?

Case study 2.1

Georgina was seeing Herbert, her psychodynamic therapist, because she had
been having some embarrassing memory lapses. She was forgetting certain
peoples names and forgetting some of her important professional appointments
with those same people. Herbert wondered if Georginas forgetfulness might be
to do with her admitted reluctance to involve herself with certain organisations
and their activities. They are all fusspot, cranky outfits, staffed by fuddy-duddies,
she told him. I leave all that sort of thing up to my father!
Herbert decided that Georginas forgetfulness was actually an unconsciously
held psychologically defensive position. He believed that unresolved and

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unconsciously held feelings about her father meant that Georgina was avoiding
reminders of him by avoiding (forgetting) about fuddy-duddy people. They
worked together on that premise for several sessions and got absolutely nowhere.
Eventually, Georginas GP referred her to a psychologist. The psychologist
explained that recent research-based discoveries had shown that there was no such
thing as the unconscious, but that memory simply existed at several levels, and in
different parts, of the brain. It also was the case that sometimes memories held at
the deepest level were hard to access and that such a process was regulated by
how the brain was hardwired. The areas of the brain where memory was stored
had been identified and so the idea that humans had an unconscious was now
redundant. In cases like Georginas, it was usually found that minor faults in the
brains hardwiring had developed over the years and that these could interfere with
memory access. He simply taught her some psychological tricks for repairing
these faults and making accessing deep memories much easier. Georgina practised
her brain-mending techniques and her forgetfulness problem disappeared.

A biological mistake?
Suppose that another of the major personality theories (for instance, the
idea that personality is derived from a mainly genetically driven process) is
found to be correct. Where would that leave any cognitive therapists whose
therapeutic practices depend on the concept that maladaptive behaviour
can be changed through learning new ways of thinking? If, for arguments
sake, we also assume that learning cannot overcome genetic biochemistry,
would the cognitive therapies now become invalid?

Case study 2.2

Elisabeth presented as a very depressed person. She always appeared to be in a
low mood and she always seemed to be certain that failure and disaster were her
lot in life. Elisabeth was one of natures pessimists. She was certainly a glass half
empty sort of a person.
Her poor levels of self-appreciation and her belief that she could never
succeed had led Elisabeth into having an extremely poor degree of self-care,
almost at a slow-suicide level. This worried her GP, who sent Elisabeth to see Jim,
who is a cognitive-behavioural therapist. Jim concluded that Elisabeths problems
were all due to her having some very negative core beliefs about herself. Jim
suggested that perhaps these negative core beliefs were causing Elisabeth
constantly to generate negative automatic thoughts about everything that
occurred in her life. For a number of weeks, Jim worked at helping Elisabeth to set

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up some personal psychological experiments that were designed to challenge her

apparently ingrained negative views of herself. There were no improvements.
Later that same year, Elisabeth volunteered to be a subject in some genetic
research that was taking place at her local hospital. The researchers found that
there is a specific personality gene, which, if absent or turned off, causes some
people to have negative self-perceptions. It turned out that in Elisabeths case that
gene was switched off. Nothing could be done to switch it back on. Elisabeth
could no more be reprogrammed to be happy than she could be reprogrammed
to have her natural hair colour change from ginger to brunette. No form of
psychotherapy was going to help Elisabeth to cheer up.

Humanists go wrong?
Let us suppose, as some would argue, that the very idea that there might be
correct, or even ideal, personality templates is actually a sort of antitherapy theory. After all, very many counsellors and psychotherapists,
especially those from humanistic backgrounds, would claim that it is
essential to be non-judgemental. Person-centred therapists would certainly
argue that people are what they are and there is no specific right or wrong
way to be. Suppose, however, that we discover that some approved
personality templates actually exist. Would this mean that judging our
clients would move from being a counselling sin to being a counselling
necessity?

Case study 2.3

Leah had always been very much a client-led therapist. She never pointed her
clients towards any particular form of emotional health. Trained in the 1970s
never to judge people, Leah had not forgotten a much respected trainer telling
her that there was never any point in asking her clients any questions. All youll
get are answers, she was told and, going with the spirit of the times, these
seemed to be very wise words indeed to Leah. Over the years, Leah had become
very averse to judging her clients or to telling them what to do. Even just thinking
about it made her very uncomfortable. As with many of her colleagues, Leah
never came to any conclusions about the effectiveness of her work. Doing so was
just not her business. It isnt proper counselling, she always said.
Last year, in order to increase her income, Leah started to take referrals from
an employee counselling agency. They required her to complete case progress
and case outcome questionnaires for each client. Leah was amazed to find that a
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questions and the answers did matter. This breakthrough led Leah to go on to
discover that there were many assessment procedures that could be used to
measure a clients personality on a pre- and post-counselling basis. It seemed that,
actually, there were rights and wrongs about successful outcomes and about
productive ways to counsel clients.

PERSONALITY THEORY AND THE TALKING THERAPIES

On the one hand, it might be that the whole idea that an approved
personality template actually exists is wrong. If this is so, we have an even
more fundamental problem than that of deciding which treatment method
to choose. After all, should it be that there are no such ideal people
templates, perhaps nothing in human personality can be judged to have
gone wrong and so no repairs are necessary If it aint broke, dont fix it!.
If this is so, perhaps there is no need for any psychological fixers and so
maybe human society does not need psychotherapists. A sobering thought.
However, on the other hand, there are the schools of thought that champion
their own ideas about what makes a proper personality template. They
know what has gone wrong and so they know what repairs to make they
hope. They know that their adopted psychotherapeutic approach is the
right one again, they hope. Unfortunately, many therapists acquire their
allegiance to a particular school of therapy before they learn anything much
about personality theory. In any case, counsellors and psychotherapists are
not usually concerned with people as a whole or with the broad sweep of
ideas about personality development. They are usually only interested in the
problems facing individuals or small groups of individuals. So, usually, they
just want to focus on what makes specific individuals into the sorts of people
they are. Nevertheless, even in specific cases, therapists are still asking:
Whats my client like? What sort of a person am I trying to help? In other
words, thinking about personality is an inevitable part of the psychotherapeutic process, whether or not the therapist acknowledges that this is
so. Overtly or covertly, directly or indirectly, personality theory is an implicit
factor, even an inherent one, in all therapeutic relationships.

REFLECTION POINT

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Are there emotionally incorrect people what, if anything, is good about them?
Are there emotionally correct people what, if anything, is bad about them?
Should counsellors repair troubled people?
Can counsellors repair damaged people?

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Later in this book, we will be looking at the various ways in which

psychotherapy is delivered. In order to do this we will first explore the
particular personality theories behind each treatment approach and then
we will consider how these psychological parents have impacted on their
therapeutic children. In other words, as well as asking what it is that makes
people tick, we will also be asking what this tells us about therapy. We will
be asking what therapy is really like what is it all about?

WHAT IS THERAPY?
As we have already noted, to the casual observer counselling and psychotherapy might indeed seem to be very much a passive, not doing very much
at all, sort of profession. After all, the clients do all the talking and the
therapists just do the listening quite an easy sort of job really. However, is
this really the case?
Is therapy really an easy job?
Easy or not, what do therapists actually do?
If we think about it, we soon realise that there are many different ways of
answering these questions and the answers usually depend on what sort of
help it is that clients are looking for and on the professional backgrounds
of the sorts of therapists that we are thinking about.

The Is therapy really an easy job? question

The Is therapy really an easy job? question is actually quite a complex one
to answer. It is, of course, true that some clients are apparently easier to deal
with than others. Not that it always seems so at the time. Like many
practitioners, I will never forget my first ever client, although in her
particular case I have never solved the easy or difficult issue. When you
have read about Mrs Harris in Case study 2.4, why not take a break and
spend a little time considering the Reflection Point which follows? You
might find it interesting to think about what your own answers are to the
easy or difficult job? debate.

Case study 2.4

I was still in training, but I had reached the stage when they were at last actually
going to let me begin work with one or two real clients. So there I was, sitting in
a real counselling room for the first time and waiting for my first ever client. I was
desperately hoping that I would be able to remember enough of what I had been
taught so far.

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Mrs Harris burst into the counselling room she did not just enter the room,
she invaded it, she conquered it, she took it over. She was a lady well into her
middle years; she was what used to be called of a certain age. She was certainly
a larger-than-life character, both in her person and in her being. With her ample
proportions crammed into an uncompromisingly belted gabardine raincoat, her
shapeless hat almost nailed to her head, and with a huge, dauntingly black,
handbag held before her like a battering ram, Mrs Harris plumped herself down
into her chair in a manner that can only be described as taking royal possession.
I was barely able to stammer out hello before she started talking. She never
stopped talking. Mrs Harris began by saying that she had never been to see a
counsellor before, that she did not know what I was expecting of her, and anyway
she just knew that she would not be able to say anything much as she had always
had difficulty in talking about herself. She was not one to put herself forward, she
said, and people were always telling her that she was too quiet for her own good.
Searching my mind for a suitably counsellor-ish response, and trying to fight
down my sense of impending disaster, I tried to offer some sort of an appropriate
comment. My attempts to speak were about as effective as a fly trying to punch
an elephant. Mrs Harris bombarded me into silence with a barrage of sound and
I remained pinned to my chair for the next hour. Coward that I was, I soon found
myself taking the path of least resistance; I did not really have any other choice
and I soon gave up any plans to do or say anything. The truth is that I had no idea
what to do anyway and all my training had flown out of the window. What did
Mrs Harris have to say? The reality is that I had little idea at the time and even less
idea afterwards. When she decided that the session was finished, Mrs Harris
gathered up herself and her belongings and emerged from her chair. Her parting
comment was, you are clever, I feel so much better now; how ever did you
manage to sort me out?. She left the field a triumphant verbal warrior, still talking
even as she progressed down the corridor, leaving behind a very dazed, very
bewildered counsellor and a suddenly very empty counselling room. I never saw
her again.

REFLECTION POINT
How would you have treated Mrs Harris?
Is counselling really a nice, easy, sitting-down job?

The What do therapists actually do? question

Thinking about the What do therapists actually do? question usually
throws up a lot of possible answers. That is because, in some ways, it could
be argued, just as every clienttherapist session is probably unique, every
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treatment session also provides its own unique answer to the debate.
Remember, a core theme in this book is that the story of counselling and
psychotherapy is actually a whole series of tales, some interlocking and some
not; some complementary and some not. As we noted in the Preface, it is
also important to keep in mind that these stories can change according to
who is telling them, where they are being told and why they are being told.
Obviously, other people will have their own individual tales from the
consulting room to tell the world about how they work. Of course, the real
answer to the What do therapists do? question (at least as far as you are concerned) will eventually be your own answer. After all, a much more interesting question is What do I actually do?. Your personal answer will evolve as
you grow as a practitioner and as you tell your own therapists tale.
The central theme underpinning my own response to the What do
therapists do? question is my belief that most clients go to see a therapist
because they feel that something is wrong or missing in their lives.
Somehow, in some way, clients might feel unfulfilled, disturbed, concerned, worried, threatened and so on, and these uncomfortable perceptions might cause them to feel frightened, puzzled, out of control, frustrated, angry, hurt, grieved or in some other way emotionally distressed.
Some clients problems might appear to be very serious. Others might
appear to be petty. Any such distinctions are unimportant. No matter how
worrisome (or not) their issues might appear to anyone else, as far as the
clients are concerned, their problems are huge or at least sufficiently
disturbing to make them want to get some help. So, in a nutshell, what
therapists do is to try to help emotionally or psychologically troubled
people. That is the what and the why parts of their work. Learning the
how part can take a lifetime.
As well as helping individuals with their concerns, counsellors and psychotherapists are also sometimes asked to help worried organisations. These
organisations can include employers, government agencies, voluntarysector bodies or indeed any group of people who believe that psychological
difficulties are somehow disrupting their functioning. All of these troubled
clients, individuals or organisations are often referred to as the clinical
population. Something is wrong and they want it put right.
Of course, it does not have to be the case that therapists only work with
emotionally unwell (psychologically dis-eased) individuals or dysfunctional organisations. It is not only the troubled who feel a need to see a
practitioner. People can (and do) access counsellors to try to find help with
all sorts of issues, dilemmas and life choices. Doing so does not necessarily
mean that they were psychologically sick to start with. For example, some
clients might go to see a therapist to work on their ongoing personal
developments or to find ways of increasing their sense of personal selffulfilment. They might go to a talking therapist to try to find ways of
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enriching their relationships with other people. In the case of organisational clients, workplace specialists might be asked to help with, or advise
on, how to add to or maximise existing levels of corporate emotional
health, staff interpersonal relationships and communal/commercial effectiveness. Untroubled clients (individuals or organisations) are often referred
to as the non-clinical population. There is nothing wrong with them as
such. Individually or collectively they might be sufficiently content or
believe themselves to be sufficiently effective. Nevertheless, they still want
to see if any improvements are possible. Perhaps they want to see if they
can function more productively.
Generally speaking, however, whether clinical or non-clinical, individual
or corporate, it is my contention that most clients go to counsellors and
psychotherapists because they feel that something is wrong. No matter
what their current emotional situations might be, from their various
points of view these psychological states do not fit their purposes and
so they want to alter them somehow or try to move on in some way.
Therefore, put in terms of a very basic proposition, it can be powerfully
argued that:
Counselling and psychotherapy is about change.
Furthermore, as it is also part of the therapists job to aid clients as they
work through their change processes, it is also powerfully arguable that:
Counselling and psychotherapy is about choices.
Indeed, it can be claimed that the BACPs own definition of counselling
(2009) reinforces such propositions. You can check out their latest definition for yourself at www.bacp.co.uk. The BACP says that:
Counselling takes place when a counsellor sees a client in a private and
confidential setting to explore a difficulty the client is having, distress they
may be experiencing or perhaps their dissatisfaction with life, or loss of a
sense of direction and purpose. It is always at the request of the client as
no one can properly be sent for counselling.
By listening attentively and patiently the counsellor can begin to perceive
the difficulties from the clients point of view and can help them to see
things more clearly, possibly from a different perspective. Counselling is a
way of enabling choice* or change* or of reducing confusion. It
does not involve giving advice or directing a client to take a particular course
of action. Counsellors do not judge or exploit their clients in any way.
In the counselling sessions the client can explore various aspects of their
life and feelings, talking about them freely and openly in a way that is
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rarely possible with friends or family. Bottled up feelings such as anger,

anxiety, grief and embarrassment can become very intense and counselling
offers an opportunity to explore them, with the possibility of making them
easier to understand. The counsellor will encourage the expression of
feelings and as a result of their training will be able to accept and reflect
the clients problems without becoming burdened by them.
Acceptance and respect for the client are essentials for a counsellor and,
as the relationship develops, so too does trust between the counsellor and
client, enabling the client to look at many aspects of their life, their
relationships and themselves which they may not have considered or been
able to face before. The counsellor may help the client to examine in detail
the behaviour or situations which are proving troublesome and to find an
area where it would be possible to initiate some change* as a start. The
counsellor may help the client to look at the options open to them and help
them to decide the best for them.
(* Authors emphasis)
Although we have noted that organisations can also benefit from the
talking therapies, in this book I shall mainly address questions about how
therapists actually work as seen from the point of view of the individual
client. I am also going to continue to assume that individual clients usually
go to see a psychological therapist because they want to put something
right. Put another way, they want to somehow give their lives new directions or perhaps to find out how to become more comfortable with their
existing ways of being. Therefore, we shall be looking at how therapists
work by concentrating on investigating how they meet the needs of the
clinical population.
In order to get a useful handle on how counsellors and psychotherapists
actually help their customers, it might help if we think about how our
clients became the sorts of individual characters that they all are. What
makes them tick or, put another way, what sorts of personalities do they
have? Having done that, we might find it helpful to consider how our ideas
about peoples personalities might influence how we go about working with
them. How do we decide which therapeutic method to employ in any
particular case?

ARE THERE TOO MANY THEORIES?

Of course, having read this far, you wont be surprised to learn, given the
disputatious nature of psychologists, counsellors and psychotherapists, that
there are quite a number of major theories of human personality. Neither
will you be surprised to learn that all these theories compete with each
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other and contradict each other. This leads to some major problems in
linking therapeutic practice to the various ways in which we think about
what makes someone tick. Which theories should we include and which
should we reject? Ideally, we would find a way to link all these personality
theories together, but of course that is outside the scope of this book.
However, we do need to at least think about how the various personality
theories might be linked together. This is because, when we explore
integrative counselling in Chapter 6, we will be trying to link up the various
counselling theories.
However, for our purposes, its convenient just for now to limit our
investigations to the three mainstream psychological theories of personality
that underpin what have historically been the three mainstream theoretical
approaches to psychotherapy:
psychodynamic;
cognitive-behavioural;
humanistic.
In Chapters 3, 4 and 5, we will examine these three personality theories and
in each case discuss some of the various counselling approaches that have
emerged from them. After that, in Chapter 6, we will briefly take a note of
some of the other main personality theories and go on to consider how
some of the more comprehensive, all-inclusive, approaches to personality
allow us to move beyond the confines of any one model of psychotherapy.
After all, it might be that the future of therapy lies in its becoming free from
theoretical model constraints. At least that is what some prominent modern
theorists seem to be suggesting (Palmer and Woolfe, 2000, and many other
authors).

SUGGESTED FURTHER READING

British Association for Counselling & Psychotherapy (BACP) (2008)
How to Get the Best Out of Your Therapist. Information Sheet C1 (Roxburgh, T).
British Association for Counselling & Psychotherapy (BACP) (2008)
What is Counselling? Information Sheet C2.
British Association for Counselling & Psychotherapy (BACP) (2008)
Am I Fit to Practise as a Counsellor? Information Sheet P9 (Gale, H).
All the above are available as free downloads from www.bacp.co.uk
(accessed Summer 2009) they are good entry-level introductions to
these topics. Information sheet C2 is particularly useful in offering an
official definition of counselling (as the BACP sees it at least).

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The psychodynamic story

CORE KNOWLEDGE
Some psychodynamic theorists believe that the evolution of human
personality is powered by instinctual drives. Others claim that social and
environmental factors also play a part.
Psychodynamicists also believe that important parts/powerful factors of and
in human personality lie in the unconscious.
Psychodynamic theorists argue that personality has three components:
the id (the original mind)
the ego (the rational mind)
the superego (the conscience).
Human personality development is a psychosexual process Freud.
Human personality development is a psychosocial process Erikson.
Psychodynamic theory suggests that some of present-day lifes interactions
are influenced at an unconscious level by some of lifes previous
interactions. When this is happening at an unconscious level, this
phenomenon is sometimes known as transference.

FREUDS PSYCHOSEXUAL THEORY

The important place of Sigmund Freud (18561939) in our current thinking
about the story of human personality cannot be overemphasised. Of course,
whether or not Freuds ideas will continue to be important as the twenty-first
century unfolds is an as yet unanswerable question. There is a huge library of
texts that tell us much about Freuds life and career (Gay, 1998; Jacobs, 1992,
2003, and many, many others). A cultured and gifted man who originally
trained as a medical doctor, Freuds early negative professional and personal
experiences as a Jewish physician in anti-Semitic, nineteenth-century Vienna
forced him to work in private psychiatric practice and then to go to Paris in
order to undertake further study. In Paris, Freud worked with the eminent
psychiatrist, Jean Charcot, who was investigating the place of the unconscious
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in human nature (personality) and ways to access any unconsciously stored

mental experiences by the use of hypnosis. Upon his return to Vienna, and in
collaboration with Joseph Breuer, Freud began to explore further the properties
of the unconscious mind by using a technique that he called free association, which, he claimed, allowed his patients to express their allegedly deeply
buried emotions, memories and supposed childhood sexual experiences (Hall
et al., 1997).
Freud initially claimed that sexuality is a central factor in the development
of human personality. It is a major mark of Freuds outstanding personal
and intellectual rigour that he was prepared to make such a claim in what
was a notably prudish period in European history. Of course, all theorists
should be evaluated in terms of the contexts within which they work and
this is equally true for Freud, who always was, and in many ways still is, a
controversial figure in the psychotherapeutic world and beyond. The reality
was that, as a Jew in nineteenth-century, notoriously anti-Jewish Europe,
Freud would have been widely perceived as being a so-called inferior
citizen. Therefore, to tell his alleged social betters in nineteenth-century
Catholic Vienna that, according to his theories of human development,
they probably either had sex with their children or their children fantasised
about having sex with them, indicated that Freud had amazing personal
and intellectual courage. Indeed, some of his admirers might even say that
Freud had chutzpah (an appropriately Yiddish term meaning admirably
cheeky, audacious or impudent).
The basic premise of the psychoanalytic view of personality is that of
mind/body dualism. This means that the mind and the body are mutually
interdependent. According to the dualism premise, the mind (personality)
is constructed (developed) in response to the needs of the body. These needs
are represented by primal or primitive instincts, such as urgent infantile
demands for food or comfort. It is how we learn to deal with these instincts
as children that makes us into the sorts of people that we are as adults.
Therefore, these primitive instincts are the very foundations of our
personalities. Each of us builds upon those foundations in various ways and
that is what makes us into the varied and various individuals that we
become.
Freud identified two main instinctual drives.
One is the power of the Life Force (Eros or libido), which includes sex
(love), but which was eventually defined by Freud as including most
forms of pleasurable bodily experiences (Bettelheim, 1983).
The other, according to Freud, is the opposite of Eros and is the power
of the Death Force (Thanatos), which drives us towards the supposed
relief from the tensions of Being (anger, fear) that it is claimed comes
from personal extinction or the end of existence (Perelberg, 1999).
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According to many psychodynamic theorists, a human infants mental

existence is nothing but instinct. They believe that a growing child has to
learn to subjugate those powerful instinctual drives for all sorts of survivaldominated reasons. For example, it would be dangerous for someone to
display too much uncontrolled or uncontrollable instinctual anger in later
life as this might well lead to self-destructive behaviour, such as attacking
someone who is too strong to be defeated. The psychodynamicists argue
that much of the process of learning to accommodate these primal or
primitive needs takes place in our early years. Therefore, it follows that
our personalities must clearly be largely the product of our childhood
experiences. For example, according to McLeod (2003), psychodynamicists
might suggest that a mother who responds too quickly to an infants
instinctual demands for food may be teaching her child that it needs to
make very little personal effort in order to get fed. In such a case, the child
might grow into a rather selfish adult who is easily frustrated if any
demands are not immediately met. Alternatively, if the mother only
responds after the hungry child has engaged in extensive crying or has had
a temper tantrum, that child might grow into an adult who believes that
needs are only satisfied by becoming angry or aggressive. (Any mothers
reading this are probably wondering why everything is always their fault!
The answer is, because the Freudians say so!)
However, Freud did much more than simply claim that childhood experiences underpin adult personality. He also claimed that these underpinnings
occurred in some specific ways, which means that he certainly believed that
there is an official personality developmental blueprint to be followed.
Freuds proposed human developmental processes are based on one of his
basic premises. He claimed that our conscious minds are influenced by the
workings of our unconscious minds. He believed that the human mind has
three developmental levels and these are usually described, as follows, by
various interpreters of Freud (such as Hall et al. (1997), Lemma (2007), etc.).
Level 1 the id: This is the original mind that is present at birth and is
a container for the primal instincts or drives that eventually motivate
our personalities. As we have already noted, this instinctual psychic
energy is derived from the two core drives of life/love (Eros or libido)
and extinction/death (Thanatos). The id is irrational and only exists
to achieve self-gratification at any cost. Put simply, the id says, I want
my cake! Gimme now! Dont care how! Dont care about what
you want! The id is a monster, self-centredly demanding immediate
wish-fulfilment and exclusively concerned with self-pleasure.
Level 2 the ego: This develops out of the id and is the rational and
conscious part of the mind. It evolves as the infant begins to discover
that primary mental images such as food or warmth are represented
in the real world by actual objects or sources. Therefore, a plan is
necessary to obtain the required item. This is the beginning of the
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higher mental functioning that plans, executes and tests the

processes, thoughts and actions that are necessary for obtaining
personal gratification from the adult world. The primary role of the
ego is not to frustrate the id but to help it find ways of getting
satisfaction and, at the same time, satisfying the demands of the
environment. It is a sort of psychological ambassador. The id says,
Yes, you might want some cake but you will improve your chances of
getting some if you play the game their way. The ego is a realist
amoral and goal-oriented.
Level 3 the superego: This develops last and is the conscience or
rulebook that sets out the boundaries of our personalities. It is the
internal, mental representation of the supposedly correct values and
ideals that a child learns from family and society. In Freudian theory,
the primary sources of this learning are the parents, who implant their
own ideals into the child by a series of punishments and rewards.
Psychodynamically, the superego has three purposes:
to curb the excesses of the id;
to inculcate a sense of morality in the ego;
to cause the person to strive towards perfection.
As the superego forms, parental control is gradually replaced by
personal control. Internalising this control helps us to create some
important qualities in our personalities. So, if we rely on firm, even
unquestioned beliefs such as lying is wrong or never be late,
according to the Freudians, we can be sure that our superegos are hard
at work. The superego says, Yes, you do want some cake and the ego
will show you how to get it. However, you must also share it because
thats the right thing to do. The superego is an idealist moral and
altruistic.
Clearly, the psychodynamic theorists argue that most personality development occurs in a persons early years. Because the Freudians claim that
those early years are mainly concerned with bodily satisfactions, they go on
to argue that personality development is a psychosexual process. During
the early part of a persons emotional growth the psychodynamicists claim
that there is a clash between the desires of the primal instincts and a
need to survive in the world as it is. In other words, human personality
development comes about as a result of a series of psychological conflicts
between the growing child and its environment. In particular, these
psychological clashes occur between children and their parents, or indeed
anyone else who is primarily significant in their upbringing and control.
Each clash, or episode of conflict, and the manner in which it is resolved,
contributes towards the way in which someones emerging personality
grows and develops. For example, it has been argued (at least by the
Freudians) that adverse infant experiences during toilet training could lead
to the adult becoming the sort of obsessively tidy person often referred to
as being anally retentive. (Yes, its mothers fault again!)
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WAS FREUD RIGHT?

The idea that human personality development emerges as a result of an
early-years psychosexual process was very revolutionary in its time and
remains the subject of heated debate and fierce dispute even today. Indeed,
there are some powerful counter-theorists who denounce Freud as a failed
person, as an inadequate researcher and as a misguided thinker (Masson,
1992; Shlien, 1987, and many others). Even Freuds own granddaughter,
Sophie, went as far as calling him a false prophet (Freud, 2002, cited in
Evans and Gilbert, 2005, p9).
It is also the case that some of the alternative, and equally powerful,
theories of personality development essentially dismiss psychodynamic
explanations of what makes each of us who we are. This dismissal is in part
due to the fact that psychodynamic theory is very difficult (many say
impossible) to test by accepted scientific methodologies. Of course, the
defenders of psychodynamic theory will probably argue that their theories
are better supported by clinical practice than by scientific study. They claim
that extensive investigations of case study reports show that their theories
are valid because, they claim, their patients get better. Their opponents
counter-argue by saying that there is no proof that any such improvements
(if they really do occur) result from psychoanalytic therapy. After all, it
might have been that the patients were going to get better anyway. For
example, many depressed patients do spontaneously recover, often quite
quickly (NICE Guideline 23, 2004). For all these reasons, Freuds opponents
argue that his psychoanalytic theories of human personality have no
evidence base.

ACTIVITY 3.1
Consider the following:
Mary saw her psychodynamic therapist regularly once a week. After two years she
found that her depression had lessened a great deal. Jim saw a clinical psychologist
once but did not get on with him, so he never went back. Two years later he, too,
found that his depression had lifted.
Why would there be such similar results from such different experiences of
treatment?
Are these outcomes really the same?

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Case study 3.1

Alfred was a very touchy sort of a chap; everybody knew it and everybody stayed
clear of him when he was in one of his moods. That was strange really because
Alfred saw himself as a very easygoing chap, nice to everyone and kind to
animals.
One fateful day, Alfreds employers held a training afternoon. The training
role-play was videoed and played back to the trainees. Alfred was horrified to see
himself engaged in what he thought had been a helpful and constructive
interchange between himself and a colleague. The supposedly nice Alfred was
being played by someone who seemed to be in a fury. Thats not like me, he
said. Oh yes it is, said everybody else.
What Alfred could just not understand was that he could be such a scary guy
and yet be totally unaware of it. By now even Alfred wasnt too fond of Alfred.
Alfred went along to see his firms counsellor. After hearing Alfreds story, the
counsellor asked Alfred, What are you angry about? Nothing at all, said Alfred.
However, as he spoke his features tightened and a scowl appeared on his face.
The counsellor pointed this out and again asked Alfred what was bothering him.
Off the top of your head, without thinking about it, who do you dislike the most
in this world, he was asked. Without any hesitation Alfred replied, I could never
stand the man who has lived next door to my parents since I was a small child
he touches small boys and I could never tell my Dad. Then Alfred said something
very interesting. Do you know, he said, I havent thought about him for years.
Are you sure? asked the counsellor.

THE PSYCHODYNAMIC PEOPLE-MAP

For now, however, we are going to continue to explore personality development on the assumption that the psychodynamic explanation of it as
being a psychosexual process is, at least, a useful working theory. From a
psychotherapeutic point of view, it is very important to note that the
psychodynamic theorists go much further than merely arguing that
personality development is a psychosexual process. They go on to claim
that the emerging personality evolves according to a set of rules a sort of
developmental template. There are fixed stages to this development, they
say, and if something goes wrong during these early-years processes, this
creates psychological and emotional tensions that lead to problems in later
years. Therefore, according to psychoanalytic or psychodynamic therapists,
improvements in your emotional or psychological well-being will arise if
you can identify these developmental errors, locate them in your unconscious and bring them into the light (your conscious).
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For the psychodynamicists, each of the psychosexual evolutionary stages

has three important components. These are:
1. a physical focus: where the childs emotional energy is targeted and
how gratification is obtained;
2. a psychological theme: directs and balances both the childs internal
bodily needs and the demands of the external world;
3. a resultant adult character trait: which lies along a too muchtoo
little continuum; if a person remains fixated or stuck at any given
stage and has related, unresolved issues, psychological problems
may arise.
Generally speaking, Table 3.1 shows how the psychodynamicists claim that
personality evolves.

Age
(years)

Stage

Physical
focus

Psychological
theme

Typical adult
character traits

01

Oral

Mouth, lips,
tongue
(sucking,
food)

Narcissistic;
Dependent
(only me)

Aggression vs.
passivity
Impatience vs.
serenity

13

Anal

Anus
(withholding
or giving
up faeces)

Self-control;
Obedience
(conflicts with
parents)

Controlling vs.
subservience
Boundaried vs.
disorganised

36

Phallic

Penis
Penis absence
Clitoris

Morality; Sexual
identity
Love for same
sex parent
Fear of other
sex parent

Promiscuity vs.
sexuality
Re-enacting
childhood
relationships vs.
rejecting them

614

Latency

Dormant

Peer relationships

Socially integrated
vs. anti-social

1420

Genital

Sex

Maturity;
Procreation;
Life-enhancement

Balanced and
mature
Supportive and
nurturing

Table 3.1: The psychosexual development of personality.

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It is important to note that, no matter how vigorously it is defended by its

proponents, at base the psychodynamic explanation of personality is an
inferential one. We cannot see the unconscious operating. We cannot
measure the id, examine the ego or dissect the superego. Neither can we
prove that children really do have fantasy sexual interactions with their
parents or that newborns are essentially narcissistic. The best that we can
do is to say that close examination of the ways in which people behave and
relate to each other and to themselves gives us grounds for believing that it
is as if the psychodynamic process is at work. The essential element in the
original psychodynamic explanation of personality is the idea that people
are unknowingly driven by their sexual instincts. In other words, it is an
animalistic theory of personality. Some theorists, Erikson for example,
would argue that the initial psychodynamic theory of personality development is too simplistic.

ERIKSONS PSYCHOSOCIAL THEORY

Erik Erikson (190294) was born in Frankfurt of Danish parents. He
eventually came to study and teach art in Vienna, where he subsequently
underwent psychoanalytic training supervised by Freuds daughter, Anna,
and eventually graduated from the Vienna Psychoanalytic Institute in 1933
(Welchman, 2000). Like his mentor Freud, Erikson too was Jewish, and so
he was also forced to emigrate, first to Denmark and then to America, where
he was able to spend the rest of his life developing his theories.
Erikson always considered himself to be a Freudian. Like Freud, Erikson
believed that childhood is very important in personality development. Also
like Freud, Erikson was an ego psychologist. He accepted many of Freuds
theoretical concepts, including the id, ego and superego, and Freuds belief
in infantile sexuality. However, Erikson rejected Freuds attempts to describe
personality solely on the basis of infant sexuality and so (very much unlike
Freud) he came to believe that personality continued to develop significantly well beyond childhood. Erikson considered that social factors were
as important as sexual factors in the development of the human personality. He therefore proposed a psychosocial stage theory of personality development (Stevens, 2008).
Eriksons version of ego psychology theory holds certain beliefs that make
his ideas quite different from Freuds (Erikson, 1965, etc.). Essentially
Erickson believed that:
the ego is of the utmost importance;
part of the ego is able to operate independently of the id and the superego;
the ego can adapt to situations and is a powerful agent in promoting
mental health;
both social and sexual factors play a role in personality development.
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Eriksons theory is much more comprehensively whole-life than Freuds,

and included information about alleged normal personality as well as
supposed neurotic, abnormal personality. He argued that personality
development is more than merely sexually driven. Erikson claimed that it
is also driven by social and cultural forces. However, like so many of the
earlier personality theorists (including Freud), Eriksons work does not have
a robust, research-based underpinning. Indeed, like Freud, his theories are
mostly unprovable. As with many psychodynamic theorists, Eriksons
proposals give us a working explanation of personality. They give a plausible description of a possible process, but not an explanation that can be
verified by testing any actual, specifically identified, causative mechanisms.
This is because Eriksons theories all essentially depend on the proposition
that personality develops as if psychosocial/sexual drives are at work.
Proving such a proposition is quite another matter.
All of personalitys developmental stages in Eriksons psychosocial theory
are present at birth, but they unfold according to an innate plan. For
Erikson, human personality development is epigenetic. This means that it
unfolds over time rather like a tulip develops from a bulb. Its all there from
the beginning, but it has to grow and evolve. Each stage builds on the
preceding stages and paves the way for subsequent stages. For humans, each
stage in personality development is characterised by a psychosocial crisis.
Each crisis arises in accordance with the associated age-related or bodyrelated development and conflicts with the demands then put on the
individual by parents and/or society. Ideally, the psychosocial crisis in
each stage should be resolved by the ego at each stage. This allows the
development of the next stage to proceed correctly. All this implies that,
just like the developing tulip, the equally epigenetic human personality can
unfold in a proper form. It can also unfold in an improper (distorted) form,
or the unfolding can even be brought to a halt. According to Erikson, it is
quite possible that, at any given growing stage, someones psychosocial
developmental needs might be incorrectly processed and so distort later
stages and eventually deform the emerging adult personality. However,
Erikson also claimed that emotional deformities can be corrected. He
believed that:
developmental stage outcomes are not permanent. They can be altered by
later experiences.
The importance of this concept for therapists is the possibility that one of
those later, possibly corrective, experiences might be provided as part of
some form of reparative psychotherapy. Realising this helps us to better
appreciate why understanding human personality development is so vital
for all therapeutic practitioners. It might be that properly understanding
what makes people tick could help us to discover some useful ways of doing
psychotherapy.
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Erikson proposed that everyones personality is a mixture of the various

traits that become paramount at each developmental stage. His theory is
based on the assumption that someones personality development can be
considered successful if an individual has more of the good traits than the
bad traits. Clearly, the ideally developed personality will only consist of
good traits. Table 3.2 overleaf sets out Eriksons theory of personality
development on a stage-by-stage basis.
Eriksons model perhaps can be better appreciated if we compare it with
Freuds psychosexual model. Jacobs (1998, p10) has produced a useful comparison table, which is reproduced in a slightly modified form in Table 3.3.
Clearly, Eriksons model of human personality is more comprehensive than
Freuds because it takes more factors into account. It includes inputs from
a persons entire life and not just their early years. It is useful because it
acknowledges that humans are more than merely the products of their
instinctual drives as modified by lifes experiences. Social influences are
important too. Therefore Eriksons theories offer us some significant steps
towards the modern ideas about human personality. Today, many theorists
see personality as being a complex combination of biological, sociological
and environmental factors. However, it must not be forgotten that Eriksons
theories, attractive as they are, and as useful as they can be when applied
in the therapy room, are at best well-argued, intellectual propositions; they
are not fact.

