1.1 What Are Counselling and Psychotherapy?

Col i n Feltham

Definitions and Aims

No single, consensually agreed definition of either counselling or psychotherapy exists in spite of many attempts across the decades in Britain, North America and elsewhere to arrive at one. The question of pinning down crucial distinctions arose in concrete terms in the UK in the first decade of the twenty-first century when the Health Professions Council (HPC) initiated preliminary steps towards legal protection of the titles counsellor and psychotherapist. Attempts to load the former with wellbeing-associated tasks and the latter with competencies in addressing more severe psychological problems soon broke down. For the purposes of this book, the following provisional working definition is offered:
Counselling and psychotherapy are mainly, though not exclusively, listening-and-talking-based methods of addressing psychological and psychosomatic problems and change, including deep and prolonged human suffering, situational dilemmas, crises and developmental needs, and aspirations towards the realization of human potential. In contrast to biomedical approaches, the psychological therapies operate largely without medication or other physical interventions and may be concerned not only with mental health but with spiritual, philosophical, social and other aspects of living. Professional forms of counselling and psychotherapy are based on formal training which encompasses attention to pertinent theory, clinical and/or micro-skills development, the personal development/therapy of the trainee, and supervised practice.

A brief, tentative definition of this kind offers some parameters but omits mention of the many, everexpanding, often competing, schools of therapy, and the arenas and the several professions (sometimes in conflict) in which they are practised. Discussions of all such conflicting claims can be found in Feltham (1995) and James and Palmer (1996). The contention advanced by this books editors is that counselling and psychotherapy, in spite of partly different historical roots and affiliations, have much more in common than they have serious and demonstrable differences and that practitioners and the public stand to gain much more from the assumption of commonality than from spurious or infinitesimal distinctions. It is often acknowledged that British counselling much more closely resembles psychotherapy as practised in the USA and parts of Europe than it does the various kinds of guidance and mentoring that it is often confused with. Certainly practitioners in this field work with many different types of goal and expectation, implicit and explicit, each of which may call for the use of somewhat different skills, but arguably little is to be gained practically from further controversy about professional titles and distinctions.

Development of Psychotherapy and Counselling in the UK

Sigmund Freud was developing psychoanalysis often considered the grandparent of most of the diverse schools in existence today in Austria in

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Pa rt I C o u n s ell ing and Psy chothera p y in Context information is available in Aldridge (2011). It is usually agreed that early American vocational guidance projects and associations (for example Frank Parsonss Vocation Bureau in Boston in 1908) laid the foundations of counselling, and guidance for the young generally was a strong element. This certainly features in the early career of Carl Rogers, who is probably the closest to being the founder of (non-directive) counselling in the 1940s. Another player is perhaps Rollo May, who, influenced by Alfred Adler, wrote what many consider to be the first counselling text in the 1920s (May, 1992). In the USA counselling was also originally closely linked with personnel management and the workplace. In general it is true to say that counselling has historical roots in practical guidance and problemsolving issues, and was often agency based rather than associated with private practice. However, it is now mainly characterized as distinctly other than advice giving and as having a primarily facilitative function. Seminal events in the UK included the establishment of the National Marriage Guidance Council in 1938, the importation of counselling training methods from the USA to the Universities of Reading and Keele in 1966 (to serve the pastoral needs of students), and the establishment of the Westminster Pastoral Foundation in 1969. The Standing Conference for the Advancement of Counselling in 1970 led to the formation of the British Association for Counselling in 1977, renamed the British Association for Counselling and Psychotherapy (BACP) in 2000. It should be said that a great deal of cross-fertilization between these developments and others in psychotherapy was taking place and the emergence of psychodynamic counselling, for example, demonstrates these close links. Alongside these developments we should also note pertinent developments elsewhere. Originally the Association of Medical Officers of Asylums and Hospitals for the Insane (AMOAHI, founded 1841), the Royal College of Psychiatrists was so named in 1971. The British Psychological Society was established in 1901. Significant mutual aid and voluntary organizations such as Alcoholics Anonymous (1935), the Samaritans (1953) and Cruse (1959) should also be included in this brief portrait, as should the parallel existence of the personal social services and its casework tradition which closely mirrored developments in counselling and psychotherapy. Theoretically, psychotherapy and counselling develop continuously, some might say all too prolifically, with significant departures from psychoanalytic theory and practice observable from its earliest days. Jung and Adler were among the earliest to break away from Freud, and similar schisms,

