Section 2: Theories and the Counselling Process

The client-counsellor relationship may vary in expression across different counselling theories and approaches. For example, in CBT the counsellor assumes a collaborative but more directive role that involves educating and guiding the client, while in person-centred therapy, the focus is on the client as the ‘expert’ in their own life. Importantly, the therapeutic relationship lies at the core of the counselling process regardless of the counselling approach used.

Counsellors from all approaches must remember to build rapport and foster the therapeutic relationship from the outset. A common ‘trap’ that many new counsellors fall into while learning about new counselling theories and approaches is jumping immediately into applying interventions before taking the time to build the therapeutic relationship. As you progress with the next few modules of your Diploma and begin using the various counselling approaches and techniques, remember to continue applying the basic rapport-building techniques that you have already learned. Although counselling techniques are an important component in the counselling process, the counselling relationship forms the foundation on which positive changes can occur. A solid therapeutic alliance must be developed before implementing techniques or interventions.

Apart from utilising effective communication skills, an important aspect of building rapport is ensuring clients are well-informed of the details of the counselling process. As you will notice in the following section and subsequent modules, the counsellor must effectively communicate details of counselling therapies or approaches with clients so that they are aware of what to expect. This also helps to ensure you have the client’s informed consent for implementing particular approaches or techniques in the counselling process, which is an important responsibility of the counsellor.

How do you create a therapeutic relationship in counselling?

This video discusses the importance of the therapeutic relationship and how it cannot be overlooked; it forms the foundation of all counselling work. There are questions that follow. 

Watch

Another important consideration that counsellors must keep in mind is that they should conduct an assessment of the client

before implementing any techniques or interventions. There are two major components of the assessment process:

• Assessing the suitability of counselling for the client.
• Assessing the client’s issues and needs to select the most appropriate approach and techniques/interventions to benefit the client.

Suitability of Counselling

Before launching into any in-depth work with a client, the counsellor should consider the suitability of counselling – in other words, how appropriate is counselling for this client? It is not uncommon for clients to seek counselling support when experiencing emotional distress; however, some clients’ circumstances or presenting issues may indicate that generalist counselling is not the most suitable intervention for them at the time. For instance, consider a client in a crisis state who may be at imminent risk and/or lack basic living needs (e.g., food, accommodation). In such cases, it may be more appropriate to engage the client with crisis or specialist services first, noting that counselling may become appropriate once their circumstances change. Other common reasons for referral include severe mental health issues, developmental delays, drug and alcohol issues, child protection issues, suicide prevention and intervention, and domestic and family violence. Some of these issues can affect the client’s safety, level of functioning and ability to benefit from counselling support in general. In some cases, clients may require referral to a specialist medical or mental health assessment to ensure they receive the most appropriate care.

As a counsellor, if you feel that the client would benefit more from another service or counsellor, it is important to discuss this with the client in an honest, respectful way. In most cases, counsellors should also manage the referral by conversing with or sending a letter or brief report to the new provider regarding the client they are referring. (Note: the counsellor must gain consent from their client to do this.) If you are unsure whether a referral is appropriate or have concerns about referring a client, you should check your organisation’s referral policy and consult your supervisor. You may also need to refer to your professional code of ethics (e.g., ACA Code of Ethics and Practice) and/or any relevant legislation (e.g., mandatory reporting legislation).

Client Needs, Issues and Goals

In addition, the counselling approach or service you or your organisation provides may not be suitable for the client’s issues or needs. For example, if a client approaches a solution-focused counsellor and tells them that they want to conduct an in-depth exploration of their childhood and how childhood issues have impacted their adult relationships, the client may benefit from a referral to a psychodynamic counsellor because the solution-focused approach on offer is not likely to meet the client’s needs.

As such, an important part of the initial assessment is considering the client’s issues, needs and goals to select the most appropriate approach and techniques for working with the client. Throughout this and the subsequent modules, you will learn that counsellors must have clear rationales for using a particular approach or technique, as not all approaches or techniques will be suitable or preferred for all clients. To make these decisions, many counsellors begin by understanding the client’s circumstances, issues, needs and goals. Information to collect may include:

• Background information about the client, including personal, family and social history.
• Current life context (e.g., health, medication, work, finances, relationship, culture).
• Client’s functioning including behavioural indicators (e.g., how they react to certain issues or changes) and cognitive indicators such as memory, organisation of thought and verbal expression. The level of client functioning will likely influence the choice of subsequent counselling approach and intervention.
• Client’s conceptualisation of the issue – how it evolved and its impacts on their life.
• Client’s goals or desired outcomes.
• Motivation and barriers to change.
• Client strengths and resources.