THE EGO AND PERSONALITY

Both Erikson and Freud were ego psychologists. This means that they
believed that personality (the self) develops as maturing individuals react
to the forces in both their inner and the outer worlds (Mitchell and Black,
1995). The danger of conflict (and scary potential chaos) is always present.
Therefore, a means of controlling the process, so that its evolution remains
orderly, is required. This controller, according to many psychodynamicists,
is the ego. It is rather like a combination of programme manager and match
referee. Therapists have long found the ego to be a useful theoretical
concept when considering how to manage their clients. Whether it is
enough is a question that will continue to puzzle practitioners. You might
understand some of these ideas a bit better if you try out Activity 3.2.

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Psychosocial
crisis

Significant
relations
(social factors)

Psychosocial
attributes

Positive
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assets

Negative
psychosocial
assets

1: Baby
(01 yr)

Trust vs. mistrust

Mother,
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To get, to give in
return

Hope, faith

Sensory distortion
Withdrawal

2: Toddler
(23 yrs)

Autonomy vs.
shame and doubt

Parents, carers

To hold on, to let go

Will, determination

Impulsivity
Compulsion

3: Infant
(36 yrs)

Initiative vs. guilt

Family,
significant others

To go after, to play

Purpose, courage

Ruthlessness
Inhibition

4: Child
(712 yrs)

Industry vs.
inferiority

Neighbourhood
and school

To complete, to
make things together

Competence

Narrow virtuosity
Inertia

5: Adolescent
(1220 yrs)

Ego-identity vs.
role-confusion

Peer groups,
role models

To be oneself, to
share oneself

Fidelity, loyalty

Fanaticism
Repudiation

6: Young adult
(2030 yrs)

Intimacy vs. isolation

Partners, friends

To lose and find

oneself in a another

Love

Promiscuity
Exclusivity

7: Middle adult
(30s to 50s)

Generativity vs.
self-absorption

Household,
workmates

To make be, to
take care of

Care

Overextension
Rejectivity

8: Old adult
(50s +)

Integrity vs.
despair

Mankind or my
kind

To be, through
having been,
to face not being

Wisdom

Presumption
Despair

Table 3.2: Eriksons psychosocial theory of personality development.

THE PSYCHODYNAMIC STORY

Stage*

Freud

Aims

Erikson

Tasks

Oral

Feeding

Baby*
(Oral)

Basic trust vs. mistrust

Anal

Muscular
pleasure

Toddler*
(Muscular-anal)

Autonomy vs. shame

and doubt

Phallic

Oedipal
resolution

Infant*
(Locomotorgenital)

Initiative vs. guilt

Latency

Learning

Child*
(Latency)

Industry vs. inferiority

Adolescence

Genital
expression

Adolescence

Identity vs. role

confusion

Adulthood

Love and
work

Young
adulthood

Intimacy vs. isolation

None

N/a

Midadulthood

Generativity vs. selfabsorption/stagnation

None

N/a

Late adulthood

Integrity vs. despair

* Authors additions/amendments.

Table 3.3: Freud and Erikson compared.

ACTIVITY 3.2
Ask yourself the following questions and note your answers:
What sort of a person am I who in my family do I take after?
What sorts of very strong feelings do I sometimes have why and when do I
have those strong feelings?
Whats my earliest memory why do I still remember it?
Find someone who has known you all your life and ask them to answer all the
above questions as they think you would answer them.
Try to explain any differences or similarities between your answers to these
questions and those that someone has given you.

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LATER DEVELOPMENTS IN PSYCHODYNAMIC THEORY

Obviously, there have been many advances in psychodynamic theory since
Freuds day. As we know, Freud believed that personality was powered by
instinctual drives. Other psychodynamic theorists believed that people
and their emotional developments were much more complicated than that.
For instance, as we have also already noted, Erikson argued that peoples
lifelong interactions with their social environments were just as influential
as instincts on the ongoing development of personality and the emergence of the self. There have been many other post-Freudian and neoFreudian theoretical advances. These include: Attachment Theory (Bowlby,
1969, 1973, 1980); the Unitary Ego (Fairbairn, 1952); True-self/False-self
(Winnicott, 1965); Psychological Archetypes, the Collective Unconscious
(Jung, 1970) and many others. Many of these theoretical standpoints are
much more mutually contradictory than they are complementary. The
psychodynamic schoolists seem to have been a traditionally disputatious lot!
Over the years, the internal politics, the disputes over theory, and the power
struggles in the psychodynamic world have been fierce, vicious even. Freud
himself was a difficult figure to disagree with. It was well known that, in
Freudian circles, agreement with the Master was expected. Either you were
an approved member (approved by Freud, that is) of the International
Association for Psycho-Analysis, or you were not. If you disagreed with
Freud you were better off not belonging. Those who broke ranks and
promoted contradictory views were certainly out. One early defector was
Jung, who believed that biologically derived motivational drives are only
part of the overall picture of human development. He argued that people
also have drives towards the integration and fulfilment of the self and that
understanding the unconscious necessitates understanding its spiritual and
transcendental components (see Jung, 1965). Ferenczi and Rank broke away
because of disputes over the importance of therapeutic technique. Many
other eminent theorists were cast out into the non-Freudian wilderness.
Melanie Klein was an important critic of some of the early psychoanalytic
orthodoxies and so she too earned the disapproval of the Freudian faithful.
Her primary reinterpretation of Freudian orthodoxy underpins what later
became known as the Object Relations School of psychodynamic theory
(Klein, 1997). It must be borne in mind that in Kleinian psychoanalysis the
term object does not mean an inanimate item or thing. It refers to the
objects (or targets) of someones relationships. These may be internal
objects (the internalised self); external relationship objects (e.g. people,
etc.); external objects that represent relationships (e.g. a childs security
blanket); and part-objects (e.g. the nurturing breast rather than the mother
herself).

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THE FREUD WARS

Melanie Klein originally trained under Freud in Vienna and subsequently
emigrated to Britain in 1926. She became a prominent member of the
British Psychoanalytical Society, which had been first formed in 1919. In
1938 (having fled Austria with her father), Freuds daughter, Anna, connected with what was already an argumentative British psychotherapeutic
scene. In the early 1940s, the tensions between the then prominent (and
vigorously competing) British psychoanalytic factions erupted into serious
conflict (Rayner, 1990). In particular, there were fundamental disagreements between Melanie Klein and Anna Freud. By 1942, these two
formidable women were generating so much tension and rivalry in the
British psychoanalytic world that the Society decided to conduct a series of
professional debates in order to try and instil peace between the warring
factions. This led to the series of famous exchanges that are known today
as The Controversial Discussions (King and Steiner, 1991).
Despite the efforts of the peacemakers, the arguments actually became more
and more intense and so, in 1946, the British Psychoanalytical Society tried
an alternative way of healing some of the rifts. It divided its training
function into three groups: the Freudian purists (led by Anna Freud after
the death of her father), the Object Relations Theorists (led by Melanie
Klein) and a rather loose group called the British Independents. This group,
which actually was the largest of the three, included such luminaries as
Gillespie, Milner, Winnicott, Bowlby, Rycroft and Balint.
Fortunately, today much of the 1940s/50s factional discord seems to have
largely died away and a workable amount of rapprochement has been
achieved (Jacobs, 2004). This is certainly true at a training level. Of course,
as they grow professionally, psychodynamic practitioners usually develop
their own individual styles of working and their own interpretations
of psychodynamic theory. Happily, there is now much common ground
between the psychodynamic schools about the basic principles that
therapists need to bear in mind when working with their clients.
These areas of agreement include some commonly held ideas about the
psyche, the unconscious and transference.

THE PSYCHE
Counsellors and psychotherapists do not have to be Freud-friendly, or
even psychoanalytic groupies, to find that psychodynamic ideas sometimes have their uses. For many practitioners (e.g. Jacobs, 2005), psychodynamic is a generic expression that explains the active part that the
psyche or inner self (commonly described as a sort of fusion of mind,
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emotion and spirit) plays in our everyday lives. The actions of the psyche,
as envisaged by many modern-day psychodynamic theorists, are
supposedly powered by much more complex drives than the simple
instinctual forces described by Freud. Today it is believed that the workings
of the psyche also depend on the active (dynamic), ongoing interrelationships that occur between people, or between people and their own
interpersonal environments (how people relate to themselves). It is about
how our past experiences (internal and external) actively influence
(consciously or not) todays activities and interactions. Todays psychodynamic practitioners claim that the psyche not only has relationships with
people (objects) that are external to the self, but also interacts internally
with the self. In other words, the psyche interacts with the psyche; the self
interacts with the self. For instance, you might be experiencing anxiety
because your good self is in conflict with your bad self over whether or
not you ought to eat a bar of chocolate. You might also be worried because
your doctor says you are overweight. All this means that, as well as the
psyche (self) having internal intra-actions with itself (good/bad self), it also
has external inter-actions with others, such as the doctor. An example of this
process could be as follows.
Suppose somebody finds themselves acting out of character; perhaps that
person uncharacteristically became frivolous and inattentive when a very
serious matter was under discussion. Thats not like you, someone else
might say (external inter-action). The person concerned might confess that
Im feeling rather silly today (internal intra-action). The implication here
is that todays aberrant, improper self (Mr Silly) actually has a real self, a
proper self (Mr Sensible). However, just for now at least, the normal,
properly sensible, self has been temporarily displaced by a deviant, silly self.
Behind this interchange, there is an implication that there is also a third
self present. This is a judgemental self (Mr Critical), who decides what is
silly and what is not. Perhaps the self-criticism (Im being silly) stems from
the person having an underlying, unconsciously held belief that frivolity
should be avoided.
It seems to be the case that a common article of faith within most, if not
all, of the psychodynamic churches is the belief that the psychodynamic
process is largely concerned with understanding the present-day effects of
someones past relationships, either with that persons own self (or selves)
or with external objects. This means that it is a core principle of psychodynamic therapy that the psyche is at work at all times whether or not
the client is aware of this process. Furthermore, the activities of the psyche,
both past and present, can be identified from a persons present-day
behaviours, relationship patterns and emotional lifestyle. The various ways
in which clients present themselves, including their behaviour during
counselling sessions, are indicators of their underlying psychological and
emotional processes. Therefore, exploring the psyche by means of attempts
59

THE PSYCHODYNAMIC STORY

to interpret these intrapersonal and extrapersonal relationships is a key

activity for the psychodynamic psychological therapist (Mander, 2000).

THE UNCONSCIOUS
The difference between the conscious and the unconscious seems at first to
be a simple one. You are either aware of what is going on or you are not.
However, the reality is not so simple because it appears that there are
different levels of awareness and unawareness. For instance, you might
think that you remember all too clearly a friends funeral that took place
two years ago. You are very aware of the sorrow you felt when you heard
your friend had died. However, you might not remember just how
overwhelming your grief and pain really were. That pain is now safely
stored away at a deeper level that is too hard to routinely access. Life seems
simpler that way.
At one level there are the easily accessible memories. Freud called these the
preconscious. For example, it might be that you have forgotten all about
a long-lost love, but going down memory lane with an old friend easily
jogs your memory. Then at a second, much lower, level there are the deeply
buried memories that are so far down in the unconscious that it can be very
hard to access them. For example, someone might have feelings of intense,
even primal, anger towards a parent figure that cannot be allowed to
surface. Possibly that person unconsciously fears that acknowledging such
potentially destructive emotions might allow some frighteningly aggressive
feelings towards an idealised parental figure to break through.
Locating such deeply buried memories (the true unconscious) can be very
difficult, sometimes perhaps even impossible. It is the task of the psychodynamic therapist to infer, to explore and to identify these hidden sources
of emotional and psychological disquiet. In the ideal therapeutic world,
the psychodynamic therapist will help the client to safely bring the
unconscious into the conscious, and convert the unaware into the aware.
Psychodynamic therapists attempt to foster the emotional growth that can
result from breaking the powerfully restrictive, unconsciously constructed,
emotional shackles that are holding the client inside a private psychological
prison; a prison that has been constructed within the unaware self.
It is a basic requirement in psychodynamic therapy that practitioners should
attempt to help their clients to access the unconsciously held experiences,
emotions and beliefs that are influencing their current lives. This is done by
reflecting on the clients behaviours in the counselling room and by
attending to the ebb and flow of the therapeutic relationship. It aint what
you say; its the way that you say it. It is also how you behave when you are
saying it that is important to the modern psychodynamic therapist.
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REFLECTION POINT
Suppose that you are telling someone that you never get angry, but you find
yourself thumping the table while saying it.
What would you infer from your words and more importantly from your
actions?
What would you guess is going on in your secret mind?

The hope, of course, is that, by making the unconscious conscious, clients

might be able to conduct their lives with more control, with less emotional
disquiet and with more fulfilment. No longer must these clients be slaves
to the unrealised and therefore uncontrollable forces (psychodynamics)
from within the unconscious parts of their own selves.

TRANSFERENCE
Psychodynamic theorists argue that not only are there links between
peoples inner selves and their external selves, but also there are links
between their past experiences and their present-day experiences (see Freud,
1986, etc.). In other words, not only do we conduct our current relationships in ways that are influenced by what is going on inside us, but we also
do so in ways that are influenced by our past experiences. Here are two
examples.
1. Bob, a normally affable, longstanding member of a social club, has
taken an instant dislike to Jim, a new member. This seems irrational as
Jim is a nice enough chap. One explanation might be that, even
though Bob is unaware of it, there is something about Jim that has
stirred up some unconsciously held memories of some of Bobs
adverse childhood relationship experiences. Bob might honestly
believe it when he says, I dont like him cant stand people with
beards. However, at an unaware level, it might be that Bob is actually
saying I cant stand reminders of my slob of a father who could never
be bothered to shave.
2. Josephine, usually a placid soul, has started to become grumpy at
work. Whats got into her? her colleagues might wonder, whereas
Josephine genuinely believes Theres nothing wrong with me
theyve all started winding me up. However, what has actually
happened is that a newly appointed office manager is reminding
Josephine at an unconscious level of a bossy teacher in her primary
school whom she detested. The result is one highly disgruntled
Josephine, although she genuinely does not know why.
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Because these feelings are held in the unconscious, Bob might genuinely
believe that he does not like beards and Josephine might really think that
her colleagues are conspiring to annoy her. In both cases, neither Bob nor
Josephine is aware of behaving any differently or that they are reacting to
the new people as if they were the real-life people whom they disliked at
earlier stages of their lives. In other words, Bob and Josephine are unconsciously transferring experiences from their pasts on to the present.
In psychodynamic counselling terms, these earlier experiences, these
buried feelings and emotions, are often unknowingly acted out by clients
in their relationships with their counsellors. Like Bob and Josephine, clients
are unconsciously transferring their pasts on to the present. This is the
psychological process known as transference. Of course, transferences
routinely occur in everyday life too. Clinically significant transferences
(client to therapist) are often encountered during therapy. Such transferences might be representative of psychologically unhealthy transferences
that are occurring outside the therapy room.
The clientcounsellor relationship often contains many clues and hints
about how clients interact with other people out in the wider world. It is the
job of the psychodynamic therapist to use the interpersonal processes
between the client and the counsellor (the transferences) to the clients
advantage. The therapist has to try to help the client to rediscover (and to
work through) past relationships in ways that are therapeutically beneficial
to current life and current relationships. Therefore, it is a fundamental
requirement that psychodynamic counsellors should work with their clients
transferences and help them to explore their feelings about these hidden
interactions as and when they emerge during the counselling sessions.
In the everyday world, clients experience many sorts of transferences with
many sorts of people. However, in the therapy room there are usually only
two people actually present the client and the therapist. Therefore, the
transferences in the counselling room can only be between the client and
the therapist. Other people might be present but only as ghosts from the
past. In other words, clients bring all their previous experiences with them
when they meet their therapists. Sometimes these ghosts are present but
unacknowledged (in the clients awareness but not yet talked about).
Sometimes they might be present but unrealised (buried in the clients
unconscious).
Transference is, of course, a two-way process. Therapists are not immune to
the possibility (probability) that their own pasts influence their interactions
with their clients. This therapist-to-client transference is known as countertransference.
Bob and Josephines cases are both instances of negative transference.
However, many positive transferences also occur both in everyday life and
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in the therapy room. Exploring positive transference can also be therapeutically useful. For example, therapists might choose to build upon any
warm feelings that their clients might have towards themselves (positive
transference), in order to reinforce the therapeutic relationship in ways
that, for example, might help clients to talk about difficult or embarrassing
topics. The danger for counsellors is to fall into the trap of believing that
transference has a real, a concrete, existence rather than just being a useful
metaphor (an error known as reification). For example, some counsellors
are reluctant to admit to disliking someone and prefer instead to concede
that they may be experiencing negative transference.

PSYCHODYNAMIC THERAPY AT WORK

Case study 3.2
June deliberately chose to see Andrew because, as she told him, I always get on
better with men. She wanted to find out why it was that her adult relationships
usually failed. June presented herself in an overtly sexual manner. She dressed
revealingly and she injected a powerful sexual content into all of her descriptions
of her life and her problems.
It was apparent to Andrew (as June cheerfully confirmed) that she routinely
tried to seduce the men that she met, previous therapists included. When, during
the third session, Andrew made it clear that he was not going to be her next
conquest, June became visibly agitated. However, the next time she appeared
there was noticeably less sexual tension around.
During later sessions, June found herself telling Andrew about her childhood.
Her father had been physically abusive to her and her sisters. When she had
grown big enough, June tried to protect them all by offering him sexual
gratification in an attempt to defuse his aggression. This did not always work and
so June came to believe that his violence was her fault because she was not sexy
enough. June eventually found out that offering sex was how she paid her way
in life.

In Junes case it eventually emerged that she had internalised three life rules
into her unconscious: men are scary; their threats can be diverted by offering
them sex; and eventually, due to her own inadequacies, her diversion
strategies would fail. June was not consciously aware of her three life rules
and she was initially oblivious to her overtly sexual behaviour. As far as she
was concerned, I dress this way because I feel more comfortable when I do
and, anyway, men always let you down in the end. Andrew gained his first,
tentative, understandings about Junes unconscious processes from his
reflections on the possible causes of the overt transferences present in the
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counselling room (that is psychotherapist talk for turning him on a bit).

His suspicions were confirmed when he noted how his rejection of Junes
advances caused her so much anxiety that she felt reluctant to continue her
therapy. It took quite a few counselling sessions before June felt safe enough
to examine the true causes of her many failed adult relationships and to trust
herself enough to try to relate to someone in a non-sexual way.

REFLECTION POINT
Do you believe that overt sexuality is really psychological transference or is it just
down to hormones?
In what ways might it have helped (or hindered) Junes therapy had she seen a
female counsellor? Would the transference/counter-transference have been any
different?
From a psychodynamic viewpoint, could your relationships with your clients
ever be non-sexual?

SUGGESTED FURTHER READING

Appignanesi, R and Zarate, O (2007) Introducing Freud: A graphic guide to
the father of psychoanalysis. Cambridge: Icon Books.
Jacobs, M (2004) Psychodynamic Counselling in Action, 3rd edition. London:
Sage.
Jacobs is an acknowledged authority on this topic. An excellent
introduction to a vital topic for all counsellors.
Jacobs, M (2005) The Presenting Past, 3rd edition. Buckingham: Open
University Press.
Mander, G (2000) A Psychodynamic Approach to Brief Therapy. London:
Sage.
A very useful, hands on, practical approach and will help you to find out
just what it is that psychodynamic therapists do. Chapter 5 is particularly
good.

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Chap ter 4

The cognitive-behavioural story

CORE KNOWLEDGE
Some psychologists argue that how we behave and how we think make us
into the sorts of people we are.
Behaviour can become automated classical conditioning.
Behaviour can be shaped or modified operant conditioning.
Thinking (cognition) can affect how we react to lifes events. Each of us
interprets our own world. The ways that we do this makes each of us who
we are.
Cognitive-behavioural therapists believe that emotional difficulties and
other forms of psychological problems arise from embedded errors in how
people think and act.
Cognitive-behavioural therapy is a partnership between therapists and their
clients in which the clients are encouraged to try to resolve psychological
issues by finding new ways of doing things or new ways of thinking about
things or both.

PERSONALITY THE COGNITIVE-BEHAVIOURAL STORY

The cognitive-behavioural (thinking-doing) explanation of the personality
story is quite straightforward. It is an approach that simply connects ideas
about how people think in the ways that they do (Ellis, 1962; Kelly, 1955)
with ideas about how they act in the ways that they do (Bandura, 1977;
Skinner, 1953). According to the cognitive-behaviouralists, the combination of the thinking and doing processes makes the person. That is all it is.
That is the cognitive-behavioural explanation of human personality in
a nutshell. There are no hidden or unconscious processes going on as
personality evolves. Personality growth is plain for all to see. There is no
need to follow any hidden or preset personality development plans, because
there are no such plans. What you see is what you get.

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Clearly, cognitive-behavioural ideas about personality development are

in complete contrast to the psychodynamic approach. For the psychodynamicists, personality comes about from the workings of an inner psyche
and it evolves in certain ways according to certain rules. However, historically Freuds detractors have always claimed that his arguments are
inherently weak because the id cannot be seen, the ego cannot be measured
and the superego cannot be examined (Shlien, 1987; Thorndyke, 1932;
Watson, 1925, etc.). Therefore, they say that Freuds alleged inner psychodynamic processes are just that allegations. They can only exist in theory
and there is no evidence that they exist in reality. At best, these critics claim
that, even if Freuds ideas are sometimes therapeutically helpful, they are
still only myths and can only explain personality on an as if it is true basis
(Eysenck, 1990; Shlien, 1987, etc.). The alternative to depending on Freuds
apparently unsupported speculations, say the cognitive-behaviouralists, is
to find out what really happens when people become people.
The cognitive-behaviouralists argue that our personalities emerge from the
easily observable processes that we can see taking place in ourselves as we
respond to events in our worlds (to our social and physical environments).
Therefore, it is claimed, the cognitive-behavioural approach to personality
is based on hard science and factual observation. Because the cognitivebehaviouralist model of personality is allegedly objective, empirical researchers
have been inspired to investigate it. An important attraction of the cognitivebehavioural theories is that they are apparently evidence-based.
According to the cognitive-behaviouralists, how you think and how you
behave makes you the sort of person you are. However, some behavioural
psychologists (see Eysenck, 1967, 1991, for example) also think that our
thinking and acting might also be governed, at least in part, by our
individual biological make-ups. After all, it does sometimes appear to be the
case that some personality traits are more ingrained than others. For
example, has someones deep-rooted stubbornness been derived from longpractised habit or might it have been genetically inherited? Nevertheless,
cognitive-behaviourists remain convinced that our personalities are a mix
of how we think and how we behave.
If we assume that we are indeed all such personality mixes, then it seems
likely that changing any of our ways of thinking, or altering any of our ways
of behaving, might cause changes in our characters. For example, suppose
that you change your self-perception from I always fail to I am competent, or change your behaviour by, say, stopping smoking. From a
cognitive-behavioural point of view, making these changes might result in
your personality changing in some way as well. The initial changes that you
make in your lifestyle or your attitude might be big or they might be small;
they might have big effects or they might make little difference. Here, for
example, is the story of a big change from a big event:
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Case study 4.1

Bill was nearly 50. He had been employed by Mega Bank Ltd for all his working
life. Recently he had become anxious, depressed and stressed. His life was getting
out of control. Thats why he had started seeing his counsellor, Genevieve.
When he came along for his third session of counselling, Bill had some
earth-shattering news. During the preceding week Bill had lost both his marriage
and his job. On the Monday, Barbara, his wife of 27 years, had simply announced
that she had had enough and just walked out. Then, on the Thursday, the bank
had made Bill redundant. Bill was in a state of shock. He had financial worries,
personal worries and no future. The third session was very difficult and very
fragmented.
A very different Bill arrived at the fourth session. He was like somebody whom
Genevieve had never met before. The impact of all the events of the last two
weeks had awakened a spark long buried in Bill. The worm had turned. He simply
announced, Im off. Bill had decided that, if nobody wanted him, he wanted
nobody. He had converted everything that he owned into cash and a round-theworld airline ticket. Ive only come to say goodbye, he said, and thats just what
he did. Bill disappeared.
Eighteen months later Genevieve happened to run into Bill once more. Bills
whole being had altered. His posture was different, his clothes were different
and his attitude to life was completely different. A revitalised Bill was back in
the UK and happily living a new way of life. Bill had no security, he had no longterm plans and he certainly didnt have any money nevertheless he was a
happy man.

ACTIVITY 4.1
Consider the following and discuss with a friend or colleague.
Did events really change Bills personality or did they simply permit the real Bill
to emerge?

COGNITIVE-BEHAVIOURAL THEORY THE BEHAVIOURAL BIT

For the first half of the twentieth century, the emphasis of the non-Freudian
investigations into personality development was mainly concentrated on
asking why one person typically seemed to have one sort of personality and usually behaved one way, whereas someone else seemed to be
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a different sort of person and usually behaved another way. These investigators, famously including Pavlov (1927), Skinner (1953) and Wolpe (1958),
among others, came to believe that personality was a result of imposed
learning from events. For example, we might get an electric shock from some
faulty wiring and so we learn that electricity is dangerous. Unsurprisingly,
from then on, we are always wary about touching electrical cables. These
investigators also came to believe that, if a particular behaviour was repeated
often enough, it would eventually become automatic or ingrained. For
example, someone who has learned through many painful experiences
that fire burns might automatically, even involuntarily, flinch away from
glowing red objects, whether or not they are really hot.
The idea that personality comes from learned behaviour leads us to
wonder if personality development is just a mechanical process. If the
behaviourists were right, it seemed likely (perhaps worryingly so) that
people could be made, unmade and remade as required. What could be
simpler? If you need a different sort of a person, simply alter how the
human machine works. Just adjust a few psychological nuts and bolts
job done.
The Behavioural Model of Personality, or behaviourism (Burrhus F. Skinner,
190490), is based on the notion that it is simply our learning from our
experiences that makes us do what we do and that makes us who we are. If
this is true, if we do not like what we have become, we can simply change
ourselves by unlearning or relearning. So if, as therapists, we come across
clients who have learned to have some wrong emotional reactions to life,
perhaps we can simply help them to unlearn these wrong feelings and to
learn the right ones instead. If we really could do this, we might be able
to simply get on with actually curing our patients rather than spending
hours helping them to agonise endlessly over their delicate inner beings
well, thats the basic idea anyway.
Clearly it would help our enquiries into how personality types come from
our learning if we could understand more about how learning works. The
learning process is usually referred to as the stimulus/response mechanism. At
its simplest it works as shown in Figure 4.1.

STIMULUS
(something happens to someone)

RESPONSE
A
PERSON
(black box)

Figure 4.1
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In the behavioural case, the way to understand this process is to visualise

the person being studied as a sort of black box. We cannot see what is
going on inside and actually we do not care. Such a lack of understanding
does not matter because it is only the result that counts. This sort of
learning is called associative learning it automatically connects stimulus
with response no thinking involved. This is how it works.
Example 1
In this first example, think about having a glass of wine (if you prefer you
can think about bacon sandwiches, chocolate bars or whatever you fancy).
We will stick to wine.
You go to the cupboard and get out the bottle (theres the clunk of the
cupboard door). The bottles clink as you pull one out. You push in the
corkscrew and pull out the cork (theres the plopping noise as the cork pops
out). You pour out the wine (theres the gurgle as the wine leaves the bottle
and falls into the glass). By now you are really ready for that wine; you
can almost taste it. This is a classically conditioned response (Ivan Pavlov,
18491936). Your learning-based response to those noise-generated stimuli
is so strong (reinforced) that you dont always need to see whats going on
in order to react. Just my describing what happens when wine is poured will
get lots of people quite excited. If someone in the next room were to open
what was actually a vinegar bottle and then pour the vinegar into a glass
bowl, many people would probably show the same I want some now!
reaction. This is exactly what happened to Pavlovs dogs when they learned
to salivate at the sound of the dinner bell, even when there wasnt any food.
Classically conditioned responses are also called rigid responses.
Example 2
In this second example, think about a teenager first entering the world of
work. At school, peer pressure taught our teenager to wear jeans (learned
behaviour 1). However, at work, different social pressures made our teenager
feel uncomfortable in jeans and influenced him or her into wearing more
formal office clothes (learned behaviour 2). Next, the management decided
to promote a more customer-friendly company image and so the employees
were encouraged to dress casually. Our teenager then started to wear smartcasual clothes because that was how colleagues began to dress (learned
behaviour 3). Clearly, if behavioural change is really this simple, if someone
in authority wanted to do so, subtle overt or covert reward/pressure systems
could be used to more or less change or manipulate another persons
behaviour at will.
These more complex, ever-changing, directed behaviour patterns are
known as operantly conditioned responses or instrumental conditioning. Such
responses are also called plastic responses because they can easily be bent or
distorted. This type of behaviour/response modification is also known as
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behaviour shaping and it is sometimes used in schools, psychiatric hospitals,

prisons and similar institutions to encourage appropriate behaviours. The
inmates of such institutions are able to obtain various treats and privileges
by being awarded points (reward) for being supposedly good. They can lose
points (punishment) if they are allegedly bad or non-conforming. Such
regimes are often known as token economies.
According to the hard-line behaviour theorists such as Skinner, learning is
all that there is to personality. We are all effectively automatons whose
personalities are made up from the particular mix of learned behaviours
that each of us has acquired. At birth we are blank slates (tabulae rasae) and
life events engrave each of our individual personality patterns into each of
our slates. For example, you might have had lots of belittling experiences
in your life and so you learned to be an introvert. Someone else has
encountered nothing but praise and admiration and so has learned to be an
extrovert we are what we are.

COGNITIVE-BEHAVIOURAL THEORY THE COGNITIVE BIT

From the middle of the last century, personality theorists more and more
came to the view that humans do not just simply react to their environments. Psychologists such as Bandura (1977), Mahoney and Arnkoff (1978)
and, of course, many others, claimed that humans dont just respond to
events in their worlds, they also try to understand what is happening to
them and this understanding determines how they react. For example,
suppose someone points a gun at you that could be frightening if you
think its a real gun or amusing if you think its a water pistol. In other
words, it is how you think about and interpret what is happening that
determines how you will react.
Clearly, if our personalities really do depend on how we think, we might be
able to change our personalities by changing our ideas. So, rather than
depending on an animalistic process, driven by powerful instinctual drives
operating outside our conscious choices (psychodynamic), the cognitive
theory of personality says that what makes each of us the person that we
are comes from our conscious thinking and our conscious choices and from
how we actively interpret life.
So now lets look again at that stimulus/response mechanism (Figure 4.2).
In the cognitive case, the person is a glass box and we can try to see (or
perhaps just guess) what is going on inside. We want to know something
about the cognitive processes that are going on within the person. This sort
of interpretations-based learning is called conceptual learning it cognitively
connects response with stimulus. Thinking is involved; thinking is essential.
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STIMULUS
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RESPONSE
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(action by someone)

Figure 4.2
Conceptual learning happens when you already have some core beliefs
established as part of your view of the world a sort of acquired mental
predisposition. It works as follows.
Suppose you are reading this book sitting in a room somewhere and
suppose that I were to tell you that the wall next to you had just been newly
painted. Your immediate reaction might be either to draw away from that
wall or to be very careful if you get near to it. Such a reaction might come
about because you possibly have a core belief that I must always be clean
and tidy. Your established ideas help you to link the concept of new paint
with wet paint and then to wet paint ruins my clothes. This final link
endangers your core belief that being well presented is all-important and so
you go to great pains to avoid touching the paint.
Alternatively, my telling you about the new paint might not have bothered
you at all. Perhaps your core belief is Being clean and tidy is unimportant.
This might mean that getting your clothes paint-stained does not worry you
at all and so your reaction to my warning is to dismiss it. The essential
question is this: do the two different core beliefs (must-be-tidy/tidinessdoes-not matter), as indicated by two different reactions (must avoid/dont
care), make two different personalities? Cognitive personality theorists say
that they do.
The cognitive theorists believe that personality is based on the idea that
people become the sorts of individuals they are, not just because of the way
that they react to their worlds, but also because of the ways in which they
interpret what has happened to them, or what is, or what might be,
happening to them. An individuals personality is therefore mainly
generated by that persons characteristic thinking patterns (cognitions).
This suggests that, from the cognitive perspective, personality types also
emerge from the ways in which individuals organise their thinking and
how they manage, integrate and organise the information that they get
from the world around them. Therefore, our personalities depend on:
what we think how we interpret our worlds;
how we deal with the incoming information (perceptions);
the way we self-monitor and self-regulate ourselves by changing or
modifying our thoughts as our circumstances and our beliefs about
those circumstances change.
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COMBINING THE COGNITIVE AND BEHAVIOURAL BITS

By speculating about adding cognitive (thinking) explanations of personality to the behavioural (doing) explanations, the earlier investigators paved
the way for modern theorists (e.g. Scott et al., 1996) to argue that human
personality develops as a combined cognitive and behavioural process. This
is how a lot of theorists (see discussions in McLeod, 2003, and many other
texts) say that it works.
Let us suppose that a client comes to see us and, for whatever reason, we
have decided to use a cognitive-behavioural method of treatment. Say, for
example, that our client has what some psychotherapists might call an
obsessive-compulsive personality. This might cause our client to feel a
powerful need to continuously tidy, organise and control his or her
surroundings. So there are events or actions (I see a messy room), and these
are followed by disturbing thoughts (This messiness is bad for me). This
causes distressing feelings (I dont like this), which leads to more actions
such as some possibly compulsive behaviours (I have to clean and tidy this
room it must be perfect). As perfection is impossible, it is likely that our
client will feel compelled to keep on repeating his or her cleaning behaviour
and, of course, keep on failing to achieve perfection. The psychological
conflict between the persons ideal (It must be perfectly clean) and the
persons reality (I cannot achieve this) might cause the client to end up
experiencing a stress reaction that could include physical symptoms (rapid
heartbeat, sweating, etc.) and emotional symptoms (anxiety, depression,
etc.).
Bearing the previous example in mind, it seems reasonable to assume that
all a persons feelings, actions, thoughts and physical symptoms are
interlinked in some way. Each persons patterns of linkages combine to
create our individual personalities. Cognitive-behavioural theories of
personality are often based on such an assumption. The 4 Gates Model (see
Figure 4.3) of how this might work comes from Scott and Dryden (1966,
p157). I have slightly modified it.
1) THINKING or COGNITION

2) PHYSICAL SYMPTOMS

3) FEELINGS or EMOTIONS

4) ACTIONS or BEHAVIOUR

Figure 4.3: 4 Gates Model.

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If we think about the four components of this model as all being possible
entry-points or gates into someones personality, it follows that any of
the four entry points might be a suitable starting place for any of our
attempts to modify that persons personality. For example, in the case of the
obsessive-compulsive client whom we have already considered, we might
think about any, or all, of the following treatment strategies.
Enter at Gate 1: Explore ways to eliminate/change unhelpful thinking
and cognition perhaps by suggesting ways to reframe the problem
(some messiness is OK, etc.).
Enter at Gate 2: Teach symptoms-management techniques, such as
relaxation therapy or engaging in physical exercise.
Enter at Gate 3: Offer psychotherapy or some other form of emotional
diversion.
Enter at Gate 4: Agree a programme of new actions and behaviours
that might help regain personal control (e.g. joining a self-help group;
reading a book that explains anxiety, and so on).
Traditionally, psychotherapists have concentrated on accessing personality
via Gate 3 (the feelings/emotions gate). This is because that is where they
believe the clients most important issues are located. Indeed, many
therapists will ignore the other gates and denigrate behavioural therapy as
only treating symptoms. It does not help with the real problem, they
claim. A powerful alternative argument (Beck, 1991) is that emotional
disorders are actually only the indicators (symptoms) of cognitive and
bodily disturbance. They are not the cause. If this is so, it can be argued that
treating the cognitive and behavioural symptoms should actually be the
preferred method of helping a client.

ACTIVITY 4.2
Suppose a group of clients are helped in some way by a form of therapy based on
cognitive-behavioural ideas about personality. Perhaps they have learned to adopt
healthier lifework balances.
Have they really permanently changed (improved), or are they just feeling a bit
better for now?
What is your response to this question?