the late nineteenth and early twentieth centuries. Before Freud there were certainly many kinds of psychologically oriented therapies and many had already used the concept of an unconscious. However, Freud has come to mark the historical pivot when previous centuries of religious, philosophical and pseudo-scientific theories and methods (from religious propitiation to shamanism, sleeping cures, magnetism, hypnotism, etc.) were challenged by serious aspirations to establish psychotherapy as a scientific discipline. Psychoanalysis is perched curiously between being perceived as a challenge to previous faith in reason (the Enlightenment) and as itself, the new grand narrative capable of rationally explaining all the psychological ills of humanity. Freud is often (although not by all) ranked with Darwin and Marx as one of the most significant scientific thinkers at the dawn of the twentieth century. Psychoanalysis moved through Europe and North America in the first few decades of the twentieth century, the International Psychoanalytical Association being established in 1910 and the British Psychoanalytic Society in 1924. The British Association of Psychotherapists (originally the Association of Psychotherapists) was founded in 1951. In spite of much public and medical resistance to psychoanalysis (which was originally radically counter-cultural), interest and support grew, partly in connection with the two world wars and the search for remedies for shell shock (the predecessor of post-traumatic stress disorder, PTSD) and other problems experienced by military personnel. Concern about scientology led in 1971 to the Foster Report [C1.1Q1] which had implications for psychotherapy, and in 1978 to the publication of the Sieghart Report [C1.1Q1] on the statutory regulation of psychotherapists. During the 1980s conferences regularly held at Rugby (organized by the British Association for Counselling (BAC)) led eventually, in 1993, to the now United Kingdom Council for Psychotherapy (UKCP). The British Psychoanalytic Council (BPC), representing training institutions with a strictly psychoanalytic affiliation. The UKCP, containing member organizations from humanistic, cognitive-behavioural and other traditions, was established in 1991. In recent years it has extended its membership categories to include psychotherapeutic counsellor and more flexible routes to membership. The development of counselling is harder to trace, there being no single dominant figure like Freud, or monolithic theory like psychoanalysis. Hans Hoxter may, however, be credited as one outstanding individual for his part in creating the counselling movement, including bringing American training ideas to Britain. Further relevant historical

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1 . 1 W h at A r e C o u n s ell ing and Psy chothera p y? factions and developments are in evidence throughout psychotherapeutic history. Hence resulted the growth of what is still thought to be the more than 400 schools (also known as theoretical orientations, approaches, brand names) of therapy we have today. The question of whether such proliferation is desirable and in clients interests, or not, must be faced by thoughtful practitioners, and indeed the integrationist movement stemming from the 1980s represents shared concern for convergence (Cooper and McLeod, 2010). On the other hand, early twenty-first century tensions regarding statutory regulation sometimes appear to be pushing the psychoanalytic, humanistic and cognitive-behavioural therapy (CBT) camps further apart (see Parker and Revelli, 2008; Weatherill, 2004; House and Loewenthal, 2008). A summary of some of the key points of this necessarily succinct history of events is provided in Table 1.1.1. Readers may also like to consult Aldridge (2011), Dryden (1997), Ellenberger (1970) and Feltham (1995; 2007).

Each has designated tasks that obviously differ from those of others, depending on context and client group. Counselling and psychotherapeutic skills are used to degrees in all these professions and, where individual workers possess dual or multiple qualifications (for example a social worker may be trained in family therapy), they may formally provide therapeutic services. However, BACP and other clinically oriented bodies strive to emphasize a distinction between casual, informal or untrained, and uncontracted use of counselling skills, and disciplined, contracted, ethically protected, formal counselling or psychotherapy. Parry (1996), too, distinguishes between: type A: psychological treatment as an integral component of mental health care type B: eclectic psychological therapy and counselling type C: formal psychotherapy. The above-mentioned groups are also related to those involved in practising the so-called complementary therapies (often regarding their work as holistic or mindbody integrated), including acupuncture, homeopathy, reflexology, aromatherapy, Alexander technique, spiritual healing, osteopathy, naturopathy, Bach flower remedies, etc. Again, practitioners may sometimes have dual qualifications and practise both psychological therapy and somatic or sensual therapies alternately or simultaneously, having due regard for appropriate contracting (Sills, 2006). Debates about the rights of certain of these groups to aspire to professional status cannot be ignored, but nor can public scepticism. In relation to distinctions between the titles of those engaged in closely related therapeutic professions, and their putatively distinctive skills and effectiveness, see Cheshire and Pilgrim (2004), Gask (2004), James and Palmer (1996) and Milton et al. (2011). Offering resistance to the professionalizing trend, particularly via the HPC, which is sometimes perceived as unnecessarily bureaucratizing and distorting therapy, is the Independent Practitioners Network (IPN) (see House, 2003; Postle, 2011) and the Alliance for Counselling and Psychotherapy (see also Parker and Revelli, 2008).