WHERE WE HAVE GOT TO SO FAR

Cognitive-behavioural ideas about human personality are certainly attractive, at least superficially. They appeal to scientists because they are testable.
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They appeal to clients because they hope to gain early relief after all, most
clients probably come along to be cured, not just to talk about cures. They
appeal to therapists because they might gain professional and personal
satisfaction from being successful helpers. However, it must always be
remembered that, at the heart of the cognitive-behavioural theories of
personality, lie the learning boxes. We cannot see into the black learning
box and we only think we can see into the glass learning box. It may be that
we are not yet able to evaluate the cognitive-behavioural explanations of
personality. Perhaps when we know a lot more than we do today about
what goes on inside the person, we might be better able to come to a
judgement. However, that is certainly a story for another day.

COGNITIVE-BEHAVIOURAL IDEAS IN PSYCHOTHERAPY

As the name implies, there are two key therapeutic components in the
cognitive-behavioural approaches to psychotherapy.
1. Cognitive: First, there are the therapeutic methods that are based on
the assumption that cognitions (thoughts, beliefs, self-images, etc.)
intervene between the stimulus and the response. One example of
this process can be found in the Rational Emotive Behavioural
Therapy Model pioneered by Albert Ellis (19132007). This
therapeutic technique is based on the well-known A, B, C principle
(Dryden, 2005; Ellis, 2001, etc.). This method assumes that stimulus
and response are not directly connected but are modified by belief.
For example, I might see someone carrying a gun (A activating
event). If my intervening thought (B belief) is that all gun bearers
are violent criminals, I might become afraid (C consequence).
However, my fear is likely to change to relief if I subsequently find
out that the gun carrier is an on-duty police officer who is there to
protect me.
2. Behavioural: Second, there are the behavioural therapy methods that
are largely based on the work of Joseph Wolpe (191597). Wolpe, a
South African who eventually became an American citizen, taught
and researched from 1965 to 1988 at the Temple Medical School in
Philadelphia. His subsequent academic years were spent in California,
where he taught at UCLA. Wolpes great contribution to behavioural
therapy was his work on desensitisation. This is a technique that uses
biofeedback to help reduce and/or eliminate the physical and
emotional symptoms that usually accompany emotionally distressing,
dysfunctional behaviours. For example, a person who is very afraid of
spiders might be taught how to use relaxation techniques to reduce
any associated anxiety symptoms, such as sweating, increased heart
rate and so on. This helps the client to reduce any fearful feelings.
Lessened fear in turn yet further reduces the physical symptoms and
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so on round and round. Geeks like me would call this a positive

feedback loop. The idea is that, eventually, the original anxieties and
phobias are either reduced to acceptable levels or are even
extinguished (Wolpe, 1976, 1990, etc.). It is important to remember
that Wolpes approach assumes that there is a direct link between the
stimulus (e.g. spotting a spider) and the immediate response (e.g.
anxiety). There are no intervening processes.
It is arguable that the behavioural theories of personality evolved, in part,
as a rebellion against the early dominance of the psychoanalytic view
of human personality. By the mid-1950s, some of the more committed
behaviourists were arguing that human personality is nothing more than
the accumulation of learned behaviours (Skinner, 1953, 1971, etc.).
However, by the 1970s there was another rebellion, this time against the
extremes of the behaviourists position. This second rebellion is sometimes
called The Cognitive Revolution (see Westbrook et al., 2007, etc.). The
cognitive theorists argued that thinking was also an important element in
the development of personality.
Cognitive therapy very much depends on the work of Aaron T Beck
(b. 1921), who, upon retirement, became Emeritus Professor of Psychiatry
at the University of Pennsylvania. Beck argued that mental processes
(thinking, believing, evaluating and so on) all contribute to the human
psychological condition (Beck, 1999, 1975, etc.). When these processes
become unhelpful, people suffer emotionally. When that suffering becomes
too much, they seek help. It is the cognitive therapists task to help clients
to change their harmful thinking. For example, someone who believes that
they might be about to fail to achieve a promotion at work might also have
an underlying general belief that he or she is a person of little value. This
poor self-evaluation will probably have been reinforced over the years by
that person continually failing in life, usually by giving up trying too soon
(Whats the point? I cant win!). Such people are often said to be setting
themselves up to fail. In cases like these, it is the cognitive therapists task
to help such a client to identify, and then to challenge, this negative (and
personally destructive) core self-image.

CBT IS BORN
Cognitive-behavioural therapy (CBT) is a term that actually describes a
range of therapeutic approaches. These approaches are all based on certain
common principles that are mainly derived from investigating the
established links between learning, thinking and behaviour (Beck, 1995;
Leahy, 2003). CBT is not a single-method therapy it does not offer a onesize-fits-all therapeutic technique that allegedly suits all clients irrespective
of their individual needs. It is a collaborative approach to psychotherapy in
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which the practitioner and the client mutually agree on a tailor-made

treatment programme that best suits each clients particular needs. CBT
clients play a very active role in their own treatments.
Behaviour therapy and cognitive therapy very much grew up together and,
to begin with, grew in parallel. Initially, the behavioural approaches tended
to be used for anxiety-based conditions and the cognitive approaches
tended to be used for mood disorders, such as depression. However, over
the years, research-based practice has encouraged these two approaches to
become one unitary form of psychotherapy. This happened because both
therapies were found productively to complement each other and both
therapies were found to be increasingly effective across an expanding range
of psychological and psychiatric conditions (Westbrook et al., 2007). As the
two therapies evolved together and influenced each other, they inevitably
merged. Their combination has produced the general model of CBT that is
so prevalent in many of todays health service treatment programmes and
elsewhere.

SOME BASIC CBT CONCEPTS

Events (each persons experiences) are not important in themselves; it
is how we interpret those events that matters (A cigar is just a cigar,
however for me it is a pleasurable smoke, whereas for you it is a cancer
stick).
How we act influences how we think as the song says, Whenever I
feel afraid . . . I whistle a happy tune . . . the happiness in the tune
convinces me that Im not afraid.
Nobody has perfect mental health. Most of us muddle about in the
middle section of our various emotional continuums (happy sad,
shy bold, etc.), with occasional trips towards the highs at one end
and the lows at the other. We are each affected in our different ways
by where we are along our individual continuums One mans meat
is another mans poison.
It is what is going on for your clients right now that matters. That is
where your clients need therapeutic relief. If your house is on fire you
immediately call the fire brigade you worry about whether it was an
accident or arson later on.
Feelings, thoughts, behaviours and bodily symptoms all interact like a
sort of psychological cats cradle so tweak the bit of psychological
string that is nearest to hand or that is easiest to tug at.
Base everything on empirical evidence. So, do not just claim that in
theory your treatment will make your clients better prove it!
Cognitions exist at two different levels in the mind:
an easily accessed level where thoughts are either at a conscious
level or held in very easy-to-recall memories;
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a hard-to-access level where the thoughts are held in an unaware

part of someones being. It can be very difficult to bring such
thoughts to the surface.

HOW MISINTERPRETING LIFES EVENTS CAN CAUSE PROBLEMS

If we get our thinking wrong (unhelpful or distorted cognitions), we might
cause ourselves all sorts of psychological problems. An important job for
the CB therapist is to try to help clients to discover how this might be
happening in their own individual cases. Only then can they be helped to
put things right. Knowledge is empowering. We can get the wrong idea
about ourselves or about what is happening to us in two important ways.
1. Negative automatic thoughts (NATs): We all have them. They are our
stereotypical ideas about ourselves: Im no good at DIY; People dont
like me; Whatever I do goes wrong. NATs are all the puttingourselves-down ways in which we interpret (often inaccurately) what
goes on in our worlds. Like the name implies, NATs automatically
frame our existence. Very often NATS are all too plausible and are
apparently easily confirmed: Maria, would you like to come to the
pub with me this evening?, Sorry, cant make it tonight. A negative
NAT confirms your interpreting this rejection as yet more proof of
your supposed unpopularity. However, the reality might be that Maria
actually regrets missing out on spending an evening with you, but she
has to work a nightshift. NATs are usually held at an awareness level
or at a level that is only just below awareness. One way of defeating
NATs is to challenge them. Find the courage to ask Maria if she is free
later in the week. You might get a pleasant surprise.
2. Core beliefs (CBs): These are the fundamental ideas that provide the
bedrock of our views about ourselves. A core belief that I am bad can
underpin such NATs as People dont like me; I shouldnt join that
club; People who say they like me are only pretending. Core beliefs
tend to be buried deeply in our unaware levels and are hard to
identify and change.
Either or both of these cognitive processes (NATs and CBs)
contribute to our psychological problems. Their fundamental purpose
is to influence how we interpret lifes events. These interpretations can
be helpful or harmful. The following basic model shows us how CBT
theorists think NATs and CBs might interfere in our lives.

A BASIC MODEL OF CBT

The CBT theorists tell us that our attitudes to ourselves and our worlds are
mainly due to our interpretations of what we think is really going on
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around us. This suggests that CBT should be a multi-method approach to

psychotherapy one that allows each clients treatment plans to be
individually crafted. If we combine this interpretation is all concept with
the 4 Gates Model of personality, we can construct a very useful, generic
model of the CBT approach to most psychological difficulties. In this
combination model, if anything goes wrong at any given location, that is
the place where the CBT practitioner starts work. See Figure 4.4 for my
suggestion of what such a model looks like.

A LIFE EVENT

HARMFUL
INTERPRETATION

HARMFUL
INTERPRETATION

1) THINKING or COGNITION

2) PHYSICAL SYMPTOMS

3) FEELINGS or EMOTIONS

4) ACTIONS or BEHAVIOUR

Figure 4.4

Case study 4.2

Berties marriage was in tatters. His intense anger with everybody (including his
wife) had caused her to threaten to leave him. Bertie was scaring people. He was
even scaring himself. He consulted Valerie, a CB therapist, and asked her to tell
him how he could regain his self-control and save his marriage. Valerie could see
that Bertie was actually physically and psychologically exhausted (physical
symptoms + emotions/feelings). Eventually, she discovered that Berties problems
began every morning at 4 a.m. That was when his neighbour, Tony, started up a
huge, noisy lorry and drove off to work. Not only did this wake Bertie up, but his
immediate fury due to his neighbours apparent lack of consideration (cognition
1) made Bertie angry all day long. He lay there every morning fuming (emotion)
and could not get back to sleep (behaviour 1). Berties days all started badly and
got worse.

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Valerie questioned Bertie about his thoughts on Tonys lack of consideration

(harmful interpretation).Were they correct? She suggested that he should try to
talk to Tony and so check out what was actually happening. The following week,
Bertie reported that he had found out that Tony was being compelled to work far
away from home in order to save his job. That was why he had to leave at such
an early hour (helpful interpretation). Bertie was now feeling very sorry for his
neighbour (cognition 2). He had also started to notice that, over the last couple
of days, his general anger had started to calm down a bit (behaviour 2). However,
he was still losing sleep.
Valerie next taught Bertie some relaxation techniques and encouraged him to
practise them at home. He also began to try them out each morning when he
was wakened so early (behaviour 3). Bertie soon found that he could nod off again
(behaviour 4). After a few weeks of practising his newly learned skills, Bertie no
longer even noticed when Tonys lorry started up.

PROBLEM ASSESSMENT
A proper assessment of a client is an essential preliminary before any
treatment can be planned or before CBT can begin. A clients whole life
should be assessed and not just the immediate presenting problem(s). For
example, an attempt to treat a particular client for depression is quite likely
to fail if the therapist does not discover that the client also needs to address
an alcohol misuse problem. However, once it has been established that a
clients problems are indeed of a psychological nature, the specific contributing issues can be identified and their theoretical origins evaluated
(diagnosis). Next, the clients problems should be assessed in terms of why
obviously harmful behaviours are currently being kept up. In sum, the
therapist needs to try to understand not only how the client acquired the
problem in the first place, but also why and how that problem is being kept
alive. This last issue is vital. We must find out what the clients problemmaintenance behaviours are. If we do not, and if we do not find ways to
interrupt these maladaptive behaviours, we will probably find that all our
attempts to help our client will get nowhere fast.
For example, suppose that you are scared of getting cancer. Smoking a
cigarette might reduce your anxiety in the short term, but doing so will
ensure that your fear is kept alive in the long term. There are a number of
very common adverse-behaviour preservation processes. They can be very
subtle and hard to spot. Very often the client is unaware of acting in such
self-defeating ways. Among these problem-maintenance processes are the
following.

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Playing it safe
A safety behaviour, no matter how apparently harmful, might be maintained because it seems to prevent something else that is even more
threatening from happening. For example, someone who is actually
healthy but who fears a heart attack might avoid risky exercise and so
become dangerously unfit. Someone else who is frightened that people
might not like their real person might curry favour by being overly helpful
to others, even at the expense of his or her own needs.

Running away
Some people avoid their problems by escaping from them. For example, a
person who claims to prefer buying everything online might actually be
forgoing the actually preferred pleasures of personal shopping due to an
unadmitted, or possibly unacknowledged, fear of crowds.

Withdrawing
This is particularly common maintenance behaviour in depressed people.
Depression usually induces a lowered mood in its victims. This might result
in someone who is normally quite sociable believing that going out
somewhere or perhaps meeting people is no longer worthwhile. This
reduction in normal activity, and the resulting reduction in stimulation,
leads to increased depression. This in turn leads to even more reductions in
activity. The persons mood is thus lowered still further. A downward spiral
has been established.

We are all doomed

This involves the client putting the worst possible interpretations on
everything. Nothing simply goes a bit wrong; mistakes are always total
catastrophes. For example, some people on a diet who eat a piece of
chocolate might just see their slips as a bit of a hiccup on the road to their
target weights. However, our troubled clients would probably see such a
sin as indicating total failure and so give up dieting altogether.

Super-worrying
This is best illustrated by a typical case. For example, a driver who was
injured in a car crash might now become automatically, yet unnecessarily,
excessively anxious whenever another car gets near even if that car is
being driven quite safely. This over-worrying is also known as hypervigilance.
Because such clients worry all the time, any little problem at all imme80

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diately becomes very scary a pain in the stomach is not indigestion but
cancer of the colon; a cough is a symptom of tuberculosis and not just a
mild cold. Even if these misconceptions are put right by a doctor, they still
serve to increase that persons physical and psychological anxiety/worry
levels and so increase the already established tendency to super-worry.

I told you so
Here is another typical example. A client who fears rejection might become
socially anxious and so seem to be a bit hostile to other people. This only
serves to make the other people unfriendly too. The original social anxiety
increases and so does our clients apparent hostility. Such clients have
clearly set up self-fulfilling prophesies I told you they didnt like me!
There are, of course, many other problem-maintenance behaviours and the
hardest of all to spot are the ones that seem most plausible.

ACTIVITY 4.3
Victoria always used a special cream that was guaranteed to make her look ten
years younger. Those things never work, her friend claimed. They must do, said
Victoria. As soon as I put it on I feel so much more youthful and so much more
attractive.
Explain this exchange between Victoria and her friend using the basic CBT
model.
How many different ways of doing this can you find?

SOCRATIC QUESTIONING
A very important, indeed fundamental, treatment method in CBT is an
approach called Socratic questioning. In fact, Padesky (1996) called it the
essential foundation of CBT. Put simply, and in keeping with Socrates wellknown philosophical style, it is a way of asking our clients challenging
questions. The eventual conclusions are, of course, their own. As some
theorists tell us (Beck et al., 1979, etc.), in the ideal, CBT clients effectively
become their own therapists. Socratic questioning is used to encourage
clients to reappraise their current thinking about their situations. It does
not encourage clients to have correct thoughts, but it does encourage
them to evaluate and, if they find it necessary, to amend their own
thinking. Here is an example of how competent Socratic questioning might
be used beneficially in psychotherapy.
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Case study 4.3

Miranda was convinced that she would fail her degree. Her counsellor, Angus,
thought that Socratic questioning might help. It went like this.
Assessment
Angus
When did you first start thinking you will fail?
Miranda Just after I came back to uni last October. It was around about the
time that I had to find a B&B in a hurry as my flat-share place had
been given to someone else.
A What goes through your mind when you think about your exams?
M The college doesnt want me they want to chuck me out.
Discovering
A Suppose you were sitting in the exam hall right now, what would you do?
M Id open up the paper, see that I couldnt do it and Id panic and run away.
A Suppose that what actually happens is that you look at the paper and find
that you know the answers?
M Id feel safe and feel a part of this place after all Id feel wanted.
Challenging
A How does feeling that you will fail help you?
M It doesnt really, but it does show that I shouldnt be here.
A How do you know that you are not wanted at this university?
M Why else would my flatmates have chucked me out?
A Does that really mean that nobody else here wants you either?
M Well, now I come to think of it, the Athletics Club do want me for the
competition trials.
Problem-solving
A How could you make yourself feel more wanted at this university?
M I could see if anybody would let me join their flat-share. I heard that Pete
needed someone.
A How can you check that out?
M Ill ask him this evening.
(One week later)
Review
A How did it go with Pete?
M I moved in last night.
A How are your studies going?
M It all seems a lot easier somehow now what did you do to me?
A Nothing what did you do?

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BEHAVIOURAL THERAPY TECHNIQUES

Much of the behavioural modification element in CBT is carried out
through a series of client-suggested and client-led experiments (BennettLevy et al., 2004). The therapist assists this process by encouraging clients
to test their existing beliefs by carrying out behavioural experiments on
themselves. The clients do this in order to find out if their beliefs and
expectations really do work out in practice. In addition, clients are
encouraged to devise, and again to try out, new ways of behaving that
might serve to ease their fears. For example, people who are afraid of
crowded places might be encouraged to experiment by gradually exposing
themselves to increasingly crowded situations. In each case they would
arrange the trial so that they had an easily accessible escape route. At the
end of each test, these clients would be invited to evaluate their distress
levels, say on a score out of ten. As they continue to experiment, they will
often find that their distress level scores will start to decrease and possibly
even eventually fade to zero. This first process is known as in situ
desensitisation. It can also be done in the therapy room by inviting the client
to imagine the distressing circumstances in a sort of emotional role-play.
This second process is known as vicarious desensitisation.
There is a third process that is a way of using extreme exposure to rapidly
reduce anxieties and eliminate false beliefs. It is called flooding or implosive
therapy (Stampfl, 1973). Do NOT try this at home! Not many practitioners
would try it anywhere! The method is surprisingly simple probably too
simple. For example, suppose someone is afraid of snakes. You simply lock
them in a room with a large number of non-venomous snakes and leave
them there until they discover that the snakes cannot hurt them. The idea
is that the person will eventually calm down and the fear will disappear.
Well, that is the theory anyway and, when it works, it works at once,
miraculously. However, the chances of emotionally scarring someone for
life seem pretty high too client help or client abuse?

COGNITIVE THERAPY TECHNIQUES

A major principle underlying the cognitive element in CBT is the idea that
existing thoughts can be reappraised and reframed. This is because, as we
now know, if we can change the way we interpret events, we can change
the ways in which we react to them. The first thing to do is to discover what
the clients thoughts are that are associated with a given feeling. For
example, a depressed person might have thoughts about being helpless or
having no future (Im sad; Im a loser, etc.). A manic person might have
thoughts about being invincible or always being safe from harm (Nothing
can touch me!). The therapists task is to nudge the client towards trying to
adjust these thoughts or towards trying out different beliefs. The clients are
then asked to test out if the new ways of thinking about things are any more
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appropriate or any more helpful. If they are, it might be that lots of other
things could change for that client too, all for the better we hope. Here is
an example.

Case study 4.4

Jessica just could not stop herself verbally harassing her partner, Frank. It had
become so bad that he had felt compelled to move out, although he did not really
want their relationship to end. She very much wanted him back home and so, in
desperation, she consulted Gerald, who is a CBT counsellor. Jessicas story went
like this:
Frank and I were on a dream holiday in the Caribbean. It was the time of
the World Cup and Frank had been keeping up with the football via the TV
in the hotel bar. On the Tuesday, it was the big final and it was also the first
anniversary of our getting together. We had booked a super-romantic
dinner at a superb restaurant to celebrate. During the morning of our big
day, Frank remembered that the Cup Final was on that evening but he told
me that he would miss the match and go out with me instead. During the
meal I just couldnt stop having a go at him. It was a horrible evening.
Gerald asked Jessica, When you were shouting at him, what was going through
your mind?
Jessica replied, I just knew that he couldnt love me because, if he did, he
would never even have thought about watching that match.
Gerald asked Jessica just to test out what would happen to her feelings if she tried,
just for now, to deliberately change her thinking to, Yes, its true that Frank would
have liked to see the match. However, the fact that, despite all that, he still decided
to be with me anyway actually proves just how much he really does love me.
Jessica tried out this new way of evaluating Franks actions. It feels weird, she
said. Its like a light has switched on inside me I do feel strange. By strange,
as Gerald eventually discovered, Jessica actually meant less angry.

WHAT CB THERAPISTS MIGHT ALSO BE DOING

CBT has an enviable track record of proven efficacy (Roth and Fonargy,
2005). The current state of the research strongly suggests that it is a very
helpful treatment method for:

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generalised anxiety disorder;

health anxiety;
obsessive-compulsive disorder;
panic disorder;
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post-traumatic stress disorder;

social anxiety;
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However, there is also mounting evidence that CBT can also be usefully
delivered by alternative methods. These include working in groups, selfhelp programmes such as reading suitable texts or using the internet, and
working with couples. In addition, CBT is also starting to appear in some
interesting variants. These include compassion-based therapy (Gilbert, 2005);
mindfulness-based cognitive therapy (Segal et al., 2002); and behavioural
activation (Martell et al., 2001). Westbrook et al. (2007) offer a useful review
of a number of these very modern CBT techniques.
One direction that CBT is certainly going in will be to remain as the
NHSs preferred model of psychotherapy for the foreseeable future (NICE,
2004). Counsellors currently in training, or counsellors currently considering furthering their existing skills, would be well advised to bear this
in mind.

REFLECTION POINT
CBT only deals with symptoms and doesnt address the real problems. Is this
true? Does it matter?
CBT practitioners tell their clients what to do in order to get better. Is this always
true? Is it ever true?
What, if anything, could counsellors and psychotherapists add to the practice of
CBT? Alternatively, could the use of CBT diminish counselling practice?

SUGGESTED FURTHER READING

Westbrook, D, Kennerly, H and Kirk, J (2007) An Introduction to Cognitive
Behaviour Therapy. London: Sage.
A good entry-level book. Chapter 4, Assessment, is a vital read.
Wills, F (2008) Skills in Cognitive Behaviour Counselling & Psychotherapy.
London: Sage.
Wilson, R and Branch, R (2006) Cognitive Behavioural Therapy for Dummies.
Chichester: Wiley.

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Chap ter 5

The humanistic story

CORE KNOWLEDGE
Humanists believe that personality is powered by the so-called soft drivers
creativity, love, growth, self-actualisation, autonomy, etc.
The main humanistic personality theories include:
the person-centred approach;
the existential approach;
the gestalt approach;
the hierarchy of needs approach.
The basic unit of personality is the self and the basic purpose of existence is
self-actualisation.
Early-years personality development is largely fuelled by a need to love and
be loved. This need, when fulfilled subject to parental sanctions and
control, establishes a persons developmental conditions of worth.
Person-centred, or Rogerian, therapy was one of the most important
developments in the talking therapies during the second half of the
twentieth century.
Person-centred therapy is more a way of being (as evidenced by the
therapists own personal qualities) than it is a way of working, a therapeutic
technique or a set of applied treatment rules.

INTRODUCTION
The humanistic accounts of what makes people tick, when collected
together, are usually called the Third Force in personality theory. This
Third Force came to the fore in the second half of the twentieth century as
psychologists tried to move beyond the psychodynamic and behaviourist
ideas about personality that, up until then, had been the only two kids on
the block. In general, it seems that humanistic theorists prefer explanations
of human development that include the so-called soft personality drivers,
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such as creativity, love, growth, self-actualisation, autonomy and so on (the

list can be as long as you care to make it). Some of the more well-known
innovators in humanistic psychology include Fromm, Horney, Rogers,
Maslow, Allport, Moustakas and many others.
The basic principle that underpins the various humanist explanations of
personality is deceptively simple. People are just what they are right now;
what they are today; what they are in the here and now. There are no ideals,
no hidden blueprints and, therefore, there can be no failures because there
is no way to measure success. Humanists say that understanding people
does not need the hard science of behaviourism; it does not need the
supposed advanced skills of the psychodynamic movements specialist,
guru-like psychological interpreters. All we have to do is to listen to what
people are really telling us. If we want to know what makes someone tick,
all we have to do is to really hear the stories that lie behind the words.
Understanding people does not need experts; it just needs good listeners.
The key element in understanding humanistic ideas about personality is the
concept of the self. This is because humanistic psychologists believe that
each of us continues to develop our individual selves as we reflect on lifes
ever-occurring experiences. In other words, the self is a lifelong work in
progress. Humanists argue that maximising and optimising the growth of
our individual selves (self-actualisation) is the ongoing, core purpose of
personality development. In other words, self-actualisation is the ultimate
purpose of the human being. There are a number of ways in which humanist theorists explain how this might come about. We will now explore
four of the main humanistic approaches to the understanding personality.
These are:

the person-centred approach;

the existential approach;
the gestalt approach;
the hierarchy of needs approach.

THE PERSON-CENTRED APPROACH

The person-centred approach has been largely attributed to the seminal
work of Carl Rogers (190287). Of course, many other theorists (Carkhoff,
Gendlin, Greenberg, Elliot, Truax, etc.) have also made, and in many cases
are still making, significant contributions to the development of personcentred theory (Lietaer, 1990). However, Rogers has probably been one of
the leading figures (if not the leading figure) in humanist personality theory
and psychotherapy over the last 50 years. Like those of many great thinkers,
his ideas have permeated general society. It is not hard to see that many
Rogerian concepts (e.g. refraining from judging people; emphasising/
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respecting individuality, etc.) are readily identifiable as integral elements in

the moral and philosophical foundations of many twentieth-century,
liberal, social structures. For many people, Rogerian/humanistic beliefs have
become part of their everyday language and shared attitudes. For example,
there is often a socio-political presumption that maladaptive behaviour
(violence, criminality, substance abuse, etc.) should be understood more
and condemned less. In other words, societys liberals tend towards being
non-judgemental about anybody, and respectful towards everybody. This
includes those who allegedly deviate from societys assumed norms.
Carl Rogers grew up in a Midwest rural community in America, where the
Protestant religion played a central role in everyday life. Indeed, he intended
to become a church minister until exposure to other cultures during a trip
to a Christian conference in China, together with his early experiences in
theological college, led him to break away from the rigidly religious
background of his family upbringing. He then returned to his original love
of science and went on to study psychology at Columbia University. After
graduating, Rogers started out on what became his extremely successful
career in clinical psychology. Rogers spent much of his career in academia,
first at the University of Chicago (194557) and then at the University of
Wisconsin (195763). Over time, Rogers became more and more disillusioned with higher educations internal power politics. As a result he left
Wisconsin for California in 1963, where he became very involved with the
Encounter Group movement. He also became a Resident at the Centre for
Studies of the Person in La Jolla. Rogers major innovative contributions to
person-centred therapy had been mostly completed by the late 1970s and in
his final years he became interested in worldwide conflict resolution.
Although he abandoned his early-life plans to enter the ministry, Rogers
continued to believe in many of the fundamental moral principles of his
religious background, such as respect for individuals, the importance of
offering people unconditional love and the personal benefits of offering
forgiveness to others. Rogers also believed in self-redemption that
everyone is unique and that we are all constantly struggling towards selffulfilment (self-actualisation). Much of Rogers person-centred research
concentrated on investigating ways of exploring, enhancing, perhaps even
rediscovering, these qualities in each of us. Rogers believed that such
morally high-level attributes are at least inherent in all of us, even if they
are not always actually present in any obvious ways. These beliefs can be
seen as persistent threads running through all of Rogers work.
Throughout his career, Carl Rogers principle interests, and indeed the core
of his lifes work, were centred on developing his innovative theories about
psychotherapy. Because Rogers was mainly interested in therapy, his views
on personality evolved more as by-products of his work as a pioneering
counselling theorist and practitioner. His eventually emerging model of
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personality was based on certain fundamental beliefs. For example, Rogers

believed that human behaviour is exquisitely rational (Rogers, 1961, p194).
He also believed that the core of mans nature is essentially positive (Rogers,
1961, p73), and that man is a trustworthy organism (Rogers, 1977, p7).

Rogerian theory
Rogers approach to personality is based on the concept of the self. The
self, according to Rogers, is the sum of all of a persons experiences that are
available at any given time (Rogers, 1959). Therefore, the self must be the
product of a persons interactions with other people and that persons
awareness of being. This means that peoples perceptions of their individual
selves are the organised set of characteristics that the individual perceives
as being peculiar to himself/herself (Ryckman, 1993, p106). Another way
of putting this would be to say that our self-perceptions are how we, as
individuals, would each describe our own personalities. Equally, other
peoples perceptions of us are how they would describe our personalities
from their own points of view. Note the word perception. We are talking
about how people perceive or interpret events. We are not talking about
absolute or objective fact.
Clearly, self-ness is the key to personality in the Rogerian universe. If
someones experiences lead them to say, I am an xyz sort of a person, then
xyz-ness is probably a significant part of that individuals self-identity or
personality. The Rogerian approach to personality (the self) is based on his
argument that there are two basic developmental drives. These are:
1. the need for self-actualisation;
2. the need to be loved and valued.
Self-actualisation
According to Rogers (1959), people have an actualising tendency, which
is an implied drive towards fully developing and satisfying all their
emotional capacities and physical needs. Actualisation is a directional
(onwards and upwards) process that is ever-present. It can only be suppressed and never destroyed (Rogers, 1977). Ideally, the actualising
tendency will promote satisfactory mental and bodily growth. Put another
way, in its psychological form, actualisation is an essential function of the
emerging self. This means that actualisation can be seen as the power
behind ongoing attempts to experience the self in ways that are consistent
with peoples own established views of what makes them tick (their selfperceptions). Therefore, this type of actualisation is usually known as selfactualisation (Maddi, 1996).

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The need to be loved and valued

In terms of personality development, Rogers believed that a strong need to
be loved and valued exists from early childhood. Children, he argued, will
naturally seek love and approval from their parents. If that love is given
unconditionally, children are able to freely express inner feelings and are
able to attain their full potential. However, when obtaining that love is
possible only if the child behaves in ways approved by the parents, that love
is said to be conditional. In other words, obtaining love and positive valuations depends on the child accepting the parents own values. Rogers called
this shaping of the childs personality by giving and removing parental
approval the conditions of worth process of personality development.
The conditions of worth, an apparently innocuous phrase, actually summarises the whole of the Rogerian understanding of child development.
This is because he claimed that childhood experiences have an enduring
influence on someones whole life if they become internalised values and
self-concepts. At first glance, it seems that Rogers is agreeing with Freud. Are
not his internalised values and Freuds superego simply different words for
the same process? Humanistic theorists would argue that there is actually a
huge difference between the two concepts. They claim that, for Rogers, the
internalised values are the persons own values; they are personal qualities.
For Freud, the internalised values are symbolic representations of other
people who have been significant in a persons early years. In that sense,
the Freudian internalised values are not personal qualities but images of
someones childhood lawgivers. The humanists also go on to argue that
there is another and much more important difference. They claim that, for
Freud, much (if not most) of personality is fixed in childhood, whereas, for
Rogers, personality development is a lifelong process.
According to person-centred theory, personality does not depend on the
unconscious re-enactment of previous experiences (Rogers, 1961). Unlike
the psychodynamic position, there is no place in the person-centred world
for the unconscious. Nevertheless, some humanistic theorists (e.g. Mearns
and Thorne, 2000, etc.) do suggest that there is an area of the self wherein
the client experiences mental activities that are at the edge of awareness.
However, for Rogerians, personality is wholly dependent on the individual
consciously understanding or interpreting the self as I am now and the self
as I would like to be. In Rogerian thinking, the fully developed person (the
personality ideal) is the fully functioning individual. Such a person is fully
congruent and able to accept feelings as guides to actions. Unafraid of
feelings, comfortable with emotions and open to experiences, the actualised
self is autonomous and independent of the approval of others.

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In sum it can be argued that, like many other humanistic psychologists,

Rogers, too, was a child of his socio-political time. He proposed a very
individualistic, me-focused view of society and of how individual personalities might develop in such a culture. The world is, of course, everturning and it might be that individualism will be replaced by collectivism
in the likely overcrowded, resource-scarce world of the future. Rogers will
not reign for ever.

ACTIVITY 5.1
Person-centred humanism: is it properly self-concerned, self-respecting, self-valuing
and self-developing, or just self-centred, self-obsessed and selfish? You decide.

THE EXISTENTIAL APPROACH

Existentialists believe that the mind/body debate, which is so important to
the Freudians and the behaviourists, is actually irrelevant. Their argument
is that all the information about someones inner self and someones
external world can only exist in that persons consciousness. There is only
me (or from your point of view only you); there is nothing else. A more
academic way of putting that is to say that observers, and that which they
are observing, are just different aspects of each other they are all one
(Husserl, 1997).
This means that humanists argue that peoples personality traits only come
into existence when their experiences give them good reason for coming to
believe that they have certain qualities in their individual personalities.
What they see outside themselves and what they see inside themselves is
all the same thing. For example, suppose that a series of abusive interchanges between a worker and a manager over time result in the worker
feeling a bit second-class. Suppose also that all this unpleasantness has
caused the worker genuinely to believe that he or she really is an inadequate
person. Now it might be that, if you or I met that particular worker, we
might think that this negative self-assessment is completely wrong. We
might think that the worker is good at all sorts of things. However, our
external, supposedly objective, opinions do not matter. In the workers
world, observations of self and reflections on personal experiences are the
same thing. In his or her own eyes, the worker has become a second-class
person. From their point of view this is an existential fact and it does not
matter what anyone else says.
All this suggests is that we have no existence, no substance (no personality),
apart from that which comes from our being-in-the-world (Cooper, 2003;
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Heidegger, 1962; Spinelli, 1996, etc.). The world cannot exist without us
and we cannot exist without the world. It is a mutually dependent interrelationship. In other words, our entire substance (including our personalities) comes from our individual interpretations of our interactions
both with each other and with our wider worlds. The universe is not out
there; each of our universes is inside each one of us. If this is true, each of
our individual existences (our personalities) depends on our own unique
experiences and our interpretations of those experiences. There cannot
be any approved or finished personalities because each individuals
personality is both a one-off and, at the same time, also in unending
development. Personality therefore comes from the individual ways in
which each of us makes meaning out of our existences and that is what puts
the existence into existentialism and the human into humanistic. The
inference here, of course, is that the whole of creation only exists in our
individual consciousnesses. This means that, if there is no us, there is no
universe. Some people might find this idea to be more of an excessively
finely tuned, philosophical theory than a useful definition of reality. Are we
really our own creators? You tell me!
The existential explanation of personality becomes important for humanistic psychotherapists when our attempts to create meaning for ourselves,
to interpret our worlds, go wrong. After all, if meaning in our individual
selves and our worlds only exists in our individual consciousnesses, outside
of ourselves there can only be meaninglessness (or nothing). In existential
terms, meaninglessness is non-existence (or death). This is, of course, a
very scary idea (van Deurzen-Smith, 1988, 2002). Therefore, if we encounter
a significant conflict between how we think we have made our world
meaningful and our actual experiences, our very existence is threatened and
we become frightened (Spinelli, 1994). This is the disturbed psychological
state that existentialists call angst. In theory, at least, we can get rid of our
angst by either recreating ourselves or by recreating our worlds. From an
existentialist point of view it does not matter which we choose it is all the
same thing. Here is an example of how all this might work.

Case study 5.1

About ten years ago, Bill was a rail-crash victim. He was badly injured and this
resulted in his losing a leg. He was in hospital for a long time and that was where
he met his wife. She was one of his nurses. They have been happily married for
ten years and they have twin daughters.
Before the crash, Bill had been a soldier, but the loss of his leg meant that he
had to be invalided out of the army. Bill never seemed to get over this major

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disruption in his lifestyle. His overwhelming anger with the railway company was
preventing him from moving on and making what he might even have agreed
was a success of his new life. He went to see a counsellor. Bill spent much of the
first session grieving for the life he might have had. Over and over again, Bill kept
on repeating, If only I could turn the clock back to five minutes before the crash.
Id quickly change carriages and escape unhurt.
OK, said the therapist. Suppose I could give you a magic button, one that
will let you remake your world. Press it and you will go back to just before the
crash. Change carriages and you wont be injured. Of course, that would mean
that you never went into hospital, you never met your wife and you never had
any daughters. So, its up to you are you going to press the button?
Bill went very quiet!

THE GESTALT APPROACH

For many people, gestalt psychotherapy is essentially based on the work of
Fritz Perls (18931970) and his wife Laura (190592). Like many others in
psychotherapys history, they were refugees from the Nazis. They eventually
settled in New York, where they were prominent among the devotees of the
1940s1950s avant-garde culture in the arts, drama and radical politics. Fritz
loved the theatre and Laura was an accomplished musician. Fritzs own style
of therapy-delivery tended to be confrontational and often involved getting
the client to act out lifes experiences in order to discover their real meanings. He tended to despise academic theory, which he famously used to refer
to as over-intellectualised and as being mostly bullshit (Ginger, 2007).
In common with most humanistic ideas about people, gestalt beliefs about
personality are also based on the celebration of individual freedom and
creativity (Perls, 1948; Perls et al., 1951). The word gestalt is a German
one and its definition includes such concepts as pattern, shape and
wholeness of form. Gestalt psychologists believe that, as people grow
and develop, they organise their experiences and thoughts into patterns
and this is how they try to understand their worlds and themselves. This
will make sense if you think about the vast amount of information
impacting on all of us at any given time. There is far too much data coming
in from all directions to keep it all at an overt level in our minds. If you also
add all the inputs that we have received since birth into this huge
incoming-data stream, it can clearly be seen that we are in serious danger
of information overload. One way to control this information onslaught is
to organise it into clusters (patterns, or gestalts). We can then group these
patterns into sections and file them into a sort of internal mental catalogue.
It will then be much easier to call up the relevant catalogue sections when
the need arises and then to search within them for the exact item that is
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required. The supposed alternative to such a gestalt-based, organised internal information catalogue is chaos.
Gestalt psychology addresses the person as a functional whole. This is why
gestalt-based personality theories are considered to be holistic. They look
at the person in the round and do not separate out the constituent parts.
Completeness, in personality terms, comes as someone strives towards everhigher levels of personal integration or self-actualisation. Therefore, gestalt
personality theory is principally one of growth and education, with the
focus on health and not on psychological dis-ease (Latner, 1986).
It must be remembered that these organisational patterns (gestalts) do not
spring into existence in a complete or finished form. They need to be built
up over time. This means that a fully developed personality is made from
integrating the required completed patterns or wholes as they emerge.
Therefore, if there are any incomplete personality patterns, this is an
indication that more growth or development is either needed or is yet to
come. However, if there is stalled or unintegrated growth in the development of someones personality patterns, that person might be experiencing
distressful emotional conflict. In order to be fully functioning, people need
to construct whole patterns of thinking and being. Fully functioning
people have whole personalities.
The concept of wholeness is a very important concept in gestalt psychology
(Crocker, 1999). This is because, in order to construct the completed overall
patterns of being that make up someones personality, all of that persons
experiences must be properly integrated and fully interconnected. Therefore,
when everything in the personality is fully interrelated and interconnected,
clearly the resultant whole (the rounded person) is something that is much
more complex than merely being a collection of various separate personal
qualities or traits. We can use a computer as an example.
Think of the individual components of a computer. Individually they can
perform various limited functions. It is possible for the hard drive to be
connected to an external modem and so receive data independently. The
CD reader could be connected up to a sound system and so produce music
by itself. However, it is not until these two parts, and all the other necessary
bits and pieces, are put together and connected up that the computer can
function as a computer. In gestalt terms, once the pattern that we call
computer is complete, it then becomes much more than just a box
containing lots of individually useful electronic gadgets. It becomes a very
complex tool with many yet to be discovered uses. In other words, the
completeness of the assembled computer is something to be striven for.
Gestalt theorists say that this means that, when completeness is achieved,
the whole is greater than the sum of the parts. Therefore, again we come
to the gestalt view that personality is essentially a holistic proposition.
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THE HIERARCHY OF NEEDS APPROACH

Abraham Maslow (190879) was the sixth son of Jewish immigrants fleeing Russian persecution. In accordance with his parents fervent desire for
their children to better themselves, Maslow set out on his road to selfimprovement by studying law in New York, but later transferred to the
University of Wisconsin, where he studied psychology. He spent the
remainder of his academic career at Columbia University, where in 1943 he
published his theories about the place of actualisation drives in human
personality development. Maslow was a strong critic of the psychodynamic
and behaviourist theorists and their views on personality. He argued that
most of our learning and personality acquisition takes place at a conscious
level. According to Maslow, it is interference from negative elements in our
environments or our life experiences that obstructs our psychological
developments. Therefore, if we could overcome these barriers by gaining a
greater understanding of ourselves and increasing our acceptance of our
worlds, we could all achieve higher levels of psychological growth (personality development) or actualisation.
Although Maslow argued that actualisation was the driving force behind
human personality, his greater contribution was to place actualisation into
a supposed hierarchy of motivations or drives. Self-actualisation is the
highest drive, but before a person can attend to this need, he or she must
satisfy other, lower, motivations such safety or hunger. Maslows actualisation hierarchy (Maslow, 1943), as Figure 5.1 on the next page shows, is
based on five levels of need.
Once one level of need has been dealt with (for example, the need for the
basics of life such as food and water), the person can move on to the next
level (the need for safety and security). As Figure 5.1 shows us, the highest
need for a human being is self-actualisation and this, according to Maslow,
can only be dealt with when all the lower needs have been sufficiently met.
However, in times of stress or psychological discomfort, some people might
find it easier to deal with any resulting unpleasantness by regressing
(perhaps only temporarily) to a lower motivational level. For example, an
attack at the esteem level, possibly by feeling personally rejected, might
cause someone to regress to a lower level and so concentrate on satisfying
bodily requirements, perhaps by engaging in comfort eating (Ive been
dumped munch a large cream cake?).
However, Maslow went further than just providing us with a motivational
theory of personality. He also tried to describe what might constitute a
healthy human personality and how it might grow (Maslow, 1962, 1973).
Unfortunately for him, at the time that he was exploring these ideas, the
only available biographical case material came from clinical reports of
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SELF-ACTUALISATION
realising full personal potential

ESTEEM
achievements, abilities, respect

BELONGING
love, acceptance

SAFETY
shelter, security, removal from danger

BODILY REQUIREMENTS
food, air, water, rest

Figure 5.1: Maslows hierarchy of needs.

troubled patients. This meant that there were not very many examples of
apparently truly healthy personalities to choose from (always assuming
such paragons ever exist). Like many counsellors and psychotherapists, a
lack of evidence did not stop Maslow. Undeterred, he used supposed
historical greats, such as Abraham Lincoln, Albert Einstein, Eleanor
Roosevelt and so on, as his role models. His hypothesis was that, because
such people were apparently super-successful, they must therefore be fully
functioning and emotionally super-healthy. You may wish to question
Maslows assumptions. His studies of these greats led him to argue that
psychologically healthy people properly self-actualising people have:

awareness and acceptance of themselves;

openness and spontaneity;
the ability to enjoy work and to see work as a mission to fulfil;
the ability to develop close friendships without becoming overly
dependent on others;
a good sense of humour;
the tendency to have peak experiences (spiritual/emotional
satisfaction).
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It should be noted that Maslow viewed the drive for self-actualisation as

being an essential human need. For Maslow, it is not optional. At its highest
level, self-actualisation means being completely comfortable with the
self; having a full understanding of the self; knowing who you are. The
self-actualised person feels a unity with society and has moved beyond
guilt, shame and hate. Maslows detractors might say that, in some cases, it
could be hard to spot the difference between highly self-actualised and
smug.
Probably most of us find ourselves on the downside of self-actualisation.
Because all too often our personal needs are necessarily focused on the
lower drives as we struggle to survive in the world, we lose focus and concentrate our being on the lesser needs (as Maslow rates them). Therefore,
we cannot properly move towards personal growth. In Maslows terms, we
are deficient. It would appear that, if we want to become truly selfactualising, we need to have all of our lower needs fully taken care of. It is
only then that people can devote their energies into fulfilling their
potentials. However, coming back to real life, it does not seem very likely
that many of us could enjoy such a privileged existence and so very few of
us can ever be fully self-actualised. Even Maslow thought that this happy
state was only achievable by about 2 per cent of the population. Some
might think even this is far too high a figure.

SUMMING UP HUMANISTIC IDEAS OF WHAT MAKES

PEOPLE TICK
In sum, it should always be borne in mind that all four of the humanistic
personality theories discussed above are just that; they are only theories.
This is also the case with any of the other humanistic personality theories
that you might come across. Until fairly recently, there has been a scarcity
of supporting evidence apart from clinical reviews. However, this lack
is starting to be made good. In recent times, there has been significant
expansion of the supporting evidence, particularly in the case of the personcentred approaches to therapy (Elliot et al., 2008; Gurman and Messer,
2005; Patterson, 2007, etc.). Nevertheless, the humanistic approaches to
personality theory have been, and certainly still are, very influential
throughout psychology, psychotherapy and even across the wider reaches
of general society. Many influential psychologists and other thinkers agree
that, at least in personality terms, a persons subjective experiences arguably
outweigh objective reality. In other words, it is not reality as such that is
important. What is important is how each of us interprets the apparent
realities in our individual worlds. Such a constructivist-deconstructivist
attitude can be seen as permeating modern intellectual society. For many
people, the old certainties are disappearing and everything seems to be up
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for debate. Whether such views will remain tenable in the light of further
advances in our learning and knowledge is yet to be seen. For example, we
are increasingly discovering genetic markers for some personality traits.
Might it be that our personalities will eventually be found to depend more
on biochemistry than psychology; more on physics than philosophy?
It is possible to claim that the humanist personality theories were, and
perhaps still are, the children of their time, both psychologically and
socio-politically, at least in some parts of the world. It might even be that,
in the foreseeable future, their time will be over. However, whatever the
future brings, it has to be acknowledged that the importance of humanistic
thinking in our ever-evolving understanding of what makes us all tick is
undeniable.

REFLECTION POINT
Did the humanistic thinkers of the second half of the twentieth century grow
out of their times or did they help to shape them?
Outside the world of psychotherapy, where else would you find humanistic
ideas prevalent in society?
The humanist theories concentrate on empowering the individual rather than
concerning themselves with collective needs. Does this mean that they are only
relevant in social systems that are based on individual freedom?

Humanistic approaches to personality theory have given rise to a large

number of approaches to counselling and psychotherapy. The list includes
transactional analysis, encounter groups, psychosynthesis, psycho-drama,
transpersonal and many other therapy types and sub-types (Cain and
Seeman, 2002). The common factor in them all is that they tend to
concentrate on the here and now experiences of the client rather than
overly concerning themselves with either past events or predictions about
likely future activity (Schneider et al., 2002). However, probably the best
known humanistic approach internationally, and almost certainly the most
widely practised, is person-centred therapy. In the UK, person-centred counselling has probably been the most widely available counselling approach
available from the late 1970s onwards. Although imminent developments
in NHS psychotherapy provisions are likely to challenge person-centred
therapys dominance, it is likely to remain as an important therapeutic style.
Therefore, the remainder of this chapter will concentrate on exploring the
person-centred approach to counselling and psychotherapy.

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PERSON-CENTRED THERAPY IN PRACTICE

Person-centred therapy, also known as client-led, non-judgemental,
Rogerian, non-directive, experiential and so on, is of course usually
accredited to Carl Rogers (see pages 879). However, as we have already
noted, many other eminent theorists (Gendlin, etc.) have been involved in
its development. At its root is the proposition that therapists and their
clients are inherently trustworthy and well intentioned (Thorne, 2002).
Person-centred therapy emphasises the place of individual choice and
creativity in our lives (McLeod, 2003), so it naturally incorporates a
humanistic view of society. Rogers (1942) put forward an apparently simple
idea. He argued that the proper role of the psychotherapist is to help clients
to find their own solutions to their problems. According to Rogers, clients
problems usually arise when they do not adequately attend to what his
notion of personality theory suggests are peoples two basic developmental
requirements. These requirements are, as we have already noted, the need
to self-actualise and the need to be loved and esteemed by others (see pages
901). In both cases, clients grow towards psychological health when these
two needs (drives) are satisfied.

Person-centred therapy and self-actualisation

Remember, self-actualisation is the psychological process that motivates
individuals to initially secure the practical necessities of life and then
move upwards and onwards towards satisfying their emotional needs. At
its higher, more spiritual and creative levels, self-actualisation enables
clients to make helpful or beneficial judgements about the whole of
their existences (Mearns and Thorne, 2000). Therefore, a vital task for the
therapist is to help clients to explore the mechanisms and qualities of their
individual self-actualisations. Clients do this in order to better fulfil
their individual potentialities and maximise their emotional health and
growth. Of course, in the therapy room, the process of self-actualisation
is constrained by reality; by the necessary compromises that life forces on
to all of us. However, this does not mean that clients should refrain from
being ever spurred on to attempting the personal ideal; towards achieving
their own individual uniqueness. In person-centred counsellings theoretical world, it is the ultimate job of the therapist to encourage the
emergence of fully self-actualised clients (should such human perfection
actually be attainable). These flawless people would naturally be in
complete harmony with their own inner beings and with their individual
surroundings.

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The self
In contrast to these flawless peoples perfections, for the rest of us the real
self, especially the self-as-is, can be a far from harmonious state of
existence. Unhealthy or negative self-concepts can, and do, clash with any
desires for improved self-actualisation. Put simply, we might not like what
we are. Being so might make us uncomfortable, but we cannot necessarily
find a way to stop being that way. Of course, it is also possible that we might
be completely unaware that we currently exist in some sort of unfulfilled,
diminished emotional state. In either case, realised or not, the result is
personal disharmony and potential psychological ill-health. In both cases
these are the points in our lives at which we might seek or need help. These
are the places in our lives, in our individual developments, where the
person-centred therapist might choose to intervene.
In Rogerian therapy, the emphasis is on an individuals here and now. It is
the self-as-is that is important, not the self-as-was or the self-as-oughtto-be. People who are highly dependent on the judgements of others might
well be experiencing conflicts between their own inner values and
externally imposed values. This introduces the possibly of another form of
the self the self-others-expect. In Rogerian theory, emotional disturbance
also results from the intrapersonal disquiets that can arise when a person
contrasts the self as I am now with the ideal self as I would like to be or
with the self as judged by other people.

Congruence
Clearly, helping clients to explore their current self-concepts is a key
function for person-centred therapists. This is because self-concepts are how
their clients define their essential selves. Rogers argued that our selfconcepts (both clients and counsellors) might be generated either by
imposed external values or by our inner feelings about ourselves. He
believed that conflicts (incongruency) between our internal value systems
and our actual activities and experiences are the fundamental causes of
emotional disquiet (Rogers, 1961). If these self-definitions conflict with reallife experiences, psychological disharmony is a possible outcome. Suppose,
for instance, that you usually see yourself as a strong person. If you behave
accordingly, all is well. You are being psychologically congruent. However,
if instead you were to behave in a way that you perceive as being weak, you
might well become disturbed by some inner psychological conflicts. You
would be emotionally incongruent.
If there is a match (congruency) between a persons self-perceptions and
their actions or their realities, all is well. For example, if people who would
define themselves as being nurturers encounter someone in difficulty, those
people may well get a sense of personal fulfilment out of consoling or
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helping that troubled person. They have attained congruency. However, if

those same people encounter someone else in apparent need who
nevertheless rejects their offers of help, congruity may not be possible and
psychological discomfort might then arise. One way of relieving this
discomfort (attaining congruency) would be for the helpers to reframe the
rejecter as being ungrateful. An alternative, which for example might
require the helpers having to reframe themselves as being unnecessarily
interfering in other peoples lives, might be much less comfortable (much
less congruent). So, if congruence (a match between feelings and actuality)
underpins emotional good health, incongruence (a mismatch between
feelings and actuality) indicates emotional ill-health.

The core conditions

Rogers believed that the purpose of person-centred psychotherapy is to
help the client to move towards becoming a fully functioning person. By
this Rogers means a person who is unafraid to experience the totality of
emotion, who is open to inputs from all sources, and who is fully engaged
in self-actualisation, living in the here and now and fully self-aware. The
emphasis is on personal autonomy rather than dependence on others. This
idealised self-state (some might say, not so much self-actualised as selfsatisfied) is facilitated therapeutically when certain allegedly necessary and
sufficient conditions are present in the counselling relationship (Rogers,
1957). Slightly amended by me, these five core conditions are as follows.
1. Client and therapist must be in productive psychological contact.
2. The client is in a state of incongruence and feels vulnerable and
anxious.
3. The therapist is congruent or integrated in the relationship.
4. The therapist experiences unconditional positive regard for the client.
5. The therapist has an empathetic understanding of the client, which is,
to a sufficient extent, communicated to the client.
In everyday person-centred counselling terms, the normal emphasis is on
the need for the counsellor to be genuine, empathetic and accepting
(accepting is also known as unconditional positive regard). However, it
is worth noting that fulfilling condition 1 (. . . in productive psychological
contact), which is another way of saying that an effective clienttherapist
working alliance must be in place, is quite often considered to be the
primary therapeutic task by many modern therapists. This is because
modern research recognises the fundamental importance of the therapeutic
relationship. Indeed, for some theorists (Constantino et al., 2002; Safran et
al., 2002, etc.) it seems that the working alliance might almost be the all
of successful psychotherapy. In other words, for some counsellors and
psychotherapists, there is only core condition 1 the rest are irrelevant.
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REFLECTION POINT
Think about the following as they might apply to you.
Can therapists really be non-judgemental? If they cannot, can they ever be truly
congruent?
In person-centred terms, when does therapy actually stop? When should it stop?
Does the Rogerian therapeutic aim of maximising individualistic self-fulfilment
more represent a liberal/progressive view of society than it depicts a useful
therapeutic construct?

How Rogerian therapy works

In Rogerian therapy, personal growth and emotional health emerge as the
therapist helps the client towards becoming open to the full range of lifes
experiences. The ability of clients to discover how to increasingly (and
better) relate to both their inner and outer worlds is, according to Rogers, a
stage process. Rogerians claim that, at the beginning stages of therapy,
clients are focused outwardly and present themselves as being impersonal,
unable to acknowledge their own feelings or to relate to others. Such people
are very much dependent on the judgements of other people. By the final
stages of therapy, these tendencies have been reversed and the clients
increasingly trust their inner selves and other people, and are comfortable
with feeling the real immediacy of their here and now. The clients selfworth assessments now depend on self-judgements; the clients important
values are now self-evaluations. This newfound confidence in the self and
openness to experience, which is facilitated by the therapists empathy,
acceptance and genuineness, allegedly permits the emergence and nurturing of new and more fulfilling ways of being.

Case study 5.2

Sally was an outwardly successful woman, although inwardly, as she told her
counsellor, Harry, she felt a total wreck. Throughout their first counselling session
Harry sensed an underlying vulnerability in Sally and he had a feeling that she was
on the edge of a major emotional collapse. There was something about Sally a
sort of brittleness that made Harry feel uneasy.
During the first two sessions, Sally focused on her apparently successful
professional and personal life. She expressed herself in terms of other peoples
judgements: My girlfriends all think Im a bit of a laugh or My manager always
trusts me to get on with things. Sally talked freely, but only about what she had
been doing a few days ago or what she might be doing during the coming

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weekend. She never seemed to be fully present in the here and now of the
counselling room.
Harry believed that the fact that Sally had come to therapy strongly suggested
that she was actually looking for something. So what was Sally avoiding? Early in
the third session Harry decided to take a chance. He told her that he felt that she
wanted something important from him and that behind her outward air of
confidence he sensed a vulnerable and frightened person. Sally became very angry
and told Harry that he was completely disrespecting her. She threatened to leave
on the spot. Harry remained calm. He told Sally that, if she did decide to walk out,
he would still be there for her at their routine appointment time the following
week. Harry was paying attention to two person-centred counselling principles. He
was showing Sally that emotions do not have to scare people and that he still
wanted to help her. Harry was not responding to Sallys aggression by being
becoming judgemental and his empathy was not diminishing. Sally spent the
remainder of the third session in an aggressive mode. Harry remained unfazed.
Sally did come along for her next session and, at last, she seemed to be able,
hesitantly at first, to talk more about how she was feeling in the here and now of
the counselling room. She told Harry that she had been very surprised by his
controlled reactions to her outburst the previous week, but that somehow he now
seemed to be the sort of person she could really talk to. You feel safe, she said.
Do you know, for the first time in ages I dont feel like running away. Sally had
at last arrived in the counselling room as a real person.

Person-centred therapy in progress

Despite apparent evidence to the contrary from many counselling skills
training courses offered by many therapist training agencies, there is no
recognised, official set of therapeutic techniques that support personcentred therapy delivery. In other words, there is no proper way to do
Rogerian counselling. Rogers himself vehemently rejected the idea that the
delivery of person-centred therapy could be reduced to fixed processes and
techniques (Thorne, 2002). Essentially, person-centred therapy relies on
therapists who can somehow engage with their clients in ways that help the
clients to acquire self-knowledge and self-acceptance. Therapists need to be
able to transmit their own Rogerian values to the client, especially those
values that focus on the innate goodness and trustworthiness of the
individual. However, this must be done in ways that respect and value the
client. For Rogerians, the therapeutic process is client-led and not therapistdirected. It is because each client is unique (as is each counselling session)
that none of these therapeutic tasks can be achieved by relying on the
application of a one size fits all technique. Put in very basic terms, personcentred psychotherapy is so much more than just repeating what the client
has just said or, from time to time, offering summaries of what the
counsellor believes has been going on in the therapy room. Mearns and
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Thorne (2007) suggest that client growth during person-centred counselling

sessions takes place in three stages.
1. During the first stage, clients are helped to develop trust in
themselves, their counsellors and the counselling process.
2. In the second stage, the therapist and the client develop a beneficial
level of intimacy, such that clients feel increasingly able to reveal what
is really going on inside themselves (mind and body) and become
willing to explore their own experiences.
3. During the third stage, there is a high level of clienttherapist
mutuality, at such a level that both therapists and their clients are
comfortable with self-disclosure. This last stage, although presumably
very rewarding for the therapist and self-fulfilling for the client, is
clearly one that would appear to require a great deal of skilful
management. Careful attention must be paid to professional and
ethical boundaries.
Person-centred practitioners would certainly argue that none of these stages
is likely to be adequately facilitated by a simplistic application of therapeutic technique.

REFLECTION POINT
Self-disclosure a therapists dream or a therapists nightmare?
Is counselling training in techniques that complement the theory possible?
Are the higher levels of self-actualisation really relevant to Third World societies?

SUGGESTED FURTHER READING

Cooper, M, OHara, M, Schmid, P and Wyatt, G (eds) (2007) The Handbook
of Person-Centred Psychotherapy and Counselling. Basingstoke: Palgrave.
A helpful book, particularly the theoretical introduction given in Chapter 1
and the explanation of actualisation set out in Chapter 5.
Mearns, D and Thorne, B (2007) Person-centred Counselling in Action, 3rd
edition. London: Sage.
An easily read starter book. The hands-on approach to the core
conditions (Chapters 4, 5 and 6) are very much worth reading.
Tudor, K and Merry, T (2006) Dictionary of Person-centred Psychology.
Ross-on-Wye: PCCS Books.

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Chap ter 6

Personality and therapy

todays story

CORE KNOWLEDGE
In addition to the psychodynamic, cognitive-behavioural and humanistic
explanations of personality (see Chapters 3, 4 and 5), modern personality
theory includes the following.
Trait Theory
Eysencks three dimensions of personality:
1 introversion/extroversion;
2 neuroticism/emotional stability;
3 psychotic/non-psychotic.
McCrae and Costas Big Five personality dimensions:
1 extraversion: excitability, sociability, assertiveness;
2 agreeableness: positive social qualities;
3 conscientiousness: thoughtfulness, achievement focus, purposefulness;
4 neuroticism: emotional instability, anxiety, moodiness;
5 openness: insight, emotional intelligence, wide interests.
Bio-genetic Theory personality depends on internal biochemistry or
genetically inherited qualities.
Interactional Learning Theory social pressures affect personality
development.
Complex personality theories attempt to integrate all the known influences
on personality development. Such processes underpin some of the integrative
theories of counselling and psychotherapy. Integrative theories include:
Ryles Cognitive-analytic Theory integrates psychoanalytic theory with
cognitive methodology;
Clarksons Five Facets Theory argues that the therapeutic relationship is
fundamental and divides it into five modalities: working alliance;
transferential; reparative/developmental; person-to-person/real;
transpersonal;
Evans and Gilberts Relational-developmental Theory includes all the
clients relationships both inside and outside the therapy room.

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TODAYS STORIES ABOUT PERSONALITY

The ever-ongoing story of how humans have tried to make sense of what
it is that makes us all tick is probably a tale that will never end. In this
book so far, we have been focusing on exploring the psychodynamic, the
cognitive-behavioural and the humanist aspects of personality theory (the
traditional Big Three). We have also been exploring how and why these
three theories have been so important to psychotherapists. As we now
know, much of counselling, as practised to date, has been largely based on
what the Big Three psychological theories tell us about what makes people
what they are. However, times change and so too do fashions in psychology
generally and personality theory in particular. Just as fashions in personality
theory change, so too do fashions in psychotherapy. As a consequence,
partly in parallel with modern revisions in psychological theory and partly
independently, the true values of the traditional therapies are currently
being extensively reassessed. This means that counsellors will need to
continually update themselves about developments in personality psychology because any such changes might well have implications for future
developments in psychotherapy practice. In any event, today the Big
Three personality theories are far from being the only players in the game.
There are many other modern ideas about what makes people tick (see
Schustack and Friedman, 2007), indeed far too many to include them all
here. Among the many additional, currently popular, personality theories
that are around, some of the following might be of particular interest to
counsellors and psychotherapists.

TRAIT THEORY
Trait Theory is a fairly modern approach to personality theory, although its
origins can be traced back to some much earlier ideas. Way back in 1936,
Gordon Allport claimed to have found over 4,000 words in just one English
dictionary that he thought described all the supposed personality traits. He
grouped them into three levels (Allport and Odbert, 1936):
1. cardinal traits: such as narcissistic, Machiavellian and so on;
2. central traits: general qualities such as intelligent, cunning, honest
and so on;
3. secondary traits: appearing only in certain circumstances, such as
anxious, frightened, impatient and so on.
Some 30 years later, in 1965, Raymond Cattell regrouped Allports list into
16 key personality traits, which he claimed were the fundamental building
blocks of human personality. These are:

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warmth
reasoning
emotional stability
dominance
liveliness
rule-consciousness

social boldness
sensitivity
vigilance
abstractedness
privateness (sic)

apprehension
openness
self-reliance
perfectionism
tension

At about the same time, Eysenck was starting to produce a different threedimensional model of human personality traits (Eysenck, 1992a). This
model proposes that someones personality can be defined by its positions
along three continuums:
Introversion
Neuroticism
Psychotic

Extroversion
Emotional stability
Non-psychotic

Modern trait theories of personality tend to concentrate on what is

popularly known as the Big Five (McCrae and Costa, 1997). Generally
speaking, this theory proposes five broad categories of personality trait.
1. Extraversion: excitability, sociability, assertiveness, etc.
2. Agreeableness: positive social qualities, such as trust, kindness,
altruism, etc.
3. Conscientiousness: thoughtfulness, achievement focus, purposefulness,
etc.
4. Neuroticism: emotional instability, anxiety, moodiness, etc.
5. Openness: insight, emotional intelligence, wide interests, etc.
It seems reasonable to suggest that many, if not most, people can be
described in terms of any of the above lists of relatively easily observable
personality traits (Cattells 16 traits, Eysencks three continuums or McCrae
and Costas Big Five). The difficulty, of course, is how to decide which
set or subset of traits to select. Doubtlessly, debate about the numbers and
types of traits to be best employed will persist. In any case, it is arguable that
most of these trait lists are little more than common sense and so, basically,
you pays your money and you takes your choice your ideas are just as
good as anyone elses. They are certainly as good as mine.
Another major problem with Trait Theory is that it often has poor
predictability. It tells us what sort of a person you have been up until now,
but it does not necessarily tell us how you will be in five minutes time.
Sometimes the worm turns. We are all familiar with situations in which
someones behaviours in one set of circumstances are nothing like that
same persons behaviours in a similar set of circumstances or on a different
occasion. A difficulty with Trait Theory, as far as therapists are concerned,
is that it tells us a lot about where someone has got to but very little about
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how they got there. It tells us even less about where they are going. Perhaps
the theory only labels people without really explaining them.

BIOLOGICAL AND GENETIC THEORIES

Like much in personality theory, many of the current biology-based
explanations about what makes us the sorts of individuals we are, are
actually modernised versions of quite long-held ideas and beliefs. Many
earlier theories about the physiological explanations of personality types
went out of fashion in the last century but have now been resurrected in
the light of modern-day advances in biological knowledge.
For example, in 1848, a railway worker called Phineas Gage incredibly
survived having an iron bar driven through his head by a mistimed
explosion. It appeared that his personality was irreparably changed by his
injuries. This and many similar discoveries (see Lishman, 1996, etc.) led the
then contemporary theorists to begin to argue that personality must have
a biological (physiological) dimension. Nevertheless, from a psychological
standpoint, interest in the physiological constraints/determinants of
personality seemed to fade into the background as twentieth-century
theorists emphasised individual freedoms and psychological choices.
However, many modern investigators now claim to have discovered (or
perhaps rediscovered?) biological drivers in personality development. For
example, Eysenck (1990) suggested that high cortical arousal indicates
introvertism, whereas low cortical arousal indicates extrovertism. Other
modern advances in neuroscience appear to be locating numerous
physiological processes that indicate differing brain activities that are
associated with differing personality types (Yager, 1999).
Furthermore, according to the popular press at least, today we are apparently witnessing discoveries in DNA science that claim to be identifying
genes that are supposedly associated with certain personality traits.
Doubtlessly, there are many such discoveries yet to be made. As far as the
biological explanations of personality are concerned, it is very much a case
of watch this space. Clearly, this could be an ethical minefield. Will we
want to redesign our personalities by making chemical adjustments to our
brains? If we can, society might no longer have any need of psychotherapists. Chemists would probably be able to do our job quicker and more
cheaply Huxleys Brave New World indeed.

SOCIAL INTERACTIONAL LEARNING THEORY

Traditional learning theorists (Pavlov, Skinner, etc.) viewed personality
development as being little more than a mixture of qualities that are
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acquired as people interact with their environments and learn how to

respond to life events (Carver and Scheier, 2000). Later theorists (Funder,
1997; Rotter, 1981, etc.) have argued that this learning process is more than
just stimulus and response. They say that it is actually a much more
complex phenomenon and they claim this is because learning appears to
be strongly influenced by social pressures. This, they argue, is demonstrated
by the observation that, although many people might experience similar
events, they seem to produce varying responses, possibly due to their living
in a variety of mini-cultures. For example, not everybody who survives a
particular disaster is equally traumatised. Not everybody who grows up
on a sink estate becomes a social misfit. This would suggest that the
development of learning-based personality qualities is, at least in part,
socially or culturally determined.
There is a further important difference between simple stimulus response
learning and social learning. It seems that social learning can take place
without being reinforced by any obvious reward (Rotter, 1982). This
suggests that some people can altruistically learn behaviours and develop
various personality qualities (reward-free learning). Others might do so in
accordance with how they assess the value of intangible or deferred benefits
(reward-postponed learning). This concept is not dissimilar to Sullivans
(1953) view that a sufficient reward for adopting a particular behaviour
might only be an internal feel good benefit. However, Sullivan argued that
such rewards usually involve relief from internalised anxiety (immediate
reward), whereas Rotters argument allows the possibility that the reward
for altruistic behaviour might simply be an eventual increased sense of
personal worth (reward deferred).
It might seem at first glance that the Social Interactional Learning view of
personality is one in which individual development becomes quite a
complicated process a product of many internal and external forces and
drivers. Perhaps truly understanding people is too complex a task for
anybody to even begin to tackle.

EMERGING FROM THE THEORY MAZE

Clearly, having a grasp of personality theories is essential for any counsellor
trying to decide how best to work with any particular client. As always, the
basic dilemma for therapists is deciding which personality theories to work
from which ones to choose; which ones to reject? One way out of this
dilemma might be to avoid making fixed or specific choices. If we take the
view that personality is dependent on a number of factors, counsellors need
only deal with whichever of those factors seem important in any individual
case. Like so much else in psychotherapy, the answer to the Which
personality theory; which counselling method? question depends on when
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it is asked and on who is asking it. In any case, it is quite likely that the
answers will change as the therapeutic process unfolds. Therefore, it might
be helpful to consider personality as resulting from a combination of
theoretical positions, and that from time to time any one (or more) of these
might become more useful or more influential. Figure 6.1 on the next page
will give you a better idea of what I mean. For convenience I have split the
psychodynamic position into two separate parts (classically psychoanalytic
and psychodynamic therapies) and the cognitive-behavioural approach
into its cognitive and learning components.

REFLECTION POINT
Think about someone you know who is now a very different person. What caused
that change is it permanent?

What about you?

Who are you today?
Who were you ten years ago?
Who do you think you will be in 20 years time?
Why is all this so?

MODERN STORIES ABOUT THERAPY

Today, anyone thinking about investing time or money in counselling and
psychotherapy faces a bewilderingly extensive list of treatment options.
How can the customers (or indeed their therapists) possibly know which of
the many, many therapies to opt for? Which is the best? Which is the most
likely to work? The reality is that nobody knows, although it does seem that
some particular therapies can be shown to be usually effective in some
specific situations (Cooper, 2008). However, this does not mean that other
therapies cannot help too, or in many cases probably work just as well.
What we do know is that many investigations indicate that the mainstream psychotherapies are all more or less equally effective with cure rates
in the 6265 per cent region (Stiles et al., 2007; Wampold, 2001, etc.).
Such findings are not new. Similar studies have found similar results
throughout counselling and psychotherapys history (Dollard and Miller,
1950; French, 1933; Luborsky et al., 1975; Project MATCH, 1997, etc.). Some
theorists explain this apparent consistency by suggesting that there
are certain curative factors that are common to all the therapies (Norcross
and Goldfried, 2005, etc.). Ideally, these common factors, when properly
identified, could be combined into a sort of super-therapy. Then, in theory
at least, an all-embracing overarching therapeutic model should emerge
You name it well cure it! Clearly, the discovery of such an all-inclusive
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INTERACTIONAL LEARNING
Sullivan
Mischel
Funder
Rotter

PSYCHOANALYTIC
FREUDIAN

PSYCHODYNAMIC
OR POST/NEO
FREUDIAN

Sigmund Freud
Anna Freud

BEHAVIOURIST
LEARNING
Watson
Pavlov
Rayner
Skinner
Miller
Dollard

TRAIT & SKILL

Allport
Cattell

P
E
R
S
O
N
A
L
I
T
Y

Jung
Adler
Horney
Erikson
Klein
Bowlby

COGNITIVE
LEARNING
Kelly
Rotter
Bandura
Mahoney
Arnkoff

HUMANISTIC
& EXISTENTIAL
Rogers
Maslow
Perls

FIVE FACTOR
THEORY
McCrae
Costa

BIOLOGICAL & GENETIC

Galton
Terman
Eysenck
Gould

Figure 6.1: Possible influences on personality.

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therapy model is a highly desirable prospect. That is why many practitioners are interested in exploring therapy integration. As Roth and Fonagy
(1996) suggest (or perhaps hope?), ultimately, theoretical orientations will
have to be integrated as they are all approximate models of the same
phenomenon.
It seems that, generally speaking, a good-quality therapeutic relationship
between the client and the therapist, when combined with a productive
working alliance, usually indicates that a positive therapeutic outcome is
likely (Castonguay et al., 2006; Hubble et al., 2000; Norcross, 2002, etc.).
Therefore, it is not surprising that the current interest in integrative
psychotherapy includes a growing appreciation of the primary importance
of the clientcounsellor relationship. By concentrating on relationship
qualities rather that individual therapy qualities, counsellors can choose to
ignore the restrictive theory boundaries of the single-school models.
Therefore, integrative therapy is typically considered to be model-free.
Integrative practitioners are free to import, mix and remix, and generally
fiddle about with, any of the elements from any of the entire range of
available therapies as circumstances appear to indicate. For an increasing
number of counsellors, integrative psychotherapy is emerging as the
treatment method that seems to offer the most help to the most clients in
most situations.
Currently, probably the three most developed forms of integrated therapy
(in terms of being customer-ready) are Ryles Cognitive-analytic Theory,
Clarksons Therapeutic Relationships Model, and Evans and Gilberts
Relational-developmental Model. Doubtlessly, many other integrative
models are in development or about to be launched.