Allied Professions
Most (but certainly not all) would agree that counselling and psychotherapy in so far as they are professions or emerging professions are part of the health professions. Although Freud battled to have psychoanalysis recognized as separate from medicine and Rogers similarly battled with psychiatric and psychological colleagues, the psychological therapies today concern themselves largely with mental health promotion and mental illness reduction even where these terms are not used and where additional or different aims are espoused, such as personal growth and development, psychoeducation, psychopractice, etc. (see Brown and Mowbray, 2002). Counsellors are therefore often found in health and social care settings along with psychotherapists, clinical and counselling psychologists, psychiatrists and mental health nurses. A second group of related professionals includes social workers, probation officers, welfare officers, personnel managers, career guidance workers, occupational therapists, speech and communication therapists, occupational and health psychologists, and so on. Teachers, nurses, priests and others in caring roles may have closely related functions. Members of the above groups, sometimes known as the core professions, have been considered good candidates for counselling and psychotherapy training, and typical intakes to courses include members of all these groups. Each professional group has its own professional body, history, and traditions of training and supervision.

A Brief Overview of the Values of Counselling and Psychotherapy

The overarching values, and the professional ethics that stem from these, of counselling and psychotherapy were summed up in the concepts of integrity,

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Table 1.1.1 Key historical developments

Significant events Freuds Interpretation of Dreams Appearance of schools (approximate dates)

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Year

Birth/growth of institutions and professional organizations

1900 1907 First (careers) counselling centre, Boston, USA (Frank Parsons)

British Psychological Society Vienna Psychoanalytic Society

1908

1910 1913

1919 1920 1921 1924 1926

International Psychoanalytical Association National Vocational Guidance Association (USA) London Psychoanalytic Society Institute of Psycho-analysis Tavistock Clinic

Analytical psychology (Jung)

Behavioural psychology Psychodrama

British Psychoanalytic Society London Clinic of Psychoanalysis Medico-Psychological Association (MPA; previously AMOAH I, originally 1841) Alcoholics Anonymous Society of Analytical Psychology Death of Adler Death of Freud Client/person-centred approach British National Health Service T groups First student counselling service (University College Leicester) Gestalt therapy Rogerss client-centered therapy Diagnostic and Statistical Manual (DSM) 1st edn

1935 1936 1937 1938 1939 1940 1948

National Marriage Guidance Council (now Relate)

1950 1951 1952

International Association for Vocational and Educational Guidance (IAVEG)

1953 1955

Group Analytical Society American Association for Counseling and Development (AACD) American Counseling Association (ACA; originally NVCA) Samaritans

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1957 1958

Rational emotive behaviour therapy (originally RT then RET) Personal construct therapy B Transactional analysis Behaviour therapy

Table 1.1.1 (Continued)

Significant events Appearance of schools (approximate dates)

Year

Birth/growth of institutions and professional organizations

1959

Cruse Scottish Pastoral Association

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1960

1961

First fee-charging counsellor in private practice in UK Death of Melanie Klein Death of Jung J.D. Franks Persuasion and Healing Cognitive therapy Halmoss The Faith of the Counsellors Counselling training at Universities of Reading and Keele

1962 1965 1966

1969 Death of Perls and Berne Foster Report on Scientology

1970

Westminster Pastoral Foundation Association of Humanistic Psychology (USA 1962, UK 1969) First Standing Conference for the Advancement of Counselling (annual) MPA becomes Royal College of Psychiatrists

Primal therapy

1971 1975

1977 1978

National Association of Young Peoples Counselling and Advisory Services (later Youth Access) British Association for Counselling (BAC)

Neuro-linguistic programming

Association of Humanistic Psychology Practitioners (AHPP)

Society for the Exploration of Psychotherapy Integration (SEPI)

Sieghart Report on statutory regulation of psychotherapists Smith et al. The Benefits of Psychotherapy Rugby Psychotherapy Conference (set up by BAC First BAC accreditation scheme Death of Carl Rogers Death of Bowlby BPS Charter of Counselling Psychologists First UK Chair of Counselling (Windy Dryden)