RYLES COGNITIVE-ANALYTIC THEORY

Ryle (1990) has attempted to integrate psychoanalytic theory with
cognitive methodology. This model uses cognitive techniques to uncover
neurotic behaviour patterns that are then allegedly gradually deactivated
by the therapists deliberate attempts to reformulate or reprogramme the
clients emotional responses to targeted psychological problems. It could be
argued that Ryles model is not truly integrative as it does not specifically
include many important aspects of the contributing psychotherapeutic
theories.

CLARKSONS THERAPEUTIC RELATIONSHIPS MODEL

Petruska Clarkson (19482006) based her model on the idea that the
therapeutic relationship is the cornerstone of psychotherapy (Clarkson,
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2003). She went on to claim that clientcounsellor relationships can be

described as existing in Five Facets. However, this is not an ordered stage
theory because all these facets are always potentially active. The importance
of any individual facet keeps waxing and waning as the therapy progresses.

Facet 1 The working alliance

This relationship is based on a cooperative agreement between therapist
and client that they will work together on some agreed therapeutic goals
targeted at meeting the clients needs. For example, a therapist working
with a client who is misusing alcohol might propose that they mutually
agree that the client should become abstinent. The healing power in such
a working alliance might come from the therapist saying to the client,
I wont see you at times when you have been drinking, but I will always
be there for you when you are sober. In other words, the contract sets out
the therapeutically beneficial conditions (for the client) that will govern
their meetings. In fact, if the client does manage to stop drinking, the
psychologically beneficial effects of such an achievement could be so
powerful that no further help is required. Indeed, some theorists (see
Horvath and Greenberg, 1994) have argued that the working alliance can
be powerful enough to be the all of psychotherapy.

Facet 2 The transferential/counter-transferential relationship

This relationship is the experience of unconscious wishes and fears
transferred onto or into the therapeutic relationship (Clarkson, 2003, p67).
Feelings provoked in the client by the clients perceptions of the therapist
(transference) might be therapeutically helpful; they might be harmful.
Supposedly identifying or interpreting such transferences gives the therapist insights into how a client relates to other people. Counter-transference refers to feelings evoked in the therapist in response to the clients
story. Here is an example of how the transferential relationship might be
encountered during counselling:
Suppose that a client, who was lonely and frightened when sent away to
boarding school as a child, tells her therapist that she feels overwhelming
sorrow whenever each of their therapy sessions ends. It might be that this
grief comes about because the client is unconsciously associating her
therapist with her rejecting parents. Perhaps, somehow at an unaware
level, the therapist reminds her of her uncompromising father. This is
transference and it might end or become unimportant if the client can
accept the realities of her true relationship with her therapist. Doing this
might help the client to gain a better understanding of her essential self.
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Perhaps it is also the case that, when he heard how his client was bullied by
the staff at her hated boarding school, the therapist felt a strong sense of
personal anger. Possibly the therapist is unaware that he is taking her story
personally and unconsciously connecting it to his own earlier brushes with
overbearing authority figures in his own life. In such circumstances,
counter-transference can be assumed to be playing a major part in the
therapists relationship with his client.

Facet 3 The reparative/developmentally needed relationship

This relationship is the intentional provision by the psychotherapist of a
corrective/reparative or replenishing parental relationship (or action) where
the original parenting (or previous experience) was deficient, abusive or
over-protective (Clarkson, 2003, p13).
It includes those aspects of relationship which may have been absent or
traumatic for the client at particular periods of his or her childhood and which
are supplied or repaired by the psychotherapist, usually in a contracted form
(Clarkson, 2003, p13).
Here is an illustrative example:
Suppose that a client deliberately chooses to consult a female therapist in
the hope that she will be able to help him to overcome his fear of women.
During the counselling sessions it becomes apparent that the clients
inability to relate to women is rooted in his poor-quality early-years
relationship with a rejecting mother. Her abusive behaviour to him as a child
has convinced the client, even as an adult, that malefemale relationships
are dangerous. The developmentally needed therapeutic element in this
particular case might require the therapist to help the client to regress
emotionally and to revisit those troubled childhood times. It is here that the
therapist might help the client to unstick from any early-years developmental errors. For instance, this might be achieved if the therapist offers
the client unthreatening positive regard while he works through the missed
parts of his early-years personality development. In addition, by also offering
a non-judgemental attitude towards her client, the therapist may be
deliberately trying to provide him with a reparative relationship one that
allows him to benefit from experiencing some safe contact with a woman.

Facet 4 The person-to-person, dialogic or real relationship

This is also known as the core relationship or the IYou relationship (Buber,
1970). This relationship encompasses the ordinary everydayness of being
human that therapists and clients experience as they relate to each other.
This includes the immediacy and mutuality present in here-and-now,
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person-to-person relationships that the client is encouraged to acknowledge and explore during the ongoing therapeutic processes. By this means,
the clients growing understanding of their evolving, real-time relationships
with the real selves of their therapists are used to promote healing. Such
a relationship is facilitated when the therapist offers clients empathy,
unconditional positive regard, congruence, genuineness and warmth.
For example, consider the following dialogue:
Client (babbling on about anything and everything, looking anywhere
but at the therapist) Blah, blah, blather, blather, nonsense, nonsense, etc.
Counsellor (keeping the therapeutic relationship Real and immediate)
Right now, Im feeling very left out of this session. What Id be interested
to know is what the issues are that you want us to talk about today.
Client (fantasising an Unreal relationship) Sorry, sorry; you must be
getting fed up with me talking about all the wrong things.
Counsellor (anchoring the relationship in Reality) No Im not fed up
with you. I just want to know whats going on for you right now, in this room.
Perhaps the counselling can now begin.

Facet 5 The transpersonal relationship

The transpersonal relationship is allegedly the spiritual, mysterious or
currently inexplicable dimension of the healing relationship (Clarkson,
2003, p18).
Clarkson herself acknowledges that this relationship is difficult to describe
because it supposedly transcends words and reaches into a space that is
allegedly above and beyond the physical. As she says herself, it is the
timeless facet of the psychotherapeutic relationship, which is impossible to
describe, but refers to the spiritual, mysterious or currently inexplicable
dimension of the healing relationship (Clarkson, 2003, p20).
It is clearly not at all easy to find examples of such a hard-to-define way of
therapeutic being. Some theorists believe that examples of the transpersonal relationship might be found in therapeutic interventions that use
some form of creativity, such as play therapy, art therapy, or perhaps even
in therapies that refer to symbols such as Jungian archetypes, mythology
and fairy tales. It is usually considered that the therapeutic focus of the
transpersonal relationship is on fostering the clients awareness of a
spiritual self. The best definition that I ever heard was: You know its
transpersonal when you get goose bumps.
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EVANS AND GILBERTS RELATIONAL-DEVELOPMENTAL THEORY

Evans and Gilbert (2005) believe that there are self-developmental (healing?) powers in all of the clients relationships. These include relationships
both inside and outside the counselling room. The attraction of the Evans
and Gilbert model is that it clearly recognises that any series of counselling
sessions, no matter how intensive or prolonged, will nevertheless only ever
occupy a very tiny percentage of the clients life. This raises the possibility
that therapists might overemphasise their contributions to their clients
personal developments and that non-clinical relationships are as therapeutically important, possibly more so. A very brief taster of this particular
approach to integrative psychotherapy is set out in the following Case study.

Case study 6.1

Muriels GP had referred her to Adam, an integrative therapist. I dont know why
Im here, she told Adam, Ive only come because I was sent. Muriel saw her main
problem right then to be about organising her elderly mothers admission to a
nursing home and, as an ex-social worker, she felt quite capable of sorting that
out on her own. She didnt need Adam!
Adams initial reaction was to feel angry with Muriel for dismissing his skills,
but that soon changed to a feeling that he might really not be competent enough
to help her (transference/counter-transference). He also realised that any attempt
to set up a realistic, more open-ended working alliance too soon might actually
fatally disrupt their currently fragile therapeutic relationship.
Hows it going with your mum? he asked. Awful, Muriel replied. The old
bag is against anywhere that I suggest, usually just because its me who suggested
it, and she is too frail to look for anywhere on her own. As she said that, Adam
saw Muriel becoming more and more tense and there were tears just below the
surface. Some mothers can be problems, replied Adam. Mine always has been,
Muriel said bitterly, nothing I have ever done has been right for her or good
enough. Adam noted that Muriel was describing her mother as an object, the
IIt relationship. However, at the same time Muriel seemed to be denying any
IYou feeling. Nevertheless, her Real relationship with her mother (who almost
seemed to be in the room with her) was certainly powerful enough to make her
feel angry and frustrated right there, right then.
So, how am I doing as a patient? asked Muriel. Will you give the doctor a
good report about me? I bet you wont Ive already annoyed you. But Im not
annoyed with you, said Adam, Im actually feeling that you might be feeling a
little bit sad. This immediacy seemed to unnerve Muriel; God, youre just like my
Dad, she replied. On the rare occasions that he was around he could make me
feel small too. Adam reassured Muriel and told her that he was not looking down
on her. This seemed to cheer her up (reparative/developmental).

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CONCLUSION
The future of psychotherapy, as usually practised, is likely to be complex
and certainly full of argument and debate. In this sense, it mirrors the likely
future of the psychotherapy profession as a whole. However, in terms of
being deliverable treatments, the integrative therapies, in particular, are still
in their infancy. This remains the case even though they have been a source
of controversy and study over the last 25 years or so (see Norcross and
Goldfried, 1992). The development (or not) of the integrative therapies lies
at the core of the current debate about which is the real curative factor in
psychotherapy, the therapist or the therapy. Perhaps that is a tale that, in
time, you might want to tell for yourself?

REFLECTION POINT
Think about the following how might these issues affect you?
Should the various therapies be integrated might it be better to have horses
for courses?
How can prospective clients decide which therapy style is best suited to their
needs? How do trainee counsellors who study at single-therapy training centres
know which one to enrol at?

SUGGESTED FURTHER READING

Clarkson, P (2003) The Therapeutic Relationship, 2nd edition. London:
Whurr.
Heavy going but essential reading for anyone interested in integrative
therapy. Chapter 1 explains just how important the therapeutic relationship
is to successful client work.
Evans, K and Gilbert, G (2005) An Introduction to Integrative Psychotherapy.
Basingstoke: Palgrave Macmillan.
A fairly easy read. Part 2 tells you all about the authors approach to
Integrative Practice and gives a vital explanation of Integrative Theory.
Palmer, S and Woolfe, R (eds) (2000) Integrative and Eclectic Counselling
and Psychotherapy. London: Sage.
A useful handbook, but becoming a bit dated for such a fast-evolving
approach to psychotherapy.

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part 3
WHERE DO
THERAPISTS WORK?

INTRODUCTION

INTRODUCTION
There are no doubt lots of reasons why the counselling and psychotherapy
story has evolved in so many different ways and for so many different
purposes. So far we have been considering this tale from a mainly theoretical standpoint. However, there is another powerful force that is shaping
the development of the talking therapies. This comes from the need to find
practical ways of achieving the purposes and objectives of the various
individuals and organisations that deliver real-life psychotherapeutic
services to a wide range of clients or groups of clients. Here, I am referring
to those who turn the theoretical into the practical the practitioners who
are the stallholders in todays therapy marketplace. Many such services have
been set up and developed over the years. They include:

individual private practices;

group private practices;
groups with specific purposes;
localised groups;
nationwide groups;
voluntary organisations;
public services;
statutory/governmental bodies;
commercial agencies.

It seems to be generally the case that many of these services started out
pretty much disconnected from each other. Mostly, they seem to have been
set up from time to time in order to meet specific, locally or nationally
identified needs and purposes (Tyndall, 1993). Despite their often insular
beginnings, these various types of counselling and psychotherapy services
have still managed to influence both each other and the wider therapeutic
world as well. The stories of some of these therapy delivery services are
addressed in Part 3 of this book. Therefore, the following chapters will tell
you some more of the talking therapy story. However, this time, we will be
looking into some of the real-life situations in which real-life therapists
meet their real-life customers.
No individual or organisation setting up a therapy service can succeed unless
one vital requirement is attended to. It is this they all need customers or
patrons. This essential group includes clients, supporters, funders, referrers
or any other interested parties. Quite simply no patrons, no service! The
fact is that all potential patrons are being asked to invest time, effort, money
and trust in any of the therapeutic services that are trying (sometimes vying)
to catch their interest. Clearly, patrons will only invest if they believe that
their needs and purposes are likely to be met. This means that any service
that is seeking customers, support or investment has to position itself in the
personal therapy marketplace in a manner that will attract trade. As a result,
all such services are vulnerable to the influences of the market. Indeed, in
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order to survive they must often actively conform to the demands of the
customers. This is equally true for the most altruistic of the voluntary
agencies, the most practical of the government-funded services and the
worldliest of the commercial counselling and psychotherapy consultancies.
All therapy services, even those that are free at the point of delivery, demand
some sort of personal outlay from their users and investors, even if it is only
time and effort. That outlay is, in effect, a potential demand that the services
shape themselves in ways that suit the marketplace. This demand will almost
inevitably influence the styles of counselling and psychotherapy that these
services need to provide. For example, most workplace counselling agencies
subscribe to time-limited or solution-focused methods of practice and
usually only offer clients a maximum of five or six sessions. Of course, some
investigators claim that research shows that modern counselling methods
do not need to be, indeed should not be, open-ended (Draper et al., 2002;
McLeod et al., 2000). However, does the appeal of todays therapeutic brevity
truly have a sound academic base? Is the current tendency towards focusing
on short-term therapy simply an inevitable outcome of the intense
commercial competition between all the rival agencies?
This all suggests that the direct, the indirect, the overt and the covert interactions between therapists, the organisations that they work for, their client
populations and their funders/backers are all likely to have noticeable
effects on the style, type, approach, purpose and duration of the various
services being offered. Like all shopkeepers, therapys traders have a choice.
They can either adapt their merchandise to the demands of their customers
or they can go out of business! Therefore, in order to better understand the
counselling and psychotherapy story, we need to understand how the
demands of the marketplace have shaped professional practice. How might
the various organisational systems and pressures under which therapists
carry out their trade affect the ways in which the various counselling and
psychotherapeutic treatments they offer are actually applied?
There are, of course, those who believe that counselling and psychotherapy
is a purely altruistic undertaking, one that should remain independent of
any external attempts to influence it. These therapeutic purists might argue
that ethical, client-led, professional practice is an absolute one that cannot
be, must not be, compromised in any way or by any means. Alternatively,
there are those who believe that counselling is only a social enterprise like
any other and is therefore subject to the needs and requirements of the
wider society. These therapeutic realists might well subscribe to the old
saying that whoever pays the piper calls the tune. In other words, they
would argue that the demands of the talking therapy marketplace will
inevitably determine must determine which treatment approaches are
adopted and control the terms under which they are delivered.
From the standpoint of those managing counselling and psychotherapy
services, the purist/realist debate can sometimes appear irrelevant. They
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INTRODUCTION

have a service to run and limited resources with which to manage it. For
these workaday service providers, therapy, if it is to be anything, has to be
pragmatic; it has to be purposeful; it has to deliver. Such counselling and
psychotherapy services (free or paid for) are major employers/users of large
numbers of practitioners (paid or volunteer/honorary). Therefore, we need
to hear more about how the evolution of these services has influenced
therapys story. Improving our understanding of the purposes of the
individuals, the organisations and the agencies that deliver counselling and
psychotherapy to the public is essential if we want to gain a useful
appreciation of the overall story of the talking therapies.
The individual chapters set out in Part 3 tell the tales of counselling and
psychotherapy as it is delivered in the commercial sector, the educational
sector and in the National Health Service (NHS). In each case, the range of
the available services is huge and so only a limited number of examples
can be given. The commercial sectors tale (Chapter 7) is illustrated by
discussion of issues in private practice counselling and psychotherapy and
a review of some of the concerns of counsellors engaged with the employee
assistance providers (workplace counselling). In the educational sectors tale
(Chapter 8), the concerns of counsellors working in schools, colleges and
universities are explored. Counsellors and psychotherapists working in the
NHS also have their own tale to tell and this is set out in Chapter 9.
There is one obvious omission in Part 3. That is the story of the voluntary
sector. This tale has been deliberately left out because it is simply too vast to
do justice to in a single book. The voluntary sector offers therapy through a
huge variety and range of organisations, from very localised, very small
groups to formally organised, nationwide super-agencies. It includes counsellors and psychotherapists who work in many specialities, from locally
targeted mini-groups (e.g. womens shelters, youth groups, care centres, etc.)
to national and international pressure groups (e.g. substance misuse, specific
illnesses/syndromes, prisoner welfare, relationship guidance, etc.). The list is
endless. Some voluntary agencies might operate under an informal structure,
whereas others might function under strict regulation. Of course, it would
be very useful if we had a more comprehensive picture of the various ways
in which the voluntary sector works. Unfortunately, however, it seems that
research into this area of therapy is currently very limited (Moore, 2006). It
also seems that there are relatively few modern texts on relevant theory and
core issues available, although Tyndall (1993) and Stimpson (2003) offer
some useful overviews. We must hope that other authors and investigators
are focusing on addressing this gap in the market.
What follows now in Part 3 are some more of therapys tales, this time told
from the viewpoint of those offering therapeutic services to those who wish
to use them. We are now moving away from therapeutic theory and
towards the everyday reality of the workaday therapist. These, then, are the
stories of some of counselling and psychotherapys practitioners and the
work that they do.
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Chap ter 7

Working in the commercial sector

CORE KNOWLEDGE
Private practitioners:
are free to choose their own ways of working;
are only concerned with, or responsible to, one client at a time;
are not required to be formally qualified or members of a professional
organisation;
need to be able to market themselves;
need to maintain their professional contacts they should not become
professionally isolated.
Workplace counsellors:
often have to multi-task;
usually have a responsibility towards multiple stakeholders;
may be sometimes working in ways that are very different from
traditional counselling;
sometimes need to look beyond the needs of the individual client.
All commercial sector practitioners:
need to be business-aware;
need to be able to sell themselves.

THE PRIVATE PRACTICE STORY

Some might argue that the story of psychotherapeutic private practice, at
least as it might be recognised today, began in 1886 in Vienna, when Freud
started working with his psychologically troubled private patients. This was
during his early investigative phase (188699), when he was experimenting with the application of the new science of psychoanalysis to his
psychologically dysfunctional private patients (Mulhauser, 2008). It is
certainly the case that most of Freuds so-called disciples and their
followers were prominent private psychotherapeutic practitioners during
the first half of the twentieth century.

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Of course, some of psychological therapys historians might argue that the

proper tale of the talking therapies in private practice really dates from the
end of the Second World War. This was when there was an explosion in the
demand for psychological therapies from a worldwide population that had
been emotionally scarred by conflict-related trauma (Romero and Kemp,
2007). However, irrespective of when the story of private practice therapy
actually began, today it is an important part of the working lives of many
counsellors and psychotherapists. A quick check of local directories or the
internet will show that there is an abundance of available private practitioners in most areas.

Why private practice?

There are probably many reasons why therapists work in private practice
and why this is such a widespread activity. For some practitioners, limited
employment opportunities in their own particular locale might mean that
seeing private clients is essential if they wish to practise at all. Other
therapists, many of whom either practise part-time, or work for or with a
small portfolio of employers, often wish to reduce their dependency on
limited or single sources of employment. Private practice helps them to
achieve this and it is also a useful way of better ensuring and/or supplementing their incomes. Yet other counsellors and psychotherapists, such
as academics, consultants, practice trainers and so on, might often work
in ways that do not take them into regular direct contact with clients.
Therefore, for these professional practitioners, including a limited amount
of private practice work in their overall employment portfolio is an
important way of maintaining their professional skills and satisfying the
registration requirements of their various professional bodies. However,
irrespective of the reasons why therapists enter into private practice, in
most cases it is a commercial activity they nearly all charge fees.
Generally speaking, although most private counsellors and psychotherapists
tend to work alone, a significant minority work in small collective practices. In either case, probably the greatest advantage of private practice is that
it provides the therapist with an opportunity to freely apply whichever model
or style of therapy seems appropriate for the client and with which the
therapist is professionally comfortable. Those who directly employ counsellors (schools, the NHS, voluntary bodies, etc.) often require their employeepractitioners to work to their employers own particular counselling models.
Such employers are also likely to have restrictive practice rules and to demand
compliance with specified operating procedures. Private practitioners, of
course, are much freer than their directly employed counterparts, although,
of course, they do have to comply with their professions general ethical rules.
This freedom allows private therapists to cross professional boundaries at
will and to be at liberty to explore all the creative breadths and depths of
the counselling and psychotherapy profession. In other words, the private
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practitioner is free to develop a rich tapestry of informed, effective and

creative practices that can benefit an increasingly wide range of clients (Lane
and Corrie, 2006). Unlike their directly employed colleagues, private therapists can tell their own tales their personal stories because they are able
to decide for themselves on such key issues as:

how many sessions to offer a client;

how long each session should be and how much to charge;
how often the client and therapist should meet;
the counselling approach(es) to be employed;
the types of problems that can be dealt with;
the counselling environment location, room type, furnishings, etc.

However, no matter the reasons why a therapist may have decided to enter
into private practice, there are a number of professional and practical
considerations that usually need to be addressed if the practice is to succeed
(Pritchard, 2006). After all, at the end of the day, private practice in the
talking therapies is just another business and the commercial demands of
the real world have to be met. Potential private practitioners need to
ask themselves the following questions and they need to have realistic
answers ready.
Are you ready to be your own boss?
Are you a sufficiently competent practitioner to be able to work
without colleagues providing a professional safety net?
What sorts of clients will you see? What sorts of clients wont you see?
Where are you going to see your clients?
Are you going to specialise?
How much will you charge?
What arrangements need to be made to ensure your personal safety?
Do you want to work as a single practitioner or in a small collective
setting?
How are you going to deal with the professional isolation that
working as a lone private practitioner might entail?

Current issues
So, what sorts of tales about themselves do private practitioners need to
put before their prospective customers? What are their unique selling
points? After all, clients who are thinking about going to a private therapist
for the first time are usually facing a confusing array of practitioners vying
for their custom. The counselling and psychotherapy marketplace is fiercely
competitive and its practitioners can be vociferous in their sales patter. In
any given therapeutic high street there is usually an abundance of
therapists to buy from. Which one should the clients pick? How do they
make their choices?
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Professional standards
One immediate problem comes from a simple fact that the public are
probably mostly unaware of and, if it came to their attention, it might well
shock people. It is this. In the UK absolutely anyone can call themselves a
counsellor or a psychotherapist and set up in business. There are currently
no restrictions, although this may no longer be the case in a few years time
(see Chapter 10: Counselling & psychotherapy the next story). This
means that psychotherapys prospective customers have no obvious official
reference points or national standards by which they can evaluate the
quality of the various practitioners offering them their services. Few, if any,
therapists currently find themselves publicly graded by customers who
might post the equivalent of an internet product review. However, trends
in online advertising that encourage publicly available customer feedback suggest that this apparent immunity might well be about to end.
Nevertheless, right now, there is very little consumer protection for any of
counselling and psychotherapys clients.
In some cases, private practitioners claim to comply with one or other of
the ethical rulebooks. However, it is also the case that a significant number
of private practice therapists have decided not to belong, even on a voluntary basis, to any of the professional counselling bodies or organisations.
Currently, this is a matter of professional choice and such memberships are
certainly not a requirement for UK counsellors and psychotherapists (at
least for now again, see Chapter 10). Indeed, some practitioners might
react with horror should they eventually be compelled to belong to one of
the professional associations. This is because they view such organisations
as likely to subject practitioners to restrictive professional covenants ones
that they claim could potentially weaken the therapeutic power of the
clienttherapist relationship. Whether or not this is a valid argument is still
subject to considerable, and often passionate, debate. However, prospective
clients need to be aware that, if they do consult unregulated practitioners,
they are unlikely to have anywhere to take a complaint if they feel
aggrieved in any way. This also means that underperforming practitioners
are subject to no sanctions or penalties for failing to meet acceptable
standards. Private practice therapists need not subject themselves to any
form of professional policing.
Professional qualifications
It is likely that client confusion is likely to deepen further when they
discover that, even among the supposedly more formally qualified and
professionally disciplined private therapists, there is a bewilderingly wide
range of training and qualification levels. For example, some counsellors are
accredited by the British Association for Counselling and Psychotherapy
(BACP). However, this does not mean that all such practitioners are equally
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qualified. This is because, while working towards achieving BACP accreditation, all these accredited counsellors will have undergone differing
levels of counsellor training, ranging from FE college basic certificate courses
to doctoral degrees from the major universities. To add to the client confusion, it is not even necessary for BACP members to be formally accredited
before practising as counsellors. For example, in October 2008, of the then
30,379 BACP members, only 7,672 were fully accredited (personal communication, BACP Membership Department, 14 October 2008).
Choosing a therapist
However, even when therapists are suitably experienced or apparently
qualified to practise privately, they seem to offer a baffling menu of
specialities and techniques for their potential clients to select from. Anyone
reading their adverts will find a therapeutic embarrassment of riches on
offer. How are the prospective clients, with no particular knowledge of
modern therapeutic techniques, supposed to distinguish between, say,
gestalt, humanistic, CBT, solution-focused, Adlerian, person-centred, or any
of the many, many other treatment types being urged upon them? Which
approach should they choose? How can they choose? Which is the best
treatment? How can these prospective clients make an informed choice?
After all, many clients often do not really understand what it is that they
need help with, let alone what sort of help it is they require. They only
know that something is wrong and they have heard somewhere that
counselling and psychotherapy might somehow help.
If all this is not sufficiently confusing, there is yet another question that
clients have to ask themselves before deciding to enter into private therapy.
This is a question that counsellors, too, must ask themselves before agreeing
to accept a client for therapy. The question is this. Even if someone has the
sort of problem that therapy might be able to help with, say for example
mild depression or perhaps generalised anxiety, is emotional therapy
necessarily the best way forward for that client? Would it be better (or
quicker) to take some pills, get more exercise, tough it out, join an evening
class, get a social life and so on? Can anyone be sure that counselling will
not actually make things worse?
So, anyone interested in private practice counselling and psychotherapy,
whether as providers or as recipients, might be well advised to take some
time out to reflect on what they are trying to do and on what they might
actually be able to achieve. What sorts of professional stories should the
private practitioners be telling their clients? What sorts of stories do the
clients want to hear? What sorts of stories will the clients feel themselves
able to tell their therapists? It might be a good starting place, for clients and
therapists alike, to reflect upon the following Reflection Point.

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REFLECTION POINT
Answer the following from your point of view.
Is private counselling and psychotherapy safe for its practitioners?
Is private counselling and psychotherapy safe for its clients?
Is private counselling and psychotherapy something you would consider?

Clearly, there are many difficulties involved in setting up in private practice and many issues to consider. Nevertheless, private practice can be a
rewarding job and one that can test properly trained therapists to their
professional limits. Unfortunately, at best, private counselling and psychotherapy today is only likely to provide its practitioners with a part-time level
of income. However, what it certainly will do is offer therapists a satisfying
level of professional fulfilment.

Case study 7.1

Jean telephoned David, a private therapist, to ask for help with her problems.
David asked her why she wanted to come along, as he needed to make sure that
he was the right person to help her. Of course, had he decided that it would be
better to refer her on, he could easily do so. This is because, although he worked
as a lone practitioner, he also made sure that he kept in touch with people
working in the associated professions and the social welfare agencies. In other
words, he practised alone but he was not professionally isolated.
Jean described her problem. It became clear that she was emotionally
depressed. Jean also mentioned that she had had an operation on her thyroid a
couple of years ago and that she felt she had never got over it. David asked Jean
if she had seen a doctor about any of her problems and he was concerned to learn
that she had not been to see her GP for about 12 months. He urged Jean to see
her GP for a check-up before she came along for her first therapy session.
When Jean did come along for the first session, she seemed to be very
dispirited. She cried a lot and she seemed to find it hard to look at David. He asked
Jean why she had come and she said that, actually, she nearly hadnt. When she
had initially phoned, she had been feeling a little bit better that day and had
hoped that someone might be able to make her better all the time.
It was clear that Jean was very depressed. It also seemed that her mood might
be too low for her to be able to connect with the counselling process. David asked
Jean if she had seen her doctor. Jean said she had, but, when pressed, Jean
mumbled about not having seen the doctor as such, just the practice nurse.

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David realised that it was likely that Jean would need some medication to help lift
her mood enough for counselling to begin. There was also the thyroid issue.
David knew that a dysfunctional thyroid could lower someones mood. He
encouraged Jean to book an early appointment with her doctor.
When she next came to see David, Jean was obviously feeling a bit better. She
told David that the doctor had said that physically she was fine. However, as she
was very depressed, the GP wanted her to take some medication. David explained
that it was sometimes necessary for medication and counselling to work together.
Jean agreed to start taking her pills and David suggested that they should meet
again, but not for a fortnight, so as to give the medicine time to work. When they
next met, it seemed to David that her mood had lifted so much that it was almost
as if a stranger was walking through the door now her therapy could start.

REFLECTION POINT
Do some internet research on local therapy agencies and find out their policies on:
what sorts of people they think should be offering private counselling sessions;
what sorts of professional activities they think private counsellors should
undertake;
what sorts of professional activities they think private counsellors shouldnt
undertake.

THE STORY OF EMPLOYEE ASSISTANCE PROVIDERS

It was not until well into the 1980s that the employee assistance provider
(EAP)-led provision of workplace counselling in the UK, much as we would
recognise it today, began to be more widely available. This seems to have
happened not so much as a planned development, but more as a result of
a series of troubleshooting reactions to some specific workplace difficulties.
For example, after two separate incidents in which employees committed
suicide, a doubtlessly very worried Boots the Chemists responded by setting
up an employee counselling service (Coles, 2003). In yet another example,
a concerned Post Office began to offer counselling as an antidote to high
levels of employee tension after too many stress-related incidents seemed
to be occurring (Tehrani, 1997). Other incidents in other organisations
resulted in similar employee counselling services becoming established
elsewhere.
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Today, EAPs offer much more than counselling for emotionally troubled
workers (Grange, 2005). They also offer a wide range of psychological
interventions (management consultancy, coaching, mentoring, training,
awareness programmes, etc.), as part of an extensive package of overall
human relations provisions (Carroll, 2002). The workplace counsellors
story seems to be ever-expanding and, nowadays, organisational counsellors are commonly found to be operating more or less everywhere,
and at all levels, in the world of work. There are a number of possible
explanations of why this might be so. Indeed, why is workplace counselling
so often seen as being helpful to troubled employees? Of course, it might
be that the explanation is a simple one. Perhaps it is just that both
employers and their employees find workplace counselling to be generally
useful. In other words, they do it because it appears to work (Oher, 1999).
As McLeod (2001) argues, workplace counselling apparently provides
personal benefits to many employees and it also seems to provide
organisational benefits to their employers, too. However, such a simple
explanation might not be enough. Other observers might take a more
worldly view and wonder if employers sometimes use workplace counselling to try to reduce the ever-increasing levels of damages claims from
employees who claim to have been psychologically injured at work (Hughes
and Jenkins, 2003; Kinder, 2003, etc.).

Current issues
At a basic level, workplace counselling might be nothing more than
routine, everyday counselling that just happens to be paid for by the
employer. Like subsidised canteens and staff discounts, funding workplace
counselling might just be a sort of employee perk not dissimilar to private
health insurance. Perhaps this is why most workplace counselling services
are required to assist both the employees and their immediate dependants,
and to deal with all sorts of emotional or psychological difficulties. Could
this mean that workplace counselling and general purpose counselling are
actually the same as each other it is only the funding source that differs?
Alternatively, it might be argued that workplace counselling is genuinely
different from mainstream counselling because it has its own distinguishing
features. For example, the workplace counsellor might bring into play
specific, workplace-sensitised knowledge and skills that are of particular
benefit to the workplace-based client (Feltham, 1997; Summerfield and van
Oudtshoorn, 2000).
It could also be argued that workplace counselling is different from
traditional counselling because operationally it is known to be beneficial to
employing organisations as well as to individual employees (Orlans, 2003).
After all, the cost benefits to employers of having a psychologically healthy
workplace are well established (Goldberg and Steury, 2001), and there is
strong evidence to suggest that promoting good-quality interpersonal
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relationships between workers is vital for good organisational performance

(Nuttall, 2004). It seems that workplace counselling might also be potentially helpful in managing the psychological stresses and dysfunctions
that result from the ever-present drive for change that overshadows so
many of todays employment situations (Wainwright and Calnan, 2002).
Perhaps workplace counselling is indeed very different from everyday
counselling.

REFLECTION POINT
Jot down your answers to the following questions.
What are the differences between workplace counselling and everyday
counselling?
What are the similarities between workplace counselling and everyday
counselling?
Whose interests come first employees or employers? Are you sure?

What is workplace counselling?

What workplace counselling actually is can be a difficult question to
answer. To start with, we know that there are many ways in which it can
be provided. These include in-house services, out-sourced EAPs, individual
practitioners, face-to-face therapy, telephone-based therapy, internet-based
therapy, conference calls and so on (Colon, 1996; Cutter, 1996; Grange,
2005; Wright, 2001). In the UK at least, the overwhelming majority of
workplace counselling is probably provided on a face-to-face basis by the
externally sourced EAPs and their affiliate counsellors. However, even
knowing who provides it and what the arrangements are for its provision still does not really tell us very much about what workplace
counselling actually is. It might even be that the answer really depends
on who is asking the question and who is answering it. In other words,
one definition is that workplace counselling is context dependent . . . if it
is carried out at work then it is workplace counselling (Orlans, 2003).
Alternatively, Woolfe (2003) considers workplace counselling to be a form
of psychological staff-support, whereas McLeod (2001) defines workplace
counselling as the provision of brief psychological therapy for an
employee . . . paid for by the employer. It rather looks like the answer to
the What is workplace counselling? question is You pays your money
and you takes your choice.
Perhaps we can find out what workplace counselling is by looking at some
of the things that workplace counsellors do. Among the tasks that Schwenk
(2006) suggests workplace therapists might carry out are:
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employee therapeutic counselling;

training and health education;
advising the organisation; welfare and emotional/psychological
health;
facilitating organisational change;
critical incident support; trauma management;
managing conflict situations; using mediation and facilitation skills.
We could add in many other objectives, for example:

providing services to employees dependants;

stress reduction training;
staff support;
work/life balance management;
well-being strategy planning, and many more.

Another way of finding out what workplace counselling is, is to look at some
of the reasons why organisations decide to offer their employees access to
counsellors. Frierys (2006) reasons include those shown in Table 7.1.

Major reasons

Lesser reasons

Provide additional support to employees

Enhance the staff welfare provisions

Satisfy their duty of care to their

employees

Support the Human Resources

Department

Support employees through major

changes

Protect the organisation from litigation

Help alleviate stress

Encourage staff retention and loyalty

Address sickness and absence levels

Table 7.1: Frierys reasons for the provision of workplace counselling.

How workplace counsellors relate to their clients

Nevertheless, whatever it is that you believe workplace counsellors should
do (who they should work with, who they should work for, what sorts of
services should they offer), it is arguable that there is at least one major
difference between workplace counselling and everyday, general counselling. It is this: in traditional counselling only two parties are involved; in
workplace counselling multiple stakeholders have a genuine, direct interest.
These include the employing organisation itself, its line managers, its
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Human Resources and Occupational Health Departments and, of course,

the employee-clients workmates, colleagues and family.
As we have noted, in most general practice counselling relationships, there
is only a client and a counsellor. No one else intervenes unless a clinical
supervisor is consulted. Professional ethics keep the counselling sessions
confidential. Therefore, there are only two stakeholders in the standard
counselling relationship, as can be seen in Figure 7.1.

Client

Counsellor

Figure 7.1:
The everyday general counselling relationship.

However, in the case of workplace counselling, the professional relationships start to get more complicated because the organisation (and its
constituent parts) is also an essential stakeholder. Therefore, there are a
minimum of three partners in the workplace counselling relationship, and
often more, as can be seen in Figure 7.2. This complexity also has an effect
on the power balance between the various involved parties (see Figure 7.3).

Organisation

Counsellor

Figure 7.2:
The basic workplace counselling relationship.
Client

Weak relationship

Organisation

Medium relationship
Strong relationship

Counsellor

Employee

Figure 7.3: Workplace counselling power structure

(adapted from Coles, 2003, p98).

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Not only are the relationships between the interested parties more
complicated than they are in ordinary counselling, but these relationships
are further complicated by the possibility that they might vary with the
type of task or purpose that the workplace counselling session is focusing
on. Possibly, the workplace counselling is really much more of a threecornered relationship one that has three partners (client, organisation,
counsellor) and three points of focus (administrative, psychological,
professional). Figure 7.4 is my interpretation of Towlers (1997) take on how
this all works.
Organisation
(Partner 3)

Administrative
(Focus 1)

Psychological
(Focus 2)

Counsellor
(Partner 1)

Professional
(Focus 3)
Client
(Partner 2)

Figure 7.4: The three-cornered relationship (slightly amended by the author).

So, it seems arguable that EAP counsellors do have a different story to tell
from that of the everyday, mainstream counsellor. This might be because
workplace counsellors operate within some much more complicated
relationships and power structures. Perhaps this difference can be better
illustrated by means of the following Case study (which is, of course, only
another story).

Case study 7.2

Paul is a freelance counselling affiliate with a major UK EAP agency that contracts
with a number of companies. One of those companies often sent work teams
abroad on extended work packages. Quite near the end of their return home
flight, one such team was involved in an on-board emergency. A fire warning
sounded and the pilot announced that they would be making an emergency
landing. After a nerve-racking, but actually safe, landing the passengers were told

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that a computer glitch had generated a false alarm. Nevertheless, the incident
was very frightening for the passengers.
These events first came to Pauls notice when Bill came to see him via the EAP
agency. Bill had been one of the returning technicians. When he restarted work
in the UK office, Bill found that he was becoming unreasonably angry with his
colleagues. Bill wasnt being like Bill! His manager referred him to the firms
workplace counselling service.
Bill described his circumstances to Paul and it quickly became clear that he
was probably suffering from a psychological condition known as acute stress
disorder (ASD). When Paul explained to Bill that ASD was a common occurrence
in people who had been subjected to the sort of scare that Bill had experienced
on the aeroplane, Bills relief was immediate. He had been frightened that he was
going mad. He was so relieved to hear that his condition was recognisable and
explainable. It even had a name and was also treatable. Learning these simple
facts was a huge boost for Bill and this marked the turning point in his recovery.
With Pauls support, Bill managed to cope with his mood swings during the four
or five weeks that it took the ASD to fade away and for his life to get back to
normal.

REFLECTION POINT
Workplace counsellors can get involved in all sorts of multidisciplinary tasks
would you want to?
Some companies require workplace counsellors to tell them if an employee is
misusing alcohol or other drugs how would you feel about snitching on a
client?

SUGGESTED FURTHER READING

Carroll, M and Walton, M (1997) Handbook of Counselling in Organisations.
London: Sage.
Probably the most comprehensive study available good, but dated.
Hemmings, A and Field, R (eds) (2007) Counselling & Psychotherapy in
Private Practice. East Sussex: Routledge.
Hughes, R (ed.) (2004) An Anthology of Counselling at Work II. Lutterworth:
ACW/BACP.
A wide range of topics and authors.

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Hughes, R and Kinder, A (2007) Guidelines for Counselling in the Workplace.

Lutterworth: BACP.
Routine information, but useful for newcomers to EAP work. Available as a
free download from www.counsellingatwork.org.uk (accessed Summer
2009).
Palmer, S, McMahon, G and Wilding, C (2005) The Essential Skills for
Setting Up a Counselling and Psychotherapy Practice. East Sussex: Routledge.
Lots of useful ideas for the newly established practitioner. There are some
very useful chapters on business skills, law and the practicalities of
providing a private practice service.

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Chap ter 8

Working in the educational sector

CORE KNOWLEDGE
Counsellors and psychotherapists have worked in UK schools and colleges
for over 100 years.
Counsellors work with under-18s in primary and secondary education and
with post-18s in tertiary and higher education.
There are major legal and ethical issues involved when working with the
under-18s that can vary across the age ranges. The principal concerns are:
client confidentiality;
duty of care to pupil/student clients;
information disclosure.
There are numerous stakeholders in schools counselling; these include
parents, teachers, the authorities and child protection workers.
Confidentiality in schools counselling may sometimes have to be a team
function rather than purely being the counsellors responsibility.
Therapists working in schools and colleges have two essential tasks:
attending to the emotional welfare and the mental health of the
student/pupil client;
contributing to maximising the pupil/student learning experience.

INTRODUCTION
Education sector counselling is often thought of in terms of providing
psychotherapy and guidance to troubled under-18-year-olds. Typically,
these sorts of services are targeted at pupils in primary and secondary
schools. These pupil-clients are nearly all under 18 and so legally they must
be treated differently from adults. In addition, this is a client group that is
still very much progressing through age-related emotional and psychological development, so it presents therapists with some very specific
professional challenges.
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A further area of interest to the educational sector practitioner is the

provision of counselling and psychotherapeutic services for the mostly
post-18-year-old students in further or higher education. Obviously, post18-year-olds have the same rights (and no doubt many of the same troubles)
as any other adult group in society. Therefore, at first glance it might be
assumed that their needs would be no different from anyone elses.
However, as we shall see later in this chapter, the provision of psychological
services to young adults who are still in full-time education has it own
specific concerns. For example, university or college therapists will often
find themselves having to address the particular needs of young people who
may be living away from home for the first time in their lives. Clearly, it
would be a mistake to assume that all such young adults are street wise.
This chapter will begin by exploring the various concerns and issues faced
by counsellors working with school pupils. It will then go on to examine
the difficulties that are faced by practitioners who are working with
university and college students.

SCHOOLS COUNSELLING A HISTORY

Counselling in schools is not actually such a modern innovation as might
sometimes appear to be the case. Child guidance, including elementary
forms of pupil counselling, has been a feature of educational services and
childrens health provisions since the beginning of the last century (Lines,
2006). For example, the London County Council appointed Cyril Burt as its
first child psychologist in 1913 (Institute of Education Archives, 2007). In
another example, one of the earliest instances of a child guidance service
in the USA can be found in nineteenth-century Detroit, where a basic pupil
counselling service was set up in 1898 (Bor et al., 2002).
However, in the UK, schools counselling in its more modern form began to
emerge as a result of the Newsom Report (1963). This recommended that
schools should employ counsellors who could particularly focus their
efforts on students who were apparently underperforming across a range of
educational and social measures. At that time, it was believed that the
primary task of schools counsellors was to help pupils enhance their
educational experiences. Therefore, it was proposed that only experienced
and qualified teachers should be trained for this role.
Unfortunately, subsequent constraints in education budgets, and shifts in
opinion about the proper responsibilities of workaday teachers, soon began
to undermine the specialist teacher-counsellor role. Therefore, by the mid1970s/early 1980s, counselling (at least in the pastoral sense) was mostly
downgraded to being just one of the multitude of allegedly integrated
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activities that all teachers should routinely undertake. It was no longer seen
as the exclusive province of specially trained experts (Hamblin, 1986).
However, as we have seen over the last 25 years, the workload imposed on
school staff has greatly increased and indeed is still increasing. Teachers are
more and more subject to performance monitoring. The professional
demands on them from an ever-expanding National Curriculum are forever
growing. All these developments, with their correspondingly huge time
requirements, have resulted in an exponential increase in teachers workloads, together with a tendency to depersonalise many of their functions
(Watkins, 2008). This has meant that an already overstretched teaching
profession has found it extremely difficult, sometimes even impossible, to
find the time or the personal resources necessary to maintain a combined
educator/counsellor role. Something had to give and all too often that
something was pupil counselling. However, this did not stop the youngsters
bringing their emotional and social difficulties to school. Their educational
and personal developments were still at risk. There was huge demand for
counselling, but teachers were being denied the wherewithal to meet it.
Something had to be done.

SCHOOLS COUNSELLING TODAY

Nowadays, ways of providing assistance for troubled pupils increasingly
include the introduction of trained counsellors into schools to help provide a specific, student-focused pupil support service. In such cases the
counsellors often form part of a wide range of student support provision
that includes mentors, young peoples advice workers, educational social
workers, health workers, educational psychologists, learning support
assistants, peer counsellors and, of course, the schools teaching staff (Lines,
2006). This expanding use of counsellors has been made possible by the
huge increase in recent years of available practitioners emerging from
counsellor training programmes. However, few of these training programmes appear to sufficiently address the needs of embryonic schools
counsellors and their clients. This means that newly employed schools
counsellors have to resolve a number of procedural and ethical issues,
including the following.

Confidentiality
For most counsellors and psychotherapists, confidentiality is absolute and
there have even been cases of practitioners risking prison rather than
divulging a clients confidences (Jenkins, 2002). However, in a school setting, client confidentiality is not absolute and sometimes certain disclosures
are demanded by UK law, by local child protection committee rules, and by
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a range of local authority best-practice guidelines. In addition, most schools

that employ counsellors will have their own policies on such matters and,
of course, many head teachers will vigorously guard their personal, inhouse authority.
All these competing demands for information about pupil-clients combine
to create ethical minefields for schools counsellors. After all, at base,
counsellors too have a moral responsibility to protect the overall welfare of
minors and this means that they may not always be able to offer children
the same rights and privileges that are enjoyed by adults. Clearly, this very
problematic issue is further compounded as the pupil-clients ages vary and,
obviously, different standards will apply to, say, 9- or 10-year-olds from
those that will apply to 16- or 17-year-olds. For example, on the one hand,
counsellors working with primary-age children will normally need to
obtain parental consent before any therapy can commence. On the other
hand, counsellors working with secondary-age children usually do not
require parental consent. This is because the Fraser Guidelines (formerly
known as the Gillick Competence Test) apply to protect the older pupils
rights to privacy.
Good practice suggests that the consent rules applicable in UK medical
treatment settings generally should also normally apply to schools
counselling. These are comprehensively set out in the UK Department of
Health (2001a) publication, Reference Guide for Consent for Examination or
Treatment, and the very latest information can be found at the Every Child
Matters website (www.ecm.gov.uk/informationsharing). As a general
rule, best practice permits the sharing of confidential information without
client consent (with the relevant authorities only), if there is reason to
believe that the child is, or may be, exposed to risk or significant harm. This
includes harm to others.

School management responsibility

All head teachers are required to act in loco parentis. In other words, they
have the rights, duties and responsibilities of a parent while a child is in
their charge. It might be that, during a counselling session, the therapist
becomes privy to important information that the head teacher is unaware
of. This might also be the sort of information that the head teacher would
normally, perhaps even urgently, want to act upon in the childs best
interests. It might be vital for the head teacher to consult colleagues, the
childs parents or social services.
Can head teachers rely on the schools counsellor to reveal such information? Indeed, in such cases should the counsellor break counsellingroom confidentiality? In fact, this problem is actually much more complex
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than it might seem at first sight because, apart from self-referral, there are
numerous ways in which a young person might be referred to the schools
counsellor. These include referrals from special needs coordinators, class
teachers, year heads, pastoral tutors, parents, carers and so on. All these
people have a stake in the counselling process and all may feel that they are
entitled to appropriate direct feedback. In fact, it might even be in the
childs best interests that referrers quickly become aware of a childs
difficulties or personally adverse circumstances. Again, the question is, must
the counsellor divulge such information and indeed should the counsellor
do so?
Taken all round, the issue of client confidentiality in schools counselling is
nothing less than a moral maze. There appears to be no simple answer.

REFLECTION POINT
If you were a schools counsellor, who would you feel primarily responsible to:
the child; the school; the parents; society?
What would you do if your pupil-client says, Dont tell anybody but . . .?

Case study 8.1

Maddy lived next door to Caroline who had a 13-year-old daughter, Tracy. Tracy
was normally a cheerful child, but just lately seemed to be very quiet and
withdrawn. Maddy asked Tracy if anything was wrong. Tracy said that there was
something, but she could only talk about it if Maddy promised never to tell
anyone. Maddy replied that she was good at keeping secrets but that, if she ever
found out that Maddy was in real trouble, she would do whatever she felt was
right in trying to help her.
Tracy then told Maddy enough to make her suspect that Carolines long-term
boyfriend was being abusive. This was really a matter for the police or the social
services. Tracy was possibly in serious danger and needed help. What should
Maddy do? What could she do?
Maddy decided to have a word with Tracys head teacher. She did not ask
Tracys permission, though, and at first she only talked to the head about one of
her pupils. The head asked Maddy where she lived and, after finding this out,
asked if it was a nearby neighbours child that she was concerned about. When
Maddy confirmed this was so, the head was able to tell Maddy that she was pretty
sure that she knew who the child was and that steps were already in hand to try
to help her. Maddy felt sufficiently reassured to be willing to confirm Tracys
identity.

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Unknown to Maddy, Tracy was already considered to be at possible risk and

the child protection team was already aware of her situation. As it happened,
Tracy was already seeing the schools counsellor who, now forewarned, was able
to encourage Tracy to tell her just what was going on. Tracy had been made
aware from the start that the counsellor might have to tell the head what was
happening. She made a bit of a half-hearted complaint about that, although it
seemed to the counsellor that, underneath all the bluster, Tracy appeared to be
secretly relieved that somebody cared enough about her to want to actually do
something.

ACTIVITY 8.1
Sketch out an action plan that sets out how you would have handled Tracys
problems.
How would you have decided what was in Tracys best interests? What might
have helped? What might have hindered?

WHY DO WE NEED SCHOOLS COUNSELLORS?

Schools counsellors will almost certainly find that the problems brought
to them by their student-clients are as diverse, as comprehensive, and
sometimes just as intractable, as the problems that might be brought by any
client, anywhere, to any therapist. Bor et al. (2002) argue that ordinary
everyday life itself can be stressful and problematic for any child, irrespective of individual personal strengths. They include in their list of
potential stress areas worries about issues such as competitiveness, bullying,
social exclusion, racism, family crises, sibling rivalry, underachievement,
abuse, homophobia, peer pressure and substance abuse. Clearly, this list is
far from exhaustive. Geldard and Geldard (2004) even imply that pressures
from the expected and routine experiences of adolescence might, just by
themselves, appear to generate psychological conditions that could even
require treatment. Sometimes it seems that adolescence is almost akin to a
psychological illness. So, are all adolescents emotionally diseased? No
doubt, a good many of their parents, especially when feeling sufficiently
harassed, would probably agree.
So, the task of the schools counsellor, from the moment that a referred
pupil first knocks on the counselling-room door, is complex, demanding
and pressured. The counsellors immediate concern is obviously the child
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but, behind the child, rather like ghosts slipping surreptitiously into the
room, is a whole army of others (teachers, family, friends, social services,
etc.), all of whom have a direct interest in the therapy session and who have
a vital stake in the counselling process. The counsellor also has to take into
account some other, equally ghostly, although perhaps more indirect, forces
from the wider world (professional/ethical concerns, child protection
law, societys demands, etc.). Keeping all these influences in balance and
doing right by the child is almost a superhuman task. The ideal schools
counsellor needs the wisdom of Solomon, the patience of Job and the
tenacity of Robert the Bruce, together with highly developed sensitivity and
finely honed interpersonal skills. The rest of us, those of us who dont reach
such lofty perfections, and who are not such counselling paragons, must
rely on the essential quality that Napoleon looked for in his generals; we
need good luck!

Teaching staff
Parents
Carers
Family

Head teacher
Pupil support
staff

Pupilclient

Child protection
team

Schools
counsellor

UK law

Society
Government
educational
policies

Professional
ethics
Professional
standards

Figure 8.1: The schools counsellors world.

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COUNSELLING IN COLLEGES AND UNIVERSITIES

So far this chapter has concentrated on the issues faced by counsellors
working in primary and secondary education. Another important area of
counselling for therapists working in education is that targeted at meeting the needs of students in FE or HE. Counsellors working with these
usually post-18-year-olds, who are mainly full-time students, are very often
operating from within a university or college in-house counselling service.
The differences between working with this older student client group and
the younger school pupils group will be more clearly illustrated by the
following tale from a practising university counsellor.

PRACTITIONER REFLECTIONS PAULA BILES-GARVEY

A university counsellors story
It is my experience, and that of my colleagues, that our work in a well-known
universitys counselling service is expanding. We are seeing significant
increases in the numbers of our student-clients who present with mental
health problems. These include anxiety states, panic attacks, self-harm, risktaking behaviour, excessive drinking, substance misuse, eating disorders,
obsessive-compulsive disorder and depression. All of these conditions seem
to be on the increase within the student population.
Nowadays, our counselling service, like many university counselling
schemes, is linked with the NHS general practice (GP) surgeries that serve our
resident student population. This very convenient connection has resulted in
these GPs becoming much more willing to refer suitable student patients to
our counselling service. Sometimes, this is because the NHS treatment
waiting lists are too long and sometimes this is because they believe the free,
friendly, local service provided by the universitys own counsellors will be
better tailored to the needs of the universitys own students. It is very
encouraging to note that local GP practices will often set up joint meetings
between the counselling service practitioners and medical staff to discuss
matters of mutual concern and perhaps even to consider the specific needs
of some of the student-patients.
Over the course of the last three years I have found more GPs sending
their student-patients to me as clients (not their terminology). Often the client
arrives with only a post-it note (usually on a pharmaceutical companys
freebie), with the GPs diagnosis on it together with a recommended level
of counselling. Typically, such a prescription might say Alcohol problems
12 Steps or Low self-esteem 6 weeks of CBT. These sorts of referrals
(although obviously welcome in themselves) raise a number of ethical and
procedural issues for me and my university counselling colleagues. For
example, it is a rather casual system that does not feel very confidential in the

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way that information is so informally transmitted between the GPs and the
university counselling service. It is also a system in which I as the counsellor
feel that I have been instructed by the GP, even though I work for the
universitys counselling service and not for the NHS. Furthermore, it somehow
goes against the grain to be told what therapeutic interventions to use with
my clients. After all, I am a professional practitioner and wish to apply my own
skills and knowledge. I, too, may well have an opinion about the correct
assessment of a clients problems and my own plan of how to address them.
Finally, this referral method somehow seems to suggest that we university
counsellors are seen by the GPs as adjunct assistant therapists to the NHS
and not as independent professionals in our own right.
It is now often the case that many universities are starting to advertise the
various computer programs or online services that are available to people
suffering from mild emotional disorders (e.g. www.depressionalliance.org).
These have been extensively evaluated and it seems that these online services
are often helpful. It appears from student-client feedback that they can offer
significant short-term help in such cases as mild depression or anxiety, for
example. However, it seems to me that online services are unlikely to provide
the benefits that longer-term, face-to-face, therapeutic relationships can bring
about. This is particularly so in cases where the current symptoms may be
related back to early-years developmental traumas. From my point of view,
working with a client in a long-term therapeutic setting is extremely
rewarding, especially, for example, when I see the damaged attachment
issues presented by some of my young clients being repaired as we work
through their problems together.
A particular area of professional difficulty arises when student-clients ask
me to contact their therapists back home. They want me to find out what
those therapists think and what they have been doing. Clearly my clients do
not want their original therapy disrupted. They want rapid and effective help,
but I know that building a new, quality, counsellorclient relationship with me
will take as long as it takes. There are no shortcuts. It is not possible for one
therapist to suddenly replicate another. Apart from causing problems around
confidentiality, these sorts of requests place pressure on me as a university
counsellor if I decline to contact the original therapist.
A very new form of psychological pressure, and one that is particularly
applicable to student populations, can come from the extensive, negative,
use of modern information technology. In effect, this can often be very
powerful cyber-bullying. This sort of bullying usually takes place on social
networking sites. For example, by using mobile phones, videos of date rapes
are shared, intimate pictures from relationships are made public, or very
adverse comments about people are published. These cyber assaults very
often occur after a relationship ends. Hearing or seeing the outpourings of
clearly depressed young people being shared with total strangers can be
damaging to the victims. They might feel betrayed by their friends; they

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might not even be aware that their friends are commenting on their
supposed behaviour and opinions. The internet makes it far easier today for
someone to be betrayed, humiliated or socially destroyed. For example, some
students have reported that they have had to take down their profiles from
social networking websites after future employers discovered web postings
showing them in inebriated states.
Counselling in university settings can bring a whole new set of professional
and ethical concerns for the students therapists. For me, a typical example
might arise if I were to become aware of a pre-existing mental health problem
for, say, a student teacher one who is engaged in teaching practice at a local
school. It might well be the case that the student does not wish to tell a future
employer or even the faculty board about such concerns they do not want
to be stigmatised. For instance, it is possible that the student might be
suffering from an obsessive-compulsive disorder. Perhaps the student feels
compelled frequently to leave the nursery, classroom or playground to wash
hands, check doors and so on. This might mean that the counsellor has every
reason to believe that pupils, perhaps sometimes including very young
children, might sometimes be left unsupervised or otherwise at risk. By coming
to the counselling service, the client is also effectively acknowledging that
these behaviours are getting out of control. However, the standard counselling
ethical position on confidentiality precludes the counsellor from informing the
schools management or the university authorities.
I know of one real-life case that led to such an ethical dilemma. That
particular case involved a disturbed student who looked after nursery-age
children during his teaching practice. The counsellor concerned rather
cleverly resolved the resulting ethical dilemma by asking permission from the
universitys academic board to make a presentation to the academic staff
generally about the possible impacts of mental health problems on any of the
students engaged on any of the universitys professional work experience
programmes. The counsellor sought guidance from academic staff about
what students were indeed required to declare as medical problems in such
cases. The counsellor also wanted to hear their views on what might be
considered to be minor or major mental health issues or acceptable levels of
medication that might be considered safe when students were in engaged in
safety sensitive work. This counsellors rather enterprising initiative resulted in
letters being written to several government departments and to several
counselling professional bodies to try to clarify both the legal reporting
requirements and the confidentiality/ethical issues.
With child protection issues, the rules about reporting reported or disclosed
child sexual abuse are clear, but there is often a gap in practice for young people
aged between 16 and 18. At 17, young people are considered no longer to be
minors and are not treated by the child mental health services. However, it is
not until they are 18 that they are entitled to treatment from the adult mental
health services. Many college or university counsellors are very well aware that

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the 1718 group of young people do not get the help that they need or are
entitled to as they fall between the two provisions. This is an area of special
concern to the university counsellor who might meet such clients.
Like so many students, my universitys young people, too, are away from
home, often for the first time. They might be vulnerable to all sorts of
emotional and psychological difficulties, ranging from homesickness to major
depression. Sometimes, these youngsters find that psychological reactions to
previous traumatic incidents are triggered during their time at university. These
incidents include bereavement, violent attacks, neglect by parents, phobias
and so on. Excessive freedom for the first time in their lives combined with the
misuse of drugs and alcohol can also be problematic for young people. With
the greater movement of international students, cultural misunderstandings
and problems, often relating to drugs, alcohol and sex, can also arise. All these
issues, too, are of particular concern to the university counsellor.
The recent setting up of NHS early psychosis intervention services for the
crisis management of young people is very welcome, particularly as it seems
that these sorts of incidents are most likely to occur during teenage years or
early twenties and, if treated appropriately, can be ameliorated, preventing
serious mental health problems later in adult life. Early intervention is an
approach favoured in the NHS now to prevent longer-term high mental
health costs arising. The local early psychosis intervention teams have given
presentations to my universitys counselling service in a bid to publicise the
support that they can provide. This is especially important given the apparent
increase in psychosis resulting from recreational drug use.
University counselling and psychotherapy is interesting and challenging
work. We are often the unseen glue behind the scenes helping to keep the
young people on-programme. University managers need to properly understand the vital role counselling services play in student retention. Personal
one-to-one support and contact can often be the essential holding element
that is missing when students are away from home.

Paulas story is interesting from two very specific viewpoints. First, she sets
out the special practice issues that counsellors working in educational
settings have to deal with. She is clearly responding beyond the basic
psychotherapeutic needs of her clients and trying to help them cope with
some major personal developmental issues in their lives. Second, it is clear
from Paulas tale that she and her colleagues have to work well beyond the
traditional counselling boundaries. They are bravely responding to an
obvious need for them to assume a measure of pro-active responsibility for
guiding and assisting their young clients in all aspects of their lives. It
would appear that these educational counsellors have long bypassed the
purist/realist therapist debate.

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SUGGESTED FURTHER READING

Axline, V (1964, reprinted 1990) Dibs: In search of self. London: Penguin.
A warm and charming story of a real-life case read this book.
Geldard, K and Geldard, D (2008) Counselling Children: A practical
introduction, 3rd edition. London: Sage.
A useful book for those intending to specialise in working with children.
Part 3, Skills, is excellent.
Lines, D (2006) Brief Counselling in Schools. London: Sage.
A helpful, workaday book. Chapter 1 gives an excellent overview of this
topic.

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Chap ter 9

Working in the
National Health Service

CORE KNOWLEDGE
Counselling and psychotherapy services in the National Health Service
(NHS) have grown largely in parallel with the growth of the NHS.
Counselling in the NHS has two main functions:
providing an EAP service for staff;
providing treatments for patients.
Counselling has had difficulty in finding a suitable niche for itself within the
NHS hierarchy this issue remains unresolved.
Counsellors working in the NHS face issues over:
sharing information about patients;
working within imposed time limits;
working in a cost-effective manner;
working with imposed directives about how to treat clients.
The Governments policies on Improving Access to Psychological Therapies are
likely to bring about significant changes in counselling and psychotherapy
service delivery within the NHS.
Accounts of real-life NHS counselling (as told by real-life NHS therapists)
suggest that counselling within the NHS has a number of significant
differences from counselling as practised elsewhere.

INTRODUCTION
In one sense, it is obvious that the story of counselling and psychotherapy
in the National Health Service (NHS) could not have possibly begun before
1948. How could it? Before 1948, there was no NHS. However, in another
sense, it might be argued that the tale of the psychological therapies and
public healthcare provision might actually have begun as far back as 1896.
This was when Lightner Witmer (who had trained under the pioneering
psychologist, Wilhelm Wundt, in Vienna) opened what was probably
the worlds first public-access psychological clinic at the University of
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Pennsylvania. However, to begin with, those early-days psychologistpractitioners were not particularly interested in therapy as such. They were
much more interested in investigating the technical applications of
psychology to human behaviour and in promoting the academic study of
psychology; they were not particularly bothered about being clinicians
(Reisman, 1991). However, eventually, these psychological pioneers did
make some tentative attempts at patient treatment when they experimented with what today we would probably call psycho-educational
therapy. In Witmers clinic, the clinicians usual treatment methods were
mainly centred on trying to promote good mental health by teaching
correct behaviours to patients whose lifestyles were supposedly deviant.
During the early days of mental health treatments, those advocating the use
of clinical applications of psychology in patient care (especially in its later
guises in the counselling and psychological therapies) faced many problems
in becoming established within what then was a medical hierarchy that
jealously guarded its status. In part, this was because the psychotherapies
emphasised talking to, and respecting, the patient and this very much
contradicted professional attitudes that were prevalent during the late
nineteenth- and early twentieth-century practice of scientific medicine.
Traditionally, there used to be a tendency among doctors to subjugate their
patients (Moynihan, 1993). Patients were merely the carriers of the disease;
they could play no part in helping their scientific saviours to combat
illness. Patients were there to be cured; they were not there to chat with
their doctors.
Nevertheless, even in those early days, the importance of responding to the
psychological health needs of patients was slowly beginning to be accepted.
Some doctors were starting to listen to their patients. Slowly, things
improved. For example, in 1920, the Tavistock Clinic, with its emphasis on
doctorpatient dialogue and patient mental welfare, was established. In
1926, the Pioneer Health Centre in Peckham was set up to promote positive
health consciousness in partnership with its patients (Moynihan, 1993).
Gradually, what was initially seen to be a form of mental hygiene, in
which the patient played a constructive role, was viewed by more and more
doctors as being an essential part of promoting patient well-being.

THE NATIONAL HEALTH SERVICE IS BORN

The year 1948 was momentous for patient care in the UK. This was the year
in which the National Health Service (NHS) was launched into what was
expected to be a brave, new, socially conscious, egalitarian, post-war world.
From its very beginning, the NHS recognised that the universal provision
of physiological/medical treatments for physical ailments was not enough
to meet the needs of all its patients. Their levels of psychological fitness
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also needed addressing. Therefore, plans were drawn up to ensure that

mental health services became an essential part of the embryonic NHS.
To begin with, mental health provision within the NHS was what we would
call today a second-tier function. It was rarely available at the local surgery.
Patients accessed the then mental health services via their GPs, who referred
them to specialist regional units. It was not until 1971 that the Isis Centre
in Oxford opened the UKs first walk-in, locally accessible psychological
health clinic, which included the provision of psychotherapy and counselling as part of its routine treatment menu. However, the reality is that
the take-up of counselling throughout the NHS, and its recognition (at least
in some quarters) as being a valid treatment option, took at least another
20 years. Indeed, some might argue that counselling has still not been fully
accepted throughout the NHS culture.
Counselling has not found it easy to claim a respected place within the NHS
healthcare professions. The medical world has been described by East
(1995) as a tribal village society that is often hostile to newcomers. It could
be argued that the pioneer NHS counsellors were viewed with great
suspicion by many in the NHS establishment who have zealously guarded
their own professional empires. For example, in an article typical of its era,
Harris (1994) claimed that, by including counselling as part of overall
healthcare, the government may be turning its back on two centuries of
careful and dedicated work by doctors and we may be deserting medicine
for magic. Gradually, however, more positive views of counselling began
to prevail among GPs. For example, Cocksedge (1997) strongly supported
the inclusion of counselling, psychotherapy and psychological services as
an everyday part of most GP practices. Counselling was gradually coming
to find its place as one of a number of acceptable treatment choices on the
public healthcare bill of fare (Hemmings, 2000).
Initially, counselling appeared within the NHS in two main forms. In its
first form, counsellors provided employee assistance programmes for NHS
staff. However, there is no immediately obvious reason to assume that NHS
workplace counselling is any different from any of the other forms of
employee counselling that have already been discussed in Chapter 7.
Therefore, in this chapter we can ignore that side of counsellings NHS story.

A different approach to treatment

Treating patients (the second main form of NHS counselling) began to
develop as the counselling therapies started to become more and more
available at many local GP surgeries. During the late 1990s, there was a huge
expansion in counselling provision in primary care. This was fuelled in
part by the GPs growing frustration with the long waiting lists for the then
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NHS specialist psychological services (Davies, 1997). Over time, these GP

surgery-based counsellors gradually came to be seen not as merely being a
second-class substitute for the supposedly specialist psychological services,
but as a viable, alternative, professional healthcare provision. One great
attraction of this new treatment approach was that it could be tailored to
the immediate needs of individual patients. Another advantage was that it
provided an on-demand and localised, patient-friendly service (Hemmings,
2000).
The newly emerging, primary care-based counselling treatments were
mainly delivered by freelance counselling practitioners who were individually contracted to (or associated with) local GP practices. The local surgeries could use their then status as NHS fundholders to finance this
counselling provision (Brennan and Hollanders, 2006). This particular
method of providing counselling for their patients gave the GPs the marked
advantages of local control and a direct ownership of the in-house counselling services that were working with their patients (Davidson, 2000).
However, between 1997 and 2000, yet another of the NHSs policy changes
reduced the GPs fundholding powers, so much of the local funding for
primary care counselling services began to disappear (Foster, 2000).

Counsellors versus psychologists

It is unfortunate that, over the years, the ups and downs of NHS funding
for patient mental welfare services have sometimes served to exacerbate the
rivalry that a vocal minority within the psychological services already felt
towards the incoming counselling upstarts. Clearly, a scarcity of funds will
often tend to generate operational rivalries. Regrettably, it is also the case
that, for some observers, the image of professional counsellors, especially
those working from the voluntary sector, used to be that they were merely
part-time, pin-money earning, middle-class do-gooders, who were only
amusing themselves with an undemanding hobby (Hudson-Allez, 1999).
It is even arguable that, 20 or 30 years ago, such an evaluation might not
always have been entirely groundless. This is certainly not the case today.
The negative assessments that some of the healthcare professions held
about counsellors were worsened by the then scarcity of sound, practicebased evidence in support of the shorter-term mental health treatments,
such as counselling or brief psychotherapy (Roth and Fonagy, 1996, etc.).
It is also unfortunately arguable that the early disdain felt by some
counselling therapists towards any sort of scientific enquiry into their work
did not help counsellings case for demanding professional respect.
The debates and disputes between the psychologists and the counsellors
have rumbled on. On the one hand, the psychologists seem to have at least
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conceded that there might be a case for using counsellors to help them with
their excessive caseloads by taking on some of their apparently less
demanding patients (Burton et al., 1995; Kemp and Thwaites, 1998). On the
other hand, many counsellors still seem to be uncomfortable with many of
the methodological and theoretical viewpoints advanced by their allegedly
more scientific therapeutic cousins. Green (1994) summarised the earlier
territorial conflicts between the counsellors and the psychologists as being
one in which the psychologists might grudgingly be prepared to allow
counsellors to assist them with their work, if they were willing to offer lowgrade support to selected patients, whereas the counsellors wanted to be
recognised as independently skilled practitioners who were the psychologists professional equals.

RECENT HISTORY
Over the last five years or so, the position of counselling within the NHS
seems to have altered yet again. Reviews of funding and management
policies have resulted in changes in the ways in which counsellors are
employed in primary care. The tendency now is for health authorities to
purchase and manage counselling services through the primary care groups
or community trusts (Davidson, 2000). This has changed the status of
counsellors based in GP surgeries from being independent operators to
being established as part of the overall NHS structure. Indeed, nowadays,
many of the originally independent counsellors have actually become NHS
employees.
The result of these changes in their employment conditions has been to
create professional demands on primary-care counsellors that some of their
still independent colleagues (especially those practising outside the NHS)
might find unacceptable. Is it possible that the NHS counselling culture
inevitably clashes with some of the traditionally held beliefs about what
constitutes ethically sound therapeutic practice? For example, conflicts
might arise if externally imposed time constraints or instructions from
GPs about how to treat patients clash with the high value that many
counsellors place on their professional independence and their ability to
offer their clients creative and unhurried help. Other conflicts might arise
for counsellors who strictly guard patient confidentiality, when they are
confronted by the NHS need for patient information to be held in common
within any of the care teams.
Paying close attention to some of the admirable (but regrettably idealistic)
traditional counselling scruples may not always be possible in the context
of a professionally managed, frantically busy NHS, with its waiting lists, its
demands for rapid responses and, above all, its insistence on cost-effective
results. Traditionally trained counsellors who find themselves undertaking
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primary care work might find that they are exposed to culture shock. This
can hit them as soon as they encounter the full force of NHS organisational
bureaucracy and the pressure to work within certain national policy guidelines, for which they may feel no particular sense of ownership. NHS
counsellors are also required to be responsible for their professional practices, and to be publicly accountable for these practices, within the overall
NHS structure It is crucial that the professional standards developed
nationally continue to be responsive to changing service needs and to
legitimate public expectations (Department of Health, 1997). The NHS is a
robust, demanding, organisationally driven, performance-demanding world
for which few, if any, counsellor training courses prepare their graduates.

PRACTITIONER REFLECTIONS TINA GRAHAM

A GP surgery counsellors story
Parking up, Im immediately thinking about who Im seeing first today. My
nine oclock is an intelligent woman with high motivation. A pleasure to work
with and indeed I know that the session will very likely flow with ease. She has
good insight regarding her life and particularly her personal development.
Reviewing my caseload is so important for us here within the NHS, to
manage not just the business of it but also the diversity and demands of each
individual who accesses the service. This can be a challenge in itself. Thats
why my next client, on this particular day, is more demanding. She needs
more from me than my first client does in terms of her own ability to see
herself in her situation. I have to work hard at keeping her focused. She needs
lots of reassurance and time to go over her issues and problems at length. Her
pace is very different from that of my first client.
Entering the building I greet my colleagues nurses, receptionists,
doctors, secretaries as I climb the stairs to my room. First things first: answer
phone messages a couple of queries and a cancellation. Next stop: visit my
in-tray and look at the new referrals that have come from the GPs, health
visitor and the practice nurses. This counselling service usually has at least ten
referrals a week with a client uptake of about 60 per cent.
I enter my room and flick the engaged sign over; I shut the door and
hope for a little bit of quiet time before work proper begins. If I have made
good time on my journey to work, I make a few phone calls; otherwise I adjust
the chairs, reach for the clock and the tissues, place them accordingly and
open my filing cabinet. Reading my client notes and having time to reflect
upon previous work before sessions is enormously important and useful
I make sure Im back in the picture and story of each client before their
arrival. I review the work to date, think about what the clients might benefit
from, intervention-wise, or indeed cast my mind back to clinical supervision
discussions.