Solution-focused therapy

United Kingdom Standing Conference on Psychotherapy (UKSCP) Cognitive analytic therapy

1980 1982 1983 1987 1989 1990 1991 1992

British Confederation of Psychotherapists European Association for Counselling

1993

1994

United Kingdom Council for Psychotherapy (UKCP, originally UKSCP): advice, guidance, counselling and psychotherapy lead body Independent Practitioners Network UKCP Register of Psychotherapists

BPS Division of Counselling Psychology (Continued)

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Table 1.1.1 (Continued)

Significant events Appearance of schools (approximate dates)

Year

Birth/growth of institutions and professional organizations

1995

1996

United Kingdom Register of Counsellors (UKRC) (individuals) World Council for Psychotherapy

1998

BCP Register NHS Psychotherapy Services in England Review NHS Psychotherapy Services in England, Department of Health (DoH) Strategic Policy Review Data Protection Act CORE introduced

1999 2000

Association of Counsellors and Psychotherapists in Primary Care (CPC) UKRC (organizations) National Institute for Health and Clinical Excellence (NICE) BAC renamed British Association for Counselling and Psychotherapy (BACP) Universities Psychotherapy Association (UPA) adds Counselling to its title, becoming UPCA

2001

2002

2003

2004

College of Psychoanalysts British Psychoanalytic Council

2006 2007 2008

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2009 2011

BACPs Ethical Framework for Good Practice in Counselling and Psychotherapy Lord Alderdices Psychotherapy Bill Treatment Choice in Psychological Therapies and Counselling: EvidenceBased Clinical Practice Guidelines (DoH) BACPs Guidelines for Online Counselling and Psychotherapy Health Professions Council (HPC) is identified as the regulatory body for all health professions, including counselling and psychotherapy (talking therapies) UKCP establishes its Psychotherapeutic Counselling Section BACP Service Accreditation Scheme Telephone counselling (contractual) is accepted by BACP for accreditation hours Graduate mental health workers in primary care British Confederation of Psychotherapists (BCP) renamed British Psychoanalytic Council (BPC) Improving Access to Psychological Therapies Death of Albert Ellis BACP represented on HPCs Professional Liaison Group HPC Register for Applied Psychologists opened Statutory regulation plans abandoned

1 . 1 W h at A r e C o u n s ell ing and Psy chothera p y? impartiality and respect (Bond, 2010). These were developed and related by BACP (2002) to tenets of moral philosophy: fidelity (honouring the trust placed in the practitioner); autonomy (the clients right to be self-governing); beneficence (concern for the greatest good); non-maleficence (to cause least harm); justice (concern for fairness); and the practitioners self-respect (self-knowledge and care of self). Such principles are not without problems, however, since in practice there sometimes are conflicts between, for example, the wishes of a client and possible damaging consequences. Also, it is sometimes the case that what may be professionally ethical and desirable will be challenged as socially undesirable or questionable by others. Hence, the goals of individual autonomy and self-actualization, which are held by many writers as central values in psychotherapy (e.g. Hinshelwood et al., 1998), have been criticized by some sociologists as leading to an autonomy obsession, an undermining of social responsibility and a cultural insensitivity. It is therefore important to bear in mind that what we often call professional ethics (as advocated in professional codes) are not necessarily coterminous with social ethics. It follows from basic principles that counsellors and psychotherapists value non-judgementalism vis--vis clients, that they owe a duty of care to

clients (while remaining necessarily detached to varying degrees), and that their aim is the ultimate good of the client balanced by respect for the clients own choices. Due to the weight placed on respect for self-determination, most therapists are opposed to people being coerced into therapy and into remaining in therapy when they wish to leave, and actively support the principle of informed consent to therapeutic procedures. All professional bodies in this field have their own codes of ethics and practice BACPs Ethical Framework for Good Practice in Counselling and Psychotherapy (2002) being a mature example usually addressing issues of safety, contracting, competence, confidentiality, boundaries, law, advertising, complaints and so on. There are few specific prohibitions, although sexual contact with clients, exploitation of clients and breach of confidentiality are prohibitions shared by all professional bodies. Nevertheless, often genuine and valid differences in values do exist between members of different professional bodies (and networks, such as the IPN, which oppose professionalization) and different theoretical affiliations. Understanding and elaboration of the foundational philosophical assumptions of therapists are an area of theory and training that is taking a long time to mature (Bennett, 2005; Erwin, 1997; Feltham, 2010; Howard, 2000).

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