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I fire up my PC and log into my sessions for the day. It saves a wasted trip
downstairs as the patients here check in with reception before I collect them.
The work is very varied; a typical morning like the one outlined above is the
norm. Sometimes I only see two clients before lunchtime, but mostly I will see
three clients. I prefer to do the bulk of my clinical work before lunch as I often
notice my energy levels depleting in the afternoon. Again, it depends upon
my client cases, but I generally try to scatter them so that my more needy, less
motivated, clients are interspaced with my more motivated ones. Its a juggling
act at times and it is not always possible to do this as we do try our best here
to accommodate people who are late and slot them in at the times they are
best able to attend. Demands upon us have certainly increased with the
implementation of the Improving Access to Psychological Therapies paperwork.
We have had, as colleagues, to negotiate the best ways forward as far as the
data collection. There have been battles with the local health trust not only for
our jobs, but also as far as how and what data is needed from our clients.
I try to go out for a walk at lunchtime and just revitalise myself and freshen
myself up for the afternoons work. After my lunch, I usually come back to more
messages or an urgent referral that has come hot off the press from the secretaries. Often I might need to have a chat with or visit from a concerned GP about
a patient. Working together as a team is so very important; its a vital part of
working in an integrated NHS service. There is a team confidentiality that can at
times be very useful, especially when we are holding some very fragile patients.
Contact with the GP helps to bring in appropriate higher-intensity interventions
should they become necessary. Discussion about the effectiveness of medication
can be conveyed between counsellor and GP with the GP possibly reconsidering a medication if things havent improved for a patient.
My colleague knocks on my door with a concerned look Can you spare
a minute? Nodding, I usher her in and close the door. She is reviewing a
referral and has concerns as the patient is 30 weeks pregnant, and has been
placed on an antidepressant. We both query this decision and wonder how
best to approach the GP concerned as we are wondering about the thinking
behind this decision. She leaves and, by chance, another of our GPs appears
and hes in a buoyant mood. We exchange small talk and I gently broach the
subject and ask for his technical knowledge reference the referral. He clarifies
the position for me and tells me about the drug companies and the research
into medication, the stage of development of the baby and how the potential
for developmental harm is minimal now the gestation period is coming to an
end. He explains how the foetus is fully formed at 26 weeks and we have a
discussion over balancing the patients emotional needs with minimising
harm to the baby. Its a very informative conversation and settles my mind as
to the decisions and reminds me of the responsibilities GPs have to undertake
every day. I thank him for his time and input as its helped me to develop my
own knowledge a little bit further. I convey the conversation to my colleague
and return to my afternoons work.

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I see another two clients and I make sure my notes are all up to scratch.
I shut my filing cabinet. I think over my day and the interventions and the
people I have encountered. This is a typical day and other days might appear
much the same on the surface, at least the structure might, aside from days
when I supervise the two volunteers we have here. Whats never the same is
the diversity and the challenges that each new client brings to me; the
developments and difficulties I face as I try to help people move forward never
stop being unique. The reality is that each day in the life of a GP surgery
counsellor is actually a one-off.

DO NHS COUNSELLORS WORK DIFFERENTLY?

There are those who would argue that NHS counselling, particularly
counselling in primary care settings, might be heading towards becoming
a distinct psychotherapeutic profession in its own right (Hudson-Allez,
2000). This argument is further supported by the observation that many
counsellors, including those working in GP surgeries, often appear to end
up practising in similar ways to each other despite their probably having
originally come from different training backgrounds or initially claiming
allegiance to differing counselling schools (Mearns, 1999, etc.).

Workload
At first sight, the overt differences between working in a GP surgery and,
say, working in private practice or perhaps in some parts of the voluntary
sector are obvious. The private practitioner can elect to offer clients an
unhurried, time-generous service that is delivered in a calm and discreet
environment. Private clients can choose to have as many counselling
sessions as seems appropriate. Private practice counsellors can decide for
themselves when they should engage in reflection and personal or
professional development (as indeed ideally should all counsellors). In
addition, such private practitioners can opt to include sufficient time for
administrative matters as a routine part of their normal working day.
However, the counsellor working in the maelstrom of a busy GP surgery has
a very different set of working experiences. There is often a hurried, even
harried, working environment, lots of people around, hustle and bustle,
and a never-ending demand for the counsellors time. The amount of time
available to treat each patient is limited and there is rarely, if any, time
available between sessions for reflection or personal development. NHS
counselling is usually time-limited and clients do not usually get more than
six sessions with their counsellors.
Outside the NHS, a seven-hour working day probably involves about four
hours of actual face-to-face client time, with a recommended weekly limit
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of some 1820 client hours (BACP, 2008). This leaves ample time available
for administrative tasks, reading and research. However, in primary care, a
seven-hour working day will often involve at least six, and sometimes even
seven, face-to-face counselling sessions and very often includes a need to
fit in an urgent or emergency additional referral as well (in some way or
another). Somehow the relevant paperwork also has to be squeezed into
this overly crowded working day, usually by the counsellor working
voluntary overtime. NHS counsellors in full-time posts could be providing
upwards of 30 client sessions every working week. This is a formidable, even
daunting, workload. There is very little surplus time for anything else,
unless the counsellor is prepared to allocate some private time to such
professional demands as reading, reflection and clinical casework discussions with colleagues. It seems that, in NHS counselling as actually
practised, there can often be a huge gap between the real and the ideal.

Confidentiality
Client confidentiality is another area of potential divergence between NHS
counselling and counselling in other settings. The general counselling
ethical maxim that nothing goes outside the counselling room without the
clients express consent simply does not apply in NHS settings, where team
confidentiality is the order of the day. The referring doctors often require
feedback and counsellors may well wish to discuss the overall care of some
patients with the relevant GPs. After all, it is always possible that the
counsellor might obtain some vital information from the patient that the
doctor needs to know. It is also possible that the counsellor might be able
to offer some useful advice about the patients general treatment package
to the surgery medical team. (These sorts of complications were compellingly set out earlier in this chapter in Tinas Practitioner Reflections.)
Such clear limitations to counsellorclient confidentiality are further
compromised by the ever-increasing legal requirements on all counsellors
to disclose certain information about their clients to the authorities. So far,
this list includes drugs trafficking, child abuse, terrorism and money
laundering, and doubtlessly it will be expanded over time. Taking all these
factors into account strongly suggests that NHS counsellors need to develop
a new, possibly independent, ethical code one that takes context and law
into account while at the same time protecting both the counsellors and
the clients. Some attempts to resolve this issue have been made, although
proposals for a comprehensive solution are likely to be debated for some
time to come.
No doubt, counsellors who are already practising in the NHS would be able
to highlight yet more areas of difference, or even conflict, between their
mode of counselling and that as practised by other counsellors in other
contexts. It is also very likely that there are more differences yet to be
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identified. Therefore, it seems arguable that NHS counselling approaches

might eventually come to diverge permanently from other forms of
counselling in a number of significant ways. Whether these professional
differences need only to be procedural within certain contexts, or whether
they indicate fundamental changes in professional approaches to client
care, will no doubt cause yet another intense, ongoing debate between
counsellings pragmatists and counsellings purists.

PRACTITIONER REFLECTIONS BARBARA ALLEN

Counselling and psychotherapy in an NHS primary care mental health team
In my particular NHS area, there is no primary care counselling service. We
have a primary care mental health team, which is a multidisciplinary team
made up of nurses, occupational therapists and counsellors and, although I
trained as an integrative counsellor, I am employed as a mental health
practitioner. This team was developed in 2002 as a direct response to the
recommendations of the National Service Framework for Mental Health.
Despite our different professional orientations we have identical roles,
assessing patients within GP surgeries, signposting them to other services or,
if appropriate, providing a flexible number of brief therapeutic interventions.
There is no exact limit to the number of sessions provided. Brief counselling
in this instance means as few, or as many, sessions as are needed as long as
the patient problems or issues are manageable and meet the criteria of the
primary care remit. Patients are never discharged from our service in the
same way as patients are never discharged by their GPs.
Like my colleagues, all my experience has been within the primary and
secondary care mental health service. There are some similarities, and also
some fundamental differences, in the way we work. In other words, rather
like the various schools of psychotherapy, we do the same job but differently.
These differences sometimes become apparent during our weekly peer
supervision sessions. We may use different language for core concepts, which,
when discussed, reveal a shared understanding. With this weekly supervision
we have cultivated a transdisciplinary approach, exchanging views and
expertise, thereby enhancing individual core skills.
The workload leans heavily towards assessments at which a decision must
be made as to the mental state/health of the patients and whether our service
is able to meet their needs. This means that assessment skills are of paramount
importance. Rapport and relationship building, and the use of perception and
intuition during information gathering are essential parts of our work. Referral
to secondary care services is a possibility. However, it is necessary for certain
criteria to be met in order to warrant such a referral and it is often the case
that the primary care patients are not considered to be ill enough to warrant

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referral. Despite this, they have presented to our service suffering some form
of mental dis-ease and often in need of professional services in order to ease
their distress.
This means that, although I am a counsellor, I often find myself working
in ways that may be at odds with some of the more orthodox approaches to
counselling. This causes some tension and challenges to my own core beliefs.
For instance, although I usually note information during assessment and
subsequent sessions, brief factual details and significant information is logged
straight on to the computer system within the GP surgery and handwritten
information is destroyed. Patients are alerted to this fact from the outset and
are also informed of the limits to confidentiality in respect of harm to self or
others. The breaking of confidentiality in order to protect others has
sometimes felt very uncomfortable dynamically, but if a patient does disclose
information (for example, regarding abuse they have suffered) and indicates
that others may also be a risk, I have a duty of care to report such risks.
At the end of each session it is necessary for the patient to contact my
office in order to book a further appointment. This means I do not have control
of my own diary and, if the patient decides not to book a further appointment,
I have no recourse for follow-up. The GP would, of course, be aware (via the
computer system) that the patient has chosen not to engage and would either
re-refer or contact secondary services if deemed appropriate at that time.
Due to the waiting list and volume of patients seen, it is often four weeks
(at least) between appointments. In order to meet the needs of a large
number of patients, we organise and make good use of other interventions
such as workshops and groups, as well as providing self-help material in the
form of booklets (bibliotherapy).
At assessment I may identify that a patient would benefit from attending
one of our psycho-educational workshops on anxiety, mood management or
assertion before seeing me for a follow-up appointment. Each workshop is a
one-off educational session lasting three hours, run by an occupational
therapist and a counsellor. It may be that the patient could benefit from
reading a publication specific to their particular difficulty. We have an
arrangement with the local library service whereby they administer the loans
and renewals of books available on a book prescription, which we are able
to provide. Following attendance at the workshop or reading a selection of
publications, I find the patient often returns for further appointments having
gained some insight, learned helpful coping strategies or recognised issues
they feel might be beneficial to explore.
I think these interventions can sometimes provide worthwhile time-saving
shortcuts for the motivated patient. I am aware that use of such materials may
cause some to feel this is a complete abandonment of a counselling approach.
However, the building of the therapeutic relationship and developing a
clientcounsellor working alliance is, I feel, of greater importance. This is
especially so when such emphasis is placed on the patients ability to engage

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in such activity and can be helpful in allowing the patient to own their recovery
and realise their own power to implement change.
For some patients with less capacity for insight, or for some appropriately
motivated patients, it might be beneficial to employ a more CBT approach
and I make good use of homework sheets and session formats when working
with some anxious or depressed patients. Sometimes, when embarking on
such a programme, it is beneficial to see patients weekly for the first few
sessions. I have discovered that, when the patient has an understanding of
the principle of using homework sheets to challenge their negative automatic thoughts or to modify behaviour, it is possible to squeeze half-hour
sessions in at the end of my surgery to monitor progress and set new goals.
They may then make use of workshops following this in order to make
further gains.
I have found it helpful to adopt a flexible approach to try to accommodate the vast variety of presenting problems and provide whatever the
patients need to help them on their road to recovery. The approach is driven
by the patient, not by theory. Time is a commodity in short supply and I (like
all counsellors) always hold in mind the importance of every therapeutic hour
spent with each patient and so we maximise opportunities.

PRACTITIONER REFLECTIONS ALEXANDRA BOSSMAN

Counselling and psychotherapy in an NHS secondary care mental health team
I am a specialist counsellor and I work in NHS secondary services, which can
be also defined as the acute or emergency part of treatment offered to
patients who need mental healthcare. It is distinct from primary services, as
patients will be referred in and discharged out once treatment is completed.
Referrals come from all the other sectors of the health services, although GPs
refer the greatest proportion. It is also a more specialist end of the care
spectrum and those needing interventions will have complex needs and often
will have more than one diagnosis. They may be in crisis and require admission. They may be in crisis and not require admission, but can potentially be
managed at home by crisis intervention teams. Patients may be frequent
service users or presenting for the first time and they may have more than
one clinician offering support to them.
Our team is called Community Mental Health and we are a multidisciplinary group comprising psychiatrists, clinical psychologists, community
psychiatric nurses, social workers, psychological therapists, counsellors,
support workers and psychotherapists. We have a team meeting once a week
where patients will be discussed and treatment options defined, because it is
not unusual for patients to need the support of each specialism. Essentially,

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psychiatry will be responsible for medication and diagnosis, although not

exclusively; social care matters such as housing or benefits will be managed
by either the nurses or social workers, and therapy will be undertaken by
potentially all of us in some form.
So what therapy is on offer? Patients once referred into secondary care
must be seen within 18 weeks (Department of Health, 2004 No one will
have to wait longer than 18 weeks from GP referral to hospital treatment).
Given the downward pressure to see patients as soon as we can, interventions
are governed by time too. Generally, patients are offered 20 sessions of oneto-one therapy or one year of the same. The therapies on offer are cognitiveanalytic therapy, cognitive-behavioural therapy, psychodynamic counselling,
gestalt therapy, psychoanalytical approaches and systemic psychotherapy
with couples/families. Currently, we are developing group work approaches
and these will be either educationally oriented, where symptoms are discussed and thought about (obsessive and compulsive disorders, for example),
or more therapeutically oriented, where group processes drive the recovery
of individuals. There is also a dialectical therapy group, which offers a mixture of skills and therapy for those with personality disorders (borderline
disorder in particular). Just to add to the complexity of this team, very often
nurses and social workers undertake additional training and are able to offer
therapy as well as their other skills. In addition, some of the psychiatrists also
practise as therapists.
Assessment and treatment who decides?
When patients are referred there will be a referral letter, which will outline the
symptoms, current medications, risks of self-harm and general life situations.
These case narratives will be discussed by a group consisting of managers and
clinicians and together they evaluate how best a patient can be helped. If the
therapy route is chosen, patients will be allocated to a therapist for assessment
for psychological mindedness, and this process will be carried out in depth
and sometimes over a number of meetings. This represents two main aspects.
First, a good, thorough assessment enables both parties to really think about
what therapy will be about and how prepared patients are to think about
change. Second, for some people this might be the first time they have had
the opportunity to tell the whole story and feel that the facts and the
emotions attached to these events have been truly understood. Doing this
may be therapeutic in itself and sometimes a choice is made at this point not
to continue with further work.
Counselling at this point is very specific and usually focused on one or two
key areas that will have been identified at assessment. Although I will not
specifically be asked to diagnose, I will be looking for symptoms or features
that may suggest where the main area of difficulty may lie.

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My work pattern is to offer therapy as a contract on which both therapist

and patient collaborate. It is not something that I just do to them. We will talk
about timings of appointments, and how we might expect to see the impact
of them. For instance, we would acknowledge the possibility that there might
be an increase in distress symptoms initially and we discuss what that could
mean. This is a form of rehearsal for the therapy itself and it is helpful for
patients to be able to imagine what the reality of this type of work is. For
instance, if someone is attending therapy and becomes upset, they might
want to think about how they handle that on an ongoing basis. Furthermore,
we will discuss how they might manage a crisis. Who would they ring and
what other resources might they have at their disposal? Confidentiality is an
issue that will be discussed. The NHS is a bureaucracy and has paperwork that
is an essential requirement legally, and also there are psychological tools for
measuring change in the patients perceptions and thus gaining an indication
of how therapy may have helped them. Paperwork of this type is usually done
at the first session, at a midway point, and at the end. Therefore, the level of
confidentiality that a patient can expect is not what it might be if one was a
sole practitioner in private practice.
In the NHS, we have legal obligations and responsibilities as well as the
usual ethical and clinical dilemmas. However, notwithstanding this, I will
ensure patients understand how confidentiality works for them. If I need to
speak to another clinician, the psychiatrist say, about medication, I will ask
permission first. Alternatively, I will encourage the patient to speak for
themselves if there is an issue. There is also an electronic data recording
system and I will record meeting times and, if there is a clinical need, extra
information regarding the patients mental health. This is necessary if patients
are actively suicidal and needing extra help from crisis services. I may be asked
to attend discharge planning meetings for patients if they have had an
admission locally or perhaps have been referred to a specialist eating disorder
unit. Here, again, confidentiality is negotiated and therapy is seen as a piece
of work that dovetails with others, and is more like an integrative model at
this point.
As well as working as an individual therapist, I am also one half of a team
that offers systemic couple/family therapy. We see couples or families who
again may be referred by GPs or perhaps from within secondary services. A
typical day for me (if there is such a thing) will involve four or five therapy
sessions and then the necessary paperwork, liaison with other health
professionals and attending meetings if required to do so. Living and working
in a rural area, there is also a component of travelling to and from various
bases, where we see those who prefer to be seen in their communities.

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WHERE NHS COUNSELLING IS TODAY

Despite all the historical wrangling about the rightful place of counselling
in the NHS, it seems that, by 2000, at least 50 per cent of all GP practices
had some sort of access to a counsellor (Mellor-Clark et al., 2001). A major
reason why this was necessary was that GPs were (and probably still are)
spending up to 30 per cent of their working week dealing with patients
mental and emotional health problems. Much of this workload was (and
probably still is) centred on anxiety, depression and apparently psychosomatic conditions (Davidson, 2000). As it is very likely that this wide
range of mental health problems originated from an equally wide range of
causes, it seems reasonable to assume that no one method (or school) of
counselling therapy would be universally applicable. One size would almost
certainly not fit all. Therefore, primary care counsellors are developing a
wide range of therapeutic skills and techniques in order to meet these very
varying demands. We can see clear evidence of the essential need for an
innovative multi-school approach in all three Practitioner Reflections.
NHS counsellors and psychotherapists are continually required to demonstrate that their skills and techniques are likely to be successful in the
treatment of their patients. Fortunately, modern research (Elliot et al., 2008;
Stiles et al., 2006; Ward et al., 2008, and many others) indicates that
counselling and psychotherapy is indeed cost-effective and of provable
efficacy for the care of the psychologically disturbed. Not only that, but
mega-studies such as that of Brettle et al. (2008) specifically support the
notion that counselling is an economically justified, valid treatment choice
for primary care patients who suffer with non-specific, generic psychological problems. This study indicates that counselling is as equally effective
as are all other treatment modalities and, probably most importantly of all,
is likely to be equally cost-effective. On the surface this might be an
argument for claiming that counsellings place within a modern NHS has
been established. However, modern developments (such as the Governments Improving Access to Psychological Therapies policy) seem to favour the
possible, even probable, dominance of CBT within the NHSs counselling
and psychotherapy services.
As CBT and similar rapid-fire therapies are likely to be delivered by speedily
trained psychological technicians, the whole question of counsellings
professional status has been put back on the table. These issues are further
discussed in the next section of this book Part 4: Where is counselling &
psychotherapy going?

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ACTIVITY 9.1
Set out your own ideas and make some notes about these questions:
What can counsellors and psychotherapists offer the NHS that other healthcare
practitioners cannot?
How could counselling and psychotherapy evolve to fit the evolving NHS?
How could the NHS develop such that it could make better use of the specific
skills that counsellors and psychotherapists can bring to patient care?

SUGGESTED FURTHER READING

Bryant Jeffries, R (2005) Workplace Counselling in the NHS. Abingdon:
Oxford University Press.
This is a specialist text for those with a particular interest in this topic.
Department of Health (2008) Improving Access to Psychological Therapies
Implementation Plan: National guidelines for regional delivery. Crown
copyright. Available online at www.dh.gov.uk (accessed Summer 2009).
Again, this is for those with a specialist interest.
Tempest, M (2006) The Future of the NHS. St Albans: XPL Publishing.
An informative text, but one that needs to be read in conjunction with all
the rapidly emerging online NHS publications.

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part 4
WHERE IS COUNSELLING
& PSYCHOTHERAPY
GOING?

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Chap ter 10

Counselling & psychotherapy

the next story

CORE KNOWLEDGE
The statutory regulation of the psychological therapies is imminent.
Regulation will be controlled by the Health Professions Council (HPC).
Regulation might separate counselling and psychotherapy into two
different professions.
Regulation will probably result in a new set of Standards of Proficiency for
both counsellors and psychotherapists.
Regulation might result in counsellors and psychotherapists having different
levels of professional qualifications.
The talking therapies might well evolve as a degree-based profession.
The Governments current policies within the NHS are emphasising the
alleged superiority of cognitive-behavioural therapy.
The counsellors of the future might evolve as supershrinks, who are able to
work in whatever ways are necessary, or they might become sector
specialists, each with a unique service to offer.
Every therapist, from trainee to the leadership, can and should have
something to say about how their profession should, or could, develop.

REGULATING THE PROFESSIONAL THERAPIST THE DEBATE

In many ways it could be argued that the co-disciplines of counselling and
psychotherapy are already established as professional occupations. After
all, together they already have their own discrete body of knowledge
(professional discourse) one that is well established at all levels of higher
education and academic scholarship and supported by peer-reviewed
research. However, the talking therapies do currently lack what some would
claim to be two of the other essential attributes of a high-level calling. First,
therapists in the UK have no official status; they have no established
professional recognition. Second, they do not have a centrally authorised,
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nationally approved, minimum standard of practitioner training and certification. There are no officially established UK performance thresholds that
clients could (or should) expect from their therapists.
Precisely what it is that turns a job into a profession is open to argument.
For some, this process necessarily involves regulation and enforceable
discipline, whereas for others it is an attitude of mind. The imminent
statutory regulation of counselling and psychotherapy is bringing these
sorts of disputes to the fore throughout the talking therapies. Of course, as
with most contested issues in psychotherapy, the concept of professionalisation attracts passionate argument. It is a wide-ranging debate that
includes disputes over the basic purposes of counselling and psychotherapy,
together with disagreement about desirable qualification levels, performance standards, quality controls, ethics and many other equally contentious
issues.

The against argument

On the anti-regulation side are the many practitioners who would
argue that professionalisation and regulation would effectively kill the
talking therapies (Shannon, 2009, for example). This is because they see
such processes as effectively being anti-therapy. Many of these antiregulationists claim that, if therapy is confined within defined limits, it
cannot encompass the whole of the human psyche and experience. For
example, the newly established (April 2009) Alliance for Counselling and
Psychotherapy Against State Regulation (www.allianceforcandp.org)
argues that official regulation would fatally reduce client choice and
inappropriately medicalise the therapists calling. The Alliance also argues
that there is no evidence to support claims that regulation might bring
desirable operational or practical benefits (public respect, interdisciplinary
recognition, accountability, etc.) to the therapy trade. Many of regulations
dissenters particularly object to the plan to use the Health Professions
Council (HPC) as the regulatory body. They believe that the HPC does not
have the appropriate expertise. Such objectors would claim that only
therapists can understand the needs of therapists. Gladstone (2008) sums
up many of their arguments by calling therapy regulation illusory,
unethical and hazardous.
For many of the anti-regulationists, counselling and psychotherapy are art
forms that cannot be given any official restrictions and so cannot be
constrained. Many of the anti-regulationists claim that therapy is beyond
discipline. It is a way of being rather than a way of knowing. They say
that psychological counselling is a freestyle approach to people and their
needs. It cannot be a proficiency-based activity based on a measurable set
of aptitudes, abilities and techniques. This, they say, means that therapy is
a personal approach to psychological well-being; it is an attitude that is
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gradually acquired rather than a definable skill that can be systematically

taught.
Another major concern for many of those opposing counsellings professionalisation is their belief that regulation would improperly award power
and expertise to the therapist. These dissenting theorists argue that therapists and their clients should be equally authoritative, equally knowledgeable and equally responsible co-explorers in their therapeutic worlds.
Therefore, they claim that the potential personal authority and status that
professionalisation could possibly confer on therapys practitioners would
destroy such an equality-based, interpersonal power balance. For example,
Proctor (2008) argues that professionalisation and regulation will lead to
therapy as an increasingly elite profession, bolstering claims to expert
knowledge through university accredited courses and gatekeeping entry.

The for argument

The supporters of professionalisation and regulation argue that the public
would be better served by an officially recognised therapeutic profession.
Many such pro-regulationists would argue that, were the perceived status
of the counselling professions to increase, so too would the quality and
dependability of the therapy provisions and services available to the public.
This, they argue, would come about because high-status professions have
an imperative to disconnect from inadequate fellow travellers. Therefore,
the supposedly negative outcomes that Proctor (2008) suggests might result
from regulation are seen by the pro-regulationists as actually being very
positive and very desirable. They want official recognition, respect and
status for their calling. They want control. The pro-regulationists argue that
the currently unfettered and unmonitored proliferation of therapies and
therapists only serves to confuse the public and to expose clients to
exploitation. Many pro-regulationists might also argue that the lack of an
authoritative regulatory body weakens consumer protection and means
that there is no provision for the disciplining of underperforming practitioners. In addition, many pro-regulationists also claim that the public has
a right to demand that all therapists will have undertaken some form of
nationally accepted standards of education and training. It is certainly true
that no such standards currently exist.
Some modern practitioners support therapys probable imminent regulation on the grounds that they expect it to promote what they see as being
some very desirable higher levels of professional services and responsibilities. In a typical example, Kierski (2009) interviewed four very eminent psychotherapeutic practitioner-theorists (Emmy van Deurzen, Holly
Connolly, Alan Frankland and Elizabeth Campbell). Collectively, they
supported regulation of the talking therapies. All four argued that regulation will lead to enhanced public confidence in counselling and promote
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better and more rigorous standards of practice. Aldridge (2009) argues that
there is no evidence that regulation will (as some claim) destroy creativity
or therapist autonomy. She also rejects the argument that regulation will
enforce unnecessary or unethical professional limitations or practice
boundaries. Aldridge refers to the seemingly beneficial effects that regulation has had on art therapy as a practical example of the positive side of
controlled professionalisation.

Freedom or repression?
It is possible that much of the for and against war currently being fought
over the statutory regulation and professionalisation of counselling and
psychotherapy is simply a reprise of similar battles that took place at earlier
times in other professions prior to their eventual or imminent statutory
regulation (nursing, teaching, social work, etc.). In one sense, these debates
could be seen as just being particular versions of the nanny state versus
personal licence arguments that have long existed and that still create
widespread dispute within society generally. The main thrust of societys
pro-regulators (in earlier times and now) seems to target an alleged need to
protect the public, to set out service/performance benchmarks, to drive
up professional standards and to enhance practitioner status. The main
thrust of the anti-regulators (then and now) seems to be concerned with
worries about the potential diminished levels of innovation/creativity and
practitioner autonomy that might arise if the freedom of professional
practitioners is in anyway curtailed. So, both in the world as a whole and
in psychotherapy in particular, when does freedom become anarchy?
Alternatively, when does regulation become repression? Can anyone be
sure?

REGULATING THE PROFESSIONAL THERAPIST THE REALITY

The pro and con therapy regulation argument rages. It will probably do
so for the foreseeable future. However, in recent years, the inevitability of
state intervention in the direction of the talking therapies has come to
be more and more accepted as a likely political reality. As a result, the main
UK bodies concerned with psychotherapy and psychological therapies
(including, principally, the British Association for Counselling and
Psychotherapy (BACP), the United Kingdom Council for Psychotherapy
(UKCP) and the British Psychological Society (BPS)) moved to a position
whereby they have accepted (in some quarters very reluctantly) that
regulation is going to happen. Indeed, for the psychologists, statutory
regulation is already happening.
Nevertheless, the organisations claiming to speak for the UKs talking
therapies have continued to quarrel with the government about the
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methods to be employed (see accounts by Aldridge, 2006; Aldridge and

Pollard, 2005). In particular, they objected to the proposal that the HPC
should be the national regulatory body for the psychotherapeutic professions. As a result, a Representative Group of nine of the main organisations involved with the provision of psychological therapies in the UK was
set up (BPS, 2006). The Representative Group collectively accepted the need
for regulation, although they rejected the Governments proposal that the
HPC should be the regulator. They wanted therapist regulation to be
undertaken by an independent Psychological Professions Council, which
would, in some ways, have mimicked the UKs General Medical Council. As
Miller (2006) put it, our proposal for a new Independent Regulator . . .
developed because we regard the HPC route as unworkable . . . regulation
via the HPC would be disastrous. The Representative Groups underlying
premise, that therapists are best regulated if they are self-regulated, was not
accepted by the Government. Equally importantly, the Groups argument
that, if regulation must come about, the HPC should not be the regulator,
has also been firmly rejected.
To all intents and purposes, the apparently irresolvable debate about
professionalising the therapy trade is increasingly irrelevant. Unless there
is a radical change in Government policy, the pro-regulationists have won.
The fact is that, although many within the therapy profession will continue
to dissent, the Government is actively arranging for the statutory regulation
of the psychological therapies to be carried out under the remit of the HPC.
Furthermore, the Government has announced its intention to expedite the
statutory regulation of the counselling and psychotherapy professions.
Ministers have also stated that they are firmly against the proliferation of
regulatory bodies and have ruled out the possibility of creating a separate
Psychological Professions Council.
The Governments current intentions are that counselling will become an
HPC-regulated profession during 2011 (Pointon, 2008). The HPC has set up
an advisory Professional Liaison Group (PLG), chaired by Professor Diane
Waller. The PLG has now made its recommendations to the HPC. In turn,
the HPC will now advise the Government. The PLG has recommended
(subject to public consultation) that:
counsellors and psychotherapists should be on different registers from
each other;
certain professional titles (counsellor, psychotherapist, etc.) should be
legally protected;
practitioners currently registered with certain existing voluntary
bodies (BACP, UKCP, etc.) should be automatically transferred to the
new statutory register;
certain currently unregistered practitioners should be eligible for HPC
registration through a grandparenting scheme;
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registered counsellors should have attained an academic award at

National Qualifications Framework (NQF) Level 5 (HE diploma, Year 2
honours degree; foundation degree);
registered psychotherapists will need an NQF Level 7 (masters degree)
qualification.
It is expected that following the HPC report to the Government the
appropriate statutory orders will swiftly follow. It seems likely, therefore,
that regulation will come about some time before 2012. Clearly, the
eventual nature and style of the statutory orders will be of vital concern to
everybody in the talking therapies. They will profoundly affect the personal
therapy trade for years to come. Whatever the outcomes of the next few
months, the HPCs recommendations and the Governments conclusions
will shape the prospects for most of personal therapys practitioners for the
foreseeable future. At the time of writing, no one can say with any certainty
what sorts of people, with what sorts of backgrounds, education or training
tomorrows therapy practitioners will be. We do not know how they will be
officially recognised. We do not know where they will be working. We can
only guess at what sorts of services they will be offering to what sorts of
clients. Todays therapists do indeed seem to be living in interesting times.

REFLECTION POINT
Would any of therapys great thinkers and innovators have been able to develop
their ideas had they been subject to statutory regulation?
Statutory regulation of counselling and psychotherapy the nanny state at its
worst or a safeguard for an often vulnerable group of clients?

TRAINING THE PROFESSIONAL THERAPIST IDENTIFYING

THE GAPS
As we know, there are no officially recognised training schemes or qualification standards for counsellors and psychotherapists (except in the
particular case of certain chartered psychologists). The situation is that, at
present, anybody, apparently qualified or not, can call themselves a
counsellor or a psychotherapist. As a result, people claiming to have the
necessary expertise to offer some sort of talking therapy can, and do, have
all sorts of backgrounds and training (spurious or curious), or even none at
all. Just look in any of the local directories under Counselling and Advice
or Psychotherapy. You will find all sorts of people claiming to be
therapists, ranging from the weird and wonderful to those who, at least on
the surface, appear to be adequately or appropriately qualified. Even those
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who seem to be among the better qualified (according to their adverts at

least) have huge variations in their actual training levels that range from
basic six-week introductory courses to postgraduate degrees. The simple
truth is that, at present, anyone looking for a therapist is very much in
danger of buying a pig in a poke.
There are, of course, a number of voluntary organisations in the UK that
claim to represent, and in some ways qualify, various groupings of
counsellors and psychotherapists (chartered psychologists excepted).
Probably the most widely known of these more or less nationally accepted
bodies are the British Assocation for Counselling and Psychotherapy (BACP)
and the United Kingdom Council for Psychotherapy (UKCP). However,
only a minority of those offering personal therapy in the UK are actually
BACP accredited or UKCP registered or have equivalent endorsements
(COSCA Scotland, etc.). This is an unfortunate state of affairs because it
helps to maintain the currently woeful lack of consumer protection.
However, even the professional policing of practitioners who do choose to
be BACP/UKCP or similarly accredited remains limited. Neither the BACP
nor the UKCP, nor any of the other voluntary therapy organisations, has
any statutory teeth. They can only refuse to endorse defective practitioners,
they cannot stop them practising.
It is also the case that neither the BACP nor the UKCP takes on the task of
directly training those of their members who they might eventually
recognise as being proper therapists. In all cases they apparently leave
this job to the various training organisations that each of these two professional associations has deemed to have achieved Approved Training
Establishment status. It is, of course, true that the content and circumstances of the training offered by any of the BACP/UKCP-approved training
organisations have to meet some very specific, openly published criteria. In
the case of the BACP, these criteria are set out in its Accreditation of Training
Courses (2009), informally known as the Gold Book. In the case of the
UKCP, its minimum training criteria are set out in the UKCP Standards of
Education and Training (2008). Broadly speaking, both sets of criteria tend to
be somewhat in line with each other.
It is clearly arguable that learning to conform to the BACP/UKCP criteria
might be an admirable ambition for aspiring talking therapists, but is such
an attainment actually sufficient to qualify them to practise? One potential
educational weakness in both these training schemes is typified by the
UKCPs 2009 website statement that Psychotherapy is both an art and a
science and as such it is not possible to identify purely objective methods to
assess an individuals readiness to practice (www.psychotherapy.org.uk).
In other words, it seems that both of these professional bodies set out
some extremely desirable (although arguably limited) aims for training
therapists, but neither sets out specific directions on how to achieve these
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targets. Furthermore, neither body apparently defines any nationally agreed

benchmarks against which the students accomplishments might be
measured. As a result, the levels of training received by those currently
practising under the BACP and UKCP banners vary from something that is
probably little more than a FE certificate/diploma to doctoral-level qualifications.

TRAINING THE PROFESSIONAL THERAPIST PLUGGING

THE GAPS
In the UK, some of the confusion about what are the proper ways of training professional psychological therapists is probably about to be untangled.
There are two sets of national training and practice protocols currently
under development. The first is the National Occupational Standards for
Psychological Therapies (NOS) and the second is the National Standards of
Proficiency for Counselling and Psychotherapy (NSP). Details of these are as
follows.

National Occupational Standards for Psychological Therapies

A set of national occupational standards that applied to counselling only
was originally developed by the Employment National Training Organisation (ENTO). These were largely an extension of the UKs National
Vocational Qualification (NVQ) system and do not seem to have been very
influential with the counselling training agencies. ENTO began a systematic
review of these standards in 2005. However, in 2006, Skills for Health (the
Healthcare Skills Development Council) began a development project to
provide a set of National Occupational Standards for Psychological Therapies
(NOS). This is a separate and much more wide-ranging process than that
being undertaken in the ENTO review. The ENTO review is apparently an
updating of an existing set of counselling protocols; the Skills for Health
initiative is intended to provide a set of performance standards for all the
psychological therapists working in healthcare situations. The Skills for
Health report was due at the time of writing. It seems likely that the
Healthcare Skills Project will incorporate, or combine with, some of the
ENTO proposals when it finally reports. You can keep abreast of all these
developments at www.skillsforhealth.org.uk and at www.ento.co.uk.
At present, Skills for Health have developed, or are developing, Draft NOS
for four of the common therapeutic approaches or, as they call them,
therapeutic modalities. These are:
cognitive-behavioural therapy;
psychodynamic psychotherapy;
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systemic family therapy;

humanistic therapy and counselling.
The NOS are concerned with providing performance standards for therapists irrespective of the working title that any individual practitioner uses.
So, as far as the NOS are concerned, it does not matter what sort of therapist
you call yourself or what sort of training you have had. It is only when you
are working in one of the above modes that your clients can expect you to
be performing at the levels proposed by Skills for Health.
It should be noted that the NOS are standards of therapist practice and not
standards of therapist education. They are intended as working tools to help
individuals and organisations evaluate their therapeutic services as they are
delivered. The NOS are not a set of rules or academic curricula nor are they
professional qualification benchmarks. In other words, the NOS will, at
best, only inform the HPC as it finalises its proposals for the standards of
proficiency that therapists will be required to achieve in order to gain HPC
registration.

National Standards for Proficiency in Counselling and Psychotherapy

The Draft Report to the HPC from the Psychotherapists and Counsellors
Professional Liaison Group includes some proposals for a set of National
Standards for Proficiency in Counselling and Psychotherapy (NSP). This report
is likely to form an important part of the HPCs final recommendations to
the Government. The main purpose of the NSP will be to define the minimum standards of expertise required by all HPC registered practitioners.
Unlike the Skills for Health proposals, the NSP is generic and applies across
all branches of counselling and psychotherapy it is not mode specific. The
NSP qualify the worker, not the work.
The NSP do not by themselves provide the education and training organisations with a set of syllabi. However, in order to gain HPC approval, such
organisations will need to prove that their programmes produce graduates
who are capable of meeting the minimum practitioner thresholds set out
in the NSP. This is because the HPC will eventually be defining the acceptable practitioner education and training levels. In the Draft NSP there are
some 50 suggested Standards of Proficiency that could be shared by all
registered counsellors and psychotherapists. There is one proposed additional standard that supposedly will only apply to registered psychotherapists and one other proposed additional standard that will allegedly
only apply to registered counsellors. The first additional standard assumes
that psychotherapists have a particularly advanced understanding of severe
mental health issues. The second assumes that counsellors have a special
understanding of their clients concerns about well-being, life issues and
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personal transitions. Updates on these developments can be found at

www.hpc-uk.org.
The HPCs proposed National Standards generate some potential disputes.
Are the apparently different educational needs of counsellors and
psychotherapists borne out by reality? The claimed differences in training
levels might fade away in times to come. The psychotherapists alleged
superior understanding of severe mental health issues might be equalled by
that of counsellors, should counselling eventually emerge as an honours
degree-entry profession. Is it really the case that counsellors diverge from
their psychotherapist colleagues because they have a genuinely superior
understanding of well-being, life issues and personal transitions? It is quite
likely that many, if not most, psychotherapists would claim a similar level
of understanding of human need.

TRAINING THE PROFESSIONAL THERAPIST ISSUES

AND DEBATE
As far as psychotherapists are concerned, therapy is supposedly already a
mainly postgraduate-entry profession. This is the minimum educational
standard that psychotherapists have decided their registered practitioners
need to attain. However, a survey of the UKCPs list of approved training
bodies, and the programmes that they offer, gives us reason to wonder if
the true standards of every one of these approved training programmes are
truly at such an admirably high level. It also seems that the study content
of some of these programmes might vary widely. Of course, it is always open
to debate whether such educational variety is, or is not, a good thing.
The educational situation, as far as current trainee counsellors are concerned, is not dissimilar, except that their claimed minimum training
standards are lower. These standards are possibly (but not universally)
usually at about HE diploma level. Although psychotherapists claim to have
undergone a more in-depth training than counsellors routinely undertake,
this is generally only a defendable assertion as far as the differences between
the BACP and the UKCP minimum qualification standards are concerned.
For the newly emerging breed of graduate counsellors, these alleged training differences are sometimes more than made up in the third year of
the increasingly available honours degree-level counselling training programmes.
It is clearly arguable that, currently, there is a somewhat confused mix of
apparently uncoordinated approaches to UK therapist professional training.
This is unlike the situation in most of the other major professions, where
there are nationally accepted base syllabi that are offered by approved
training establishments via courses that have been independently validated
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by the Quality Assurance Agency for Higher Education. In the other major
professions the training routes first require the student to undergo generic
training at bachelors level. This is followed by a period spent in gaining
professional experience under an experienced and fully qualified mentor.
Finally, specialised or advanced training is undertaken by postgraduate
study and research. This is rarely the case in UK therapist tuition, except in
cases where the student has first enrolled on one of the growing numbers
of integrated, degree-based therapist training programmes. Will statutory
regulation change this state of affairs? Might it become the case that an
emerging combined counselling and psychotherapy profession will eventually demand an honours degree as a minimum entry-level qualification?
At present, the HPCs draft proposals for therapist education only appear to
generally endorse (or officialise) the current situation for therapy trainees.
It appears that the existing programmes approved by therapy professions
main representative bodies (BACP, UKCP, BPS, etc.) will satisfy the proposed
HPC registration thresholds. So far there has been no move to set up a fully
thought-out career training path for therapists. Interestingly, other sectors
of the socially active professions have been through similar reviews/
regradings of their practice and training standards over the years. In many
cases (social work, for example), they have gradually evolved as HE-based
callings with structured career paths. This rather suggests that the proregulationists apparent victory in therapys regulation wars is, as yet, far
from absolute. It might be that they have only been successful in the
opening skirmishes. It might also be that there are many battles yet to be
fought over the appropriate educational and training standards that will
come to be expected from the therapists of the future.

REFLECTION POINT
Should there be any differences in the training or professional practices of
counsellors and psychotherapists?
What would you include in an educational programme for talking therapists?
What would you leave out?
The talking therapies are they Art or Science?

TRAINING THE PROFESSIONAL THERAPIST A WAY FORWARD

Let us suppose that, eventually, all therapists will be required to have obtained
a minimum, entry-level educational standard equivalent to an honours
degree. Therefore, if gaining such a degree were to become an essential first
professional step, it would seem likely that eventual entry into one of
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therapys specialisms or advanced practice areas would probably require

postgraduate education. In other words, advanced professional therapeutic
practitioners are likely to evolve as masters-level specialists. Bearing in mind
the personal and professional advantages that having a rewarding career path
might bring to therapists, does Figure 10.1 suggest a suitable way forward for
tomorrows professional counsellors and psychotherapists?

Appropriate previous
education and experience

Generic therapy
honours degree

Mentored, post-degree,
experiential training

PROFESSIONAL STAGE 1
Entry-level qualified therapist

PROFESSIONAL STAGE 2
Postgraduate specialist training
(Research-based MSc)

Psychotherapy

ADVANCED
PROFESSIONAL
PRACTITIONER

Counselling

Academia
& training

Practitioner
supervision

Therapeutic
treatments

Therapy
services

Figure 10.1: The way forward for tomorrows counsellors and psychotherapists?
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THE TALKING THERAPIES AND THE NHS THE COMING YEARS

In todays NHS, the talking therapies are very often made available to
appropriately diagnosed patients. This is especially so in primary care
settings. It seems that patients experiences have caused them to come to
highly value counselling as a treatment choice (Brettle et al, 2008). It also
seems that GPs, too, value counselling, particularly when delivered through
their local surgeries. Apparently, they feel that it helps them to retain direct
control of their patients welfare (Brettle et al, 2008).
Importantly for todays NHS counsellors and psychotherapists, the general
trend of the research (Antonuccio et al., 1995; Roth and Fonagy, 2005, and
many others) seems to show that the drug-based treatments and the talking
therapies are, when taken in the round, about equally helpful in cases of
psychological and emotional disturbance. These sorts of studies also suggest
that most of the talking therapies (including CBT) are roughly speaking
about as effective as each other (see the reviews by Cooper, 2008). The
important point here is to note that none of the psychological therapies
used in the NHS is likely to be any less (or any more) useful than CBT.
Therefore, it is no doubt surprising to many therapists and non-therapists
alike to find that CBT has become the psychotherapeutic flavour of the
month throughout the NHS (see NICE Guideline 23, 2004, for example).

The CBT debate

CBTs pre-eminence is not likely to diminish in the near future. It appears
that current NHS planning is largely based on the policy makers assumption that CBT will continue to enjoy its enhanced and allegedly superior
status. This optimistic view stems in part from the Layard Report (2006).
Further support for the extensive use of CBT comes from the undeniable
fact that it has been very well defended by its supporters as being a properly
researched, legitimate, flexible and effective form of psychotherapy (Veale,
2008, and many others). Nevertheless, a significant number of counsellors
and psychotherapists remain doubtful about the true place of CBT within
the overall psychotherapeutic remit. For some of these doubters, CBT is
simply not proper therapy and probably never will be. Of course, for those
therapists who believe that the talking therapies should be combined to
form an inclusive church, with no significant distinctions between its
practices or its practitioners, such doubts are irrelevant. This is because
they consider that the overwhelming trend of the evidence still tells us that,
as far as the competing psychological therapies are concerned, indeed
everybody has won and all shall have prizes. Nevertheless, the question
remains: Why should CBT be so popular? However, perhaps a much more
important question to ask is: Will CBT really fulfil the NHS policy makers
expectations?
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Although it might be argued that the who supports CBT debate is

increasingly irrelevant for modern talking therapists, it is still the case that
the high value that the NHS places on CBT is of vital concern to all NHSbased counsellors and psychotherapists. One of the attractions that CBT has
for todays NHS largely comes from the fact that CBT has been robustly
evaluated by numerous outcome studies as being an effective and rapid
treatment method (see Roth and Fonagy, 2005, and many others). Another
attraction is that it is apparently cheap to deliver. Brief intervention CBT
has also received significant support from extensive outcomes-based
research and this is clearly of telling importance for the cost-effectivenessdriven NHS policy makers. This happy state of affairs (for CBT anyway!) is
not yet the case for the other counselling-based therapies, although the
research deficiencies, at least, are being rapidly corrected (see Cooper, 2008;
Lambert, 2004; Stiles et al., 2006, and many, many others).
The practical reality is that CBTs apparently provable efficacy, its assumed
superiority, and its hoped-for low cost, have all combined to cause the NHS
management to decide that CBT should become the future treatment of
choice for most of the mental health problems that patients bring to their
doctors (Department of Health, 2001b, 2001c). Today, the popular cure all
prescription for the psychologically troubled seems to be to provide them
with about six sessions of CBT. This seems to be the favoured treatment in
almost all cases. One reason why this might be so could be because this is
precisely what the national NHS directives recommend. Among the
problems that CBT is claimed to be effective in treating are:

anxiety disorders, including phobias, panic attacks and panic disorder;

depression and other mood disorders;
eating disorders;
psychosomatic disorders;
obsessive-compulsive disorders;
anger;
post-traumatic stress disorders;
sexual and relationship problems;
adverse habits, such as facial tics;
drug or alcohol abuse;
sleep problems;
chronic fatigue syndrome (ME);
chronic (persistent) pain.

This CBT-based treatment policy was endorsed by the National Institute for
Health and Clinical Excellence (NICE) in 2004. The NICE Clinical Guidelines
9, 22 and 23 recommend CBT as the most suitable treatment for anxiety,
depression and eating disorders. It is indeed a one-size-fits-all policy and,
what is more, this type of treatment is cheap. This is because the recommended dose of six or so sessions can allegedly be delivered by apparently
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very quickly trained workers. This means that CBT is easy to manage, easy
to plan for and easy to budget for. It is also claimed that it will be easy to
find the practitioners to provide it and inexpensive to educate them. All in
all, CBT is an NHS managers dream.
As a result of these developments and the impact of Layards very
influential report, the Government is making a pump-priming investment
of 170 million in the NHS initiative, Improving Access to Psychological
Therapies (IAPT) from 2008 onwards (NHS, 2007). More investment is
planned. The Governments objectives are set out in the IAPT Implementation Plan (Department of Health, 2008a). Their intentions are quite
clear. There is going to be a huge expansion in the availability of CBT
throughout the NHS and a similarly huge expansion in the number of CBT
therapists who will have been trained to carry out this work. Whether this
new group of therapists will be drawn from a practitioner pool that will
necessarily include many of todays other talking therapists yet remains to
be seen. None of this appears to augur well for non-CBT psychological
therapists in tomorrows NHS, unless they are prepared to radically reconsider their styles of practising.

TRAINING TOMORROWS CBT DELIVERERS FOR THE NHS

It seems that there will be two standards of CBT training made available for
what will be two classes of CBT practitioners.
1. Curriculum for high-intensity therapy workers (Department of Health,
2008b)
Courses for high-intensity workers will aim to provide a post-qualification
training in evidence-based CBT for adults with depression and/or any of
the anxiety disorders. The courses will be at postgraduate
diploma level or equivalent.* Recruitment for the courses will be
aimed at postgraduates, with trainees drawn from clinical psychologists
and psychotherapists, as well as people with experience of delivering
mental health in other professional capacities such as nursing and
counselling (and including graduate mental health workers who can
demonstrate professional and academic equivalence).
(* Authors emphasis)
2. Curriculum for low-intensity therapy workers (Department of Health, 2008c)
The curriculum is based on a modular structure of four modules delivered
over 45 days in total. Although each module has a specific set of foci and
learning outcomes, the clinical competencies build module upon module
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and courses will be expected to focus the majority of their classroom

activity on clinical competency development through clinical simulation/
role play. All modules will be assessed on participants practical demonstration of competencies, according to pass/fail criteria. Participants
will not necessarily possess previous clinical or professional
expertise in mental health*, and will be able to undertake academic
assessments at either undergraduate or postgraduate level, depending on
their prior academic attainment. Skills-based competency assessments will
be independent of academic level and must be achieved according to a
pass/fail criterion.
(* Authors emphasis)
It would not take a genius (or a confirmed cynic) to work out that, almost
certainly, more resources will be allocated to training the cheaper lowintensity workers than will be allocated to training the more expensive
high-intensity workers. The key issue here is that the person specification
for the low-intensity trainees states that they need not possess previous
clinical or professional expertise in mental health. So this question arises
low-intensity CBT workers might well be cheap to train and cheap to
employ, but is the NHSs rapidly emerging heavy reliance on CBT (effectively making it the preferred therapy) really in the best interests of the
patients or in the best interests of the NHS bean counters?

DOES COUNSELLING AND PSYCHOTHERAPY HAVE A

FUTURE IN THE NHS?
One result of the growing primacy of CBT treatments is that, in an
increasingly expanding number of NHS areas, the non-CBT counselling
services are in danger of being either discontinued or greatly reduced. If
uncorrected, this potential trend is likely to accelerate as more and more of
the new CBT technicians complete their training and come into post. In
addition, it is inevitable that ongoing NHS budget restraints and operating
stresses will continue to demand ever-higher levels of patient throughput. This all means that, if the existing NHS generalist counsellors and
psychotherapists want to survive, they might well find themselves having
to fundamentally adapt their treatment methods. Counselling practice
could well find itself having to evolve in order to meet the demands of the
highly pressured, cost-based contexts within which counsellors will find
themselves working. Of course, not all therapists will be willing to do this.
Totton (1997), for example, argues that working within such externally
imposed limits diminishes the potential benefits of therapy.
However, it can also be argued that the NHS counselling services are only
required to deliver optimum levels of benefits to each patient. A four-star
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service is not always necessary sometimes adequate will do. Therefore,

NHS counsellors will rarely be able to indulge in the luxury of the endless
personal or client self-explorations that constitute the therapeutic ideal of
psychotherapys purists. In other words, NHS counsellors and psychotherapists will probably find themselves having to choose between one of
two options. Neither appears very attractive, at least from the traditional
therapists point of view. They might have to either elect to deliver some
form of time-restricted, that-will-do, therapy that suits the then prevailing
circumstances or be sacked. The choice might be between providing good
enough therapy and providing no therapy at all. In the real world,
complying with NHS budget constraints and priority choices is a routine
operational fact of life and is likely always to be so (Tinsley, 1999). Perhaps
the harsh message for tomorrows NHS counsellors and psychotherapists
will be adapt or die!

REFLECTION POINT
Is CBT a proper counselling therapy?
Do NHS counsellors see clients or do they treat patients?
What sorts of people should the NHSs new CBT workers be?

NEW THERAPISTS FOR A NEW CENTURY

The talking therapies are rapidly evolving no question of that! But what of
the therapists themselves; are they evolving too? What might be happening
to them? Some theorists believe that the therapists of tomorrow will evolve
into being very different types of practitioners, working in different branches
of the therapy trade, each division requiring different areas of professional
expertise. Could this mean that counselling and psychotherapy will really
end up as disparate vocations? After all, McLeod (2009) has already suggested
that there are some essential differences between the ways in which counsellors and psychotherapists each view their clients. For example, it may be
that perhaps counselling reflects societys needs, whereas psychotherapy
supposedly reflects the individual patients needs.
Other theorists see the therapists of the future as developing into much
better, much more effective practitioners; superior practitioners even.
Irrespective of their original training, outside the confines of their therapeutic schools, the measure of these new improved-quality therapists
might come from their outcome-evaluated, advanced professional competencies rather than from assessing their ability to conform to schoolistic
theory. These new practitioners might evolve into what, in much earlier
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times, Ricks (1974) was already describing as a new breed of tackle-anything, wonder-therapists the supershrinks.

The supershrink
The notion of a supershrink is fundamental to the future of the talking
therapies. This is because a supershrink profession might be much more
powerful and with a much higher status than is generally the case with
todays talking therapies. It seems that the concept of a supershrink does
have some research-based support. Wampold and Brown (2005) found
evidence that, for whatever reasons, some therapists were consistently
better than others when measured by the quality of the treatment
outcomes. Other studies, for example Project MATCH (1997), seem to
support such a finding. Is there a secret ingredient that makes the supershrinks stand out? One possible explanation of the supershrink phenomenon is that it is simply happenstance. Perhaps some people are just
naturally much better therapists than others. Is there such a being as a
great therapist?
Fortunately, all is not lost for the rest of us who were not born with a natural
greatness. Performance studies, both within therapy and in the outside
world (see Colvin, 2006), usually find that, generally speaking, hard work
usually makes up for any apparent lack of giftedness or innate superior
talent. Further studies suggest that there are strategies that all therapists
could adopt that might help them to improve their effectiveness with their
clients. For example, Miller et al. (2006) found that formally engaging with
client feedback has a marked effect on therapist performance. Miller et al.
have summed up these strategies into three components.
Think: First, decide upon the therapeutic objectives and then plan
how to achieve them.
Act: Second, start work with the client and monitor your performance
by obtaining ongoing client feedback find out if your treatment
strategy is working.
Reflect: Third, reflect on your performance and, if necessary, adopt
alternative strategies.
According to Miller et al. (2006), it seems that hard work and effort are the
true keys to success in any calling, including the talking therapies (see the
review by Ericsson et al., 2006). As the old joke goes, Can you tell me how
to get to the Albert Hall please? Yes; practise, practise, practise! An
interesting point here is that, if Miller et al. (2008) are right, tomorrows
supershrink is likely to be a highly skilled technician working within laiddown operating procedures and obedient to measurable outcomes. That is
a far cry from the unrestrained, creative practitioners that some see as the
rightful heirs to the true future of proper counselling and psychotherapy.
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Counsellors and psychotherapists a parting of the ways?

There seems to be a possibility that, in a few years time, statutory regulation will initially divide counselling and psychotherapy into two different
callings with two different levels of training requirement. This could mean
that these two trades might effectively become two different professions.
Some theorists have already anticipated (even welcomed) this possibility.
For example, McLeod (2009) argues that now is the time to undertake a
radical review of the nature of counselling. This is because he suggests that
counselling is really what he calls a front-line community-based activity
within the helping professions. He suggests that counselling should be a
collaborative activity between the therapist and the client one that is
targeted at helping the client to deal with life and lifes difficulties. This
would indicate that counsellors should concentrate on understanding
people and their interrelationships in terms of their social, cultural and
organisational contexts. This is different, he argues, from psychotherapy,
which is more exclusively targeted on the individual patient and on
providing specific remedies for individual problems. In other words,
psychotherapy tends to be a narrow, focused approach to the individual,
whereas counselling tends to be a wider, society-based activity. Put crudely,
this argument seems to suggest that psychotherapy is about finding cures,
whereas counselling is about acceptance, learning and change.
If these suggested differences actually do underpin a true divergence between
counselling and psychotherapy, it seems reasonable to suggest that these coprofessions will devolve into being providers of two different types of
service, delivered by two different types of therapeutic practitioner. Each of
these two disciplines might then evolve by striving to satisfy different
professional demands. For example, the psychotherapists might advance
their profession by developing new therapies (cures?). After all, in the UK
today there is a huge, often unmet, ever-growing demand from patients
needing immediate mental healthcare fixes (McCrone et al., 2008). Could
the psychotherapists find productive ways of filling those gaps? Alternatively, perhaps the counsellors might promote their own professional
discipline by becoming more embedded within their communities. Perhaps
if counsellors came out from their consulting rooms, they might find
themselves becoming much more socially pro-active. For example, it might
be that schools counsellors could offer advice on child welfare, or perhaps
workplace counsellors could help employers to devise more productive (and
financially more advantageous?) interactions between their employees.
It is always possible that separating out counsellors from psychotherapists
might actually strengthen the two callings. A parting of the ways might be
beneficial to both professions. Yet again we can see that it is an interesting
time to be any sort of a talking therapist.

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FINAL THOUGHTS
In this book, I have been setting out how I believe my version of the story
about how counselling and psychotherapy has developed over the years. It
is the story of the need that people often have to seek out someone to listen
to them; someone to support them through their difficult times. Sometimes
it really is as simple as that people do not always want cleverology;
sometimes they just want tea and sympathy. It can be a sobering lesson
for any therapist to learn that, no matter what sort of a practitioner it is that
you choose to be, for some of your clients all your carefully acquired skills
and learning are not actually of very much interest. For some of our
customers, just being heard is enough; just being really attended to is
sufficient. Somehow, in some way, helping our clients to bring their stories
out into the open, and helping them to give themselves a voice and to tell
their tales to someone who is genuinely interested, seems to do the job. It
appears that, in some cases, all that is needed, when we are trying to find a
way to make someone feel whole again, is to help that someone to feel
validated as a person. Clients talk; we listen after all, that is how the
talking therapies got their name.
A central theme throughout this book has been my belief that counselling
and psychotherapy, indeed the talking therapies generally, are all just
different sides of the same coin. Of course, my ideas may have to be revised,
at least temporarily, if regulation does separate these two callings in legal
terms. Whether such a separation would be anything other than artificial,
and whether it will stand the test of time, currently remains a very open
question. Obviously, for many other theorists and investigators it is actually
an irrelevant question, because they are firm in their belief that all the
therapy types are inherently different.
It seems to me that the really interesting puzzle comes not from wondering
where therapy came from, but in trying to work out where it might be
going. Some theorists believe that it will go down a science-based route,
achieve practical and theoretical integration and emerge as a supertherapy. Other theorists argue that the individual therapy modalities
cannot be combined and so a meta-theory that could underpin a megatherapy cannot emerge. For yet other thinkers, the existing therapy types
should be envisaged as art forms to be worked at by unrestricted, creative
practitioners. They would claim that each therapy modality, and each
interpretation of it, is unique. As ever, some therapists want regulation;
some want freedom. Some prefer professional controls; others are more
comfortable with therapeutic anarchy.
Of course, as well as wondering where therapy is going, we also need to
think about where the therapists themselves are going. Will they continue
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to be loyal adherents of their various schoolisms? Will they become

practitioners of a united form of therapy or will counsellors and psychotherapists remain independent of each other? Will tomorrows therapists
need advanced education? A very important question concerns the growing
power of the cognitive-behavioural therapists. Are we moving towards a
psychotherapeutic world in which CBT is King!? Sometimes we define
therapists by the services that they provide (family therapist, drugs adviser,
workplace counsellor, etc.). What if, in the future, we were to develop some
new overarching service areas for counsellors and psychotherapists (social
systems designers, conflict resolvers, change managers, etc., etc.)? Would
such developments simply require us to find additional ways to define
therapists? Alternatively, would such evolutions require us to develop some
new-style super-therapists or perhaps todays practitioners simply have to
cope and get on with things if they happened to find themselves working
in these new sorts of service areas?
So, I am leaving you with many questions needing many answers! Do you
have any? Can you work something out? As for me, this is it. My tale is told;
my story is done. Now you tell yours!

SUGGESTED FURTHER READING

Cooper, M (2008) Essential Research Findings in Counselling and
Psychotherapy: The facts are friendly. London: Sage.
READ THIS BOOK! This is an excellent account of all the core issues in
therapy research. Chapter 7 is the key to the future.
Yalom, I (1991) Loves Executioner and Other Tales of Psychotherapy. London:
Penguin.
Current literature: Therapy Today, Counselling & Psychotherapy Research,
Counselling Psychology Quarterly, British Journal of Guidance & Counselling
and The Psychotherapist.

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Index
Pages given in italic type contain relevant tables and figures.
A
A, B, C principle 74
accepting, counsellors 101
actualisation see self-actualisation
acute stress disorder (ASD) 135
adolescence 142
Alcoholics Anonymous 12
Allen, Barbara 15860
Alliance for Counselling and
Psychotherapy Against State
Regulation 168
Allport, Gordon 106
angst 92
approval/love 901
Approved Training Establishment status
173
ASD see acute stress disorder
associative learning 69
asylums, mental 6
avoidance behaviour 80
B
BACP see British Association for
Counselling & Psychotherapy
Bandura, Albert 10, 70
Beck, Aaron 10, 75
behaviour preservation 7981
behaviour shaping see operant
conditioning
behavioural activation 85
behaviourism 9, 678, 75
see also cognitive-behavioural theory
Big Five personality traits 107
Biles-Garvey, Paula 1447
biofeedback 745
biological/genetic theories of personality
367, 66, 108
book prescriptions 159
Bordin, Edward 20
Bossman, Alexandra 160
British Association for Counselling &
Psychotherapy (BACP) 22, 1267, 170,
1734
definition of counselling 423
British Psychoanalytical Society 58
British Psychological Society (BPS) 170
C
Campbell, Elizabeth 16970
Cattell, Raymond 1067
CBs see core beliefs

Charcot, Jean 456

child protection issues 146
Clarkson, Petruska 11215
classical conditioning 9, 69
client-led therapy 19, 29, 83, 121
see also person-centred therapy
Cognitive-analytic Theory 112
cognitive-behavioural theory 10, 657,
724, 72
behavioural theory 9, 6770, 68
cognitive theory 10, 701, 71
therapeutic components 745
see also cognitive-behavioural therapy
(CBT)
cognitive-behavioural therapy (CBT) 10,
16, 367, 756, 779, 78, 835, 160
basic concepts 767
and the NHS 17982
problem assessment 7981
Socratic questioning 812
Cognitive Revolution, The 75
Coles, Adrian 133
college counselling 138, 1447
commercial sector see private practice;
workplace counselling
compassion-based therapy 85
conceptual learning 701, 71
conditioning 9, 6970
conditions of worth 90
confidentiality/consent
NHS versus other settings 1578, 159,
162
schools counselling 13942
congruence, feelings and actuality 1001
Connolly, Holly 16970
conscience 48
consumer protection 126, 173
Controversial Discussions, The 58
core beliefs (CBs) 77
Core Curriculum Consortium 22
cost-effectiveness 15, 1819, 163
counselling services see therapy services
counter-transference 62, 11314
cure rates 110
Curriculum for high-/low-intensity therapy
workers 1812
cyber-bullying 1456
D
Death Force (Thanatos) 46, 47
deconstructivism 12

197

INDEX

degree-based counselling 223, 234

Department of Health 1812
depression 10, 367, 80
desensitisation 745, 83
diagnosis 301, 34, 79
Dodo Effect 14
Dollard, John 20
drug therapies 16
Dryden, Windy 72
dualism, mind/body 46
E
EAPs see employee assistance providers
educational counselling
colleges and universities 138, 1447
schools 137, 13843, 143
Egan, Gerard 201
ego and superego 478, 52, 54, 90
Ellis, Albert 10, 74
employee assistance providers (EAPs)
1718, 12930, 1345
see also workplace counselling
Employment National Training
Organisation (ENTO) 174
epegenetic development 53
Erikson, Erik 524, 556
Eros see Life Force
Evans, Kenneth 116
Every Child Matters 140
existential approach 913
Eysenck, Hans 14, 107, 108
F
feedback loops 745
Ferenczi, Sndor 57
First World War 8
Five Facets Theory 11215
flooding 83
4 Gates Model 723, 72, 78
Frankland, Alan 16970
Fraser Guidelines (Gillick Competence
Test) 140
free association 46
French, Thomas 20
Freud, Anna 58
Freud, Sigmund 68, 9, 57, 58, 66, 90,
123
psychosexual theory 4552, 51, 56
Friery, Kevin 132
G
general practitioners (GPs) 1445, 1512,
153, 1546, 163, 179
confidentiality 157
primary care mental health teams
15860
workload 1567
genetic theories of personality 367, 66,
108
gestalt approach 934
Gilbert, Maria 116
Goldfried, Marvin 20
Government see regulation, professional

198

GPs see general practitioners

Graham, Tina 1546
H
Health Professions Council (HPC) 168,
1712, 1756, 177
hierarchy of needs approach 957, 96
higher education see universities
holism see gestalt approach
hospitals, mental 6
HPC see Health Professions Council
humanistic approaches 378, 867,
978
existential 913
gestalt 934
hierarchy of needs 957, 96
Rogerian/person-centred 1012, 8791,
99104
hypervigilance 801
I
IYou relationship, Five Facets Theory
11415
id 47
implosive therapy 83
Improving Access to Psychological Therapies
(IAPT) 22, 155, 163, 181
in loco parentis, schools counselling
1401
in situ desensitisation 83
industrial welfarism 17
information overload 934
instrumental conditioning 9, 6970
integrative therapies 202, 112, 117
Cognitive-analytic Theory 112
Relational-developmental Theory 116
Therapeutic Relationships Model
11215
International Association for PsychoAnalysis 57
internet
cyber-bullying 1456
online counselling 145
interpersonal dislike 8
interpretation, lifes events 779, 78
J
Jones, Ernest 8
Jung, Carl 57
K
Klein, Melanie 578
L
Layard Report 179, 181
learning
Social Interactional Learning Theory
1089
stimulus/response mechanism 6870,
68, 701, 71
Life Force (Eros/libido) 46, 47
love/approval 901
Luborsky, Lester 14

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M
madness, historical explanations of 56
market forces, therapy services 1202
cost-effectiveness 15, 1819, 163
Maslow, Abraham 957, 96
McLeod, John 7, 185
Mearns, Dave 1034
medical profession 6, 8, 16
see also general practitioners (GPs)
memory 356
mental health teams, primary/secondary
15862
Miller, Neal 20
Miller, Scott 184
mind/body dualism 46
mindfulness-based cognitive therapy 85
N
National Health Service (NHS) 22, 85, 147,
1536, 1634, 1823
CBT debate 10, 17981
CBT training 1812
confidentiality/consent 1578, 159,
162
history of counselling in 1503
primary/secondary care mental health
teams 15862
workload 1567
National Institute for Health and Clinical
Excellence (NICE) 180
National Occupational Standards for
Psychological Therapies (NOS) 1745
National Standards for Proficiency in
Counselling and Psychotherapy (NSP)
1756
negative automatic thoughts (NATs) 77
neuroscience 108
Newsom Report (1963) 138
NHS see National Health Service
NICE 180
non-clinical population 42
Norcross, John 21
NOS see National Occupational Standards for
Psychological Therapies
NSP see National Standards for Proficiency in
Counselling and Psychotherapy
O
Object Relations School 57
obsessive-compulsive disorder 72, 73
online counselling 145
operant conditioning 9, 6970
organisational clients 41, 42
see also workplace counselling
P
Pavlov, Ivan 9, 68, 69
Perls, Fritz and Laura 93
personality
correct/incorrect 334, 38
understanding/misunderstanding people
301, 338
see also personality theories

personality theories 434, 106, 10910,

111
biological/genetic 367, 66, 108
Social Interactional Learning Theory
1089
Trait Theory 1068
see also cognitive-behavioural theory;
humanistic approaches;
psychodynamic theory
person-centred approaches 29, 378, 83,
98
Rogerian 1012, 8791, 99104
philanthropists, industrial 17
physiology see biological/genetic theories
of personality
plastic responses see operant conditioning
PLG see Professional Liaison Group
post-traumatic stress 8
preconscious 60
primary care mental health teams 15860
private practice 1235
compared to NHS counselling 1567
standards and qualifications 1267
see also therapies/therapists, choice of
Professional Liaison Group (PLG) 1712
professionalisation see regulation,
professional
psyche 5860
psychiatrists 4, 6
psychodynamic theory 8, 356, 634, 66
id, ego and superego 478, 52, 54, 90
later developments 578
the psyche 5860
psychosexual theory 4552, 51, 56
psychosocial theory 524, 556
transference 613, 11314
the unconscious 9, 356, 46, 47, 601
psychologists 14950
versus counsellors 1523
psychosexual theory 4552, 51, 56
psychosis intervention, early 147
psychosocial theory 524, 556
psychotherapeutic services see therapy
services
psychotherapy, history of 1234, 14950
nineteenth century 67
research 1316
twentieth century 713
Q
qualifications, professional 1267, 172
see also training, therapists
R
Rank, Otto 57
Rational Emotive Behavioural Therapy
Model 74
regulation, professional 16772, 185
qualifications 1267, 172
standards 126, 1746
see also training, therapists
reification 63
Relational-developmental Theory 116

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INDEX

Representative Group 171

research, history of 1316
reward-postponed learning 109
rigid responses see classical conditioning
Rogers, Carl, Rogerian counselling 1012,
8791, 99104
Rosenzweig, Saul 20
Ryle, Anthony 112
S
safety behaviour 80
schools counselling 137, 1389, 1423,
143
confidentiality/consent 13942
Schwenk, Elspeth 1312
Scott, Michael 72
secondary care mental health teams 1602
self 87, 8991, 100
ego and superego 478, 52, 54, 90
psyche 5860
self-actualisation 87, 89, 99, 101
Maslows hierarchy of needs 957, 96
self-concepts, congruence 1001
self-fulfilling prophesies 81
self-reflection 301, 34
sexuality see psychosexual theory, Freud
Skills for Health 1745
Skinner, Burrhus 9, 68
Social Interactional Learning Theory 1089
Society for the Exploration of
Psychotherapy Integration 21
Socratic questioning 812
standards, professional 126, 1746
statutory regulation see regulation,
professional
stimulus/response mechanism 6870, 68,
701, 71
student teachers 146
Sullivan, Harry 109
superego 48, 90
supershrinks 184
super-worrying 801
T
teachers
student teachers 146
teacher-counsellors 1389
Thanatos see Death Force
Therapeutic Relationships Model 11215
therapies/therapists, choice of 1213, 234,
31, 34, 434, 10912, 111, 1279
errors 358

200

reasons for seeking help 403

see also integrative therapies
therapists 1835
see also training, therapists
therapy services
market forces/cost-effectiveness 15,
1819, 1202, 163
see also educational counselling;
National Health Service (NHS);
private practice; workplace
counselling
Third Force see humanistic
approaches
Thorne, Brian 104
token economies 70
Towler, John 134
training, therapists 224, 1728,
178
CBT and the NHS 1812
Trait Theory 1068
transference 613, 11314
traumatic situations 8
12-step approaches 12
U
unconditional positive regard 101
unconscious 9, 356, 46, 47, 601
uniformity myth 14
United Kingdom Council for
Psychotherapy (UKCP) 170, 1734,
176
universities
counselling in 138, 1447
degree-based counselling 223, 234
V
van Deurzen, Emmy 16970
vicarious desensitisation 83
voluntary sector services 122
W
Wachtel, Paul 20
welfarism, workplace 17
withdrawal behaviour 80
Witmer, Lightner 14950
Wolfe, Barry 20
Wolpe, Joseph 68, 745
workplace counselling 1617, 1304,
1324
employee assistance providers (EAPs)
1718, 12930, 1345
vs. traditional counselling 19

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