Obtaining and analysing such information can help counsellors select the most appropriate counselling approach to implement with clients. From there, the counsellor will use this theoretical approach to formulate a case conceptualisation and approach to counselling which will then inform the techniques and interventions used. For example, a counsellor using a CBT approach would develop a case formulation in collaboration with the client that explores the roles of behaviour, physiological responses, thoughts, and feelings on the client’s issue. Conversely, a solution-focused counsellor will focus on what the client wants and identify their strengths, successes, and resources without engaging in an in-depth assessment of the history of problems. An ACT counsellor may focus on assessing the client’s psychological (in)flexibility and desired behavioural goals, guiding the counsellor in implementing various activities and techniques with the client.

You will learn more about the different approaches to assessment, case formulation, and the selection of techniques and interventions over the next few modules; however, at this stage, the important thing to remember is that counsellors carefully select specific techniques and interventions based upon their assessment, not just select them at random. Conducting an assessment and then selecting appropriate techniques and interventions requires a thorough understanding of the underlying approach – this is why counsellors should not use approaches or techniques that they are unfamiliar with.

Check your understanding of the content so far!

A Note on Common Presenting Issues

Although the circumstances of each client seeking counselling will be unique, it is useful for counsellors to understand the common issues or concerns that clients may present with and their general characteristics. These include:

• Anxiety: Most people can relate to the experience of feeling anxious and worried. However, excessive and irrational anxiety and worries can result in distress and interfere with a person’s day-to-day functioning, leading one to seek counselling support. (This does not necessarily mean they have an anxiety disorder – anxiety disorders are mental health problems that must be diagnosed.) People who experience anxiety issues often report feelings of panic (e.g., shortness of breath, dizziness, rapid heartbeat, nausea) or anxiety reactions that are disproportionate in certain situations or occur for no apparent reason. They may also begin to avoid certain situations (e.g., taking public transport), fearing that they may suffer a panic attack. Anxiety can often lead to social isolation and is associated with developing other mental health problems, such as depression.
• Family issues: Many people seek counselling because of conflicts arising from unhelpful family interactions and dynamics. Other common issues in families may be relevant to separation and/or formation of blended families, cultural or generational differences, lack of work-family balance, and sibling conflict. These issues can result in stress, anxiety, and tension that disrupts each family member’s daily functioning. In some cases, there may be indications of violence in family relationships, which a counsellor must carefully assess and provide appropriate support following organisational requirements. Counsellors may support individual clients to develop strategies to manage family issues; some counsellors may also work with the whole family to foster stronger and positive family relationships.
• Grief and loss: Although loss is a normal part of life, some loss experiences that are sudden, unexpected, and significant can lead to immense emotional turmoil and distress for individuals. Grief refers to reactions to loss, an individualised experience that varies by nature of loss, personal characteristics, and the social and cultural context in which the person is living. People who experience loss and grief may seek counselling support for various reasons, including understanding their grieving reactions (e.g., intense emotions) and coping with the wide impacts of loss on their daily lives. (You will learn more about providing loss and grief support in CHCCCS017 further along in your Diploma.)
• Parenting: Parenting is one of the most challenging tasks and a common source of stress for people, particularly when there has not been positive support or sufficient resources. Becoming a parent and the changing needs of children and family often brings about immense changes in a person’s lifestyle, choices, and relationships. Counsellors may help parents to understand their parenting styles, communication patterns in the family, and developmental needs of children and build confidence and skills in positive parenting behaviours. In some cases, clients may have been engaged with child protection services, and counselling is a part of intervention for the family, which adds to the complexity of issues.
• Pregnancy: Fertility or pregnancy issues can lead to one seeking counselling support. Fertility issues are often related to experiences of loss (e.g., loss of control) and significantly impact a person’s relationship and self-esteem. Complicated pregnancies and miscarriages can also cause immense stress to the person and their family. As such, clients will likely report intense emotions, frustrations and stress associated with pregnancy-relevant issues. Counsellors may also help clients with communication and relationship issues surrounding pregnancy experiences.
• Relationship: This may include challenges arising from all kinds of social relationships, though more commonly referring to spousal or romantic relationship issues. Some common topics may include communication, infidelity, conflicts, intimacy and sexual issues and separation. Relationship difficulties can leave people feeling emotionally vulnerable, fatigued, and angry, with reduced abilities to meet other life responsibilities. A counsellor may support individuals to develop strategies and resources to address these challenges and/or work with the couple together to facilitate positive understanding, communication and behaviours.
• Self-esteem: Low self-esteem can immensely impact a person, particularly because they are likely to present with many negative self-perceptions and criticisms. They may find it difficult to recognise their strengths and positive qualities and have low expectations of counselling outcomes or life. Their lack of confidence can impact their ability to make decisions, engage in social situations, take up opportunities and challenges, and communicate with others (unable to speak up for themselves or being overly aggressive).
• Social isolation: This issue impacts not only those living in geographically isolated areas but also many individuals living in metropolitan areas with minimal contact or support from others. Individuals experiencing social isolation are at risk of experiencing serious mental and physical health conditions, including insomnia, tiredness and elevated blood pressure, and increased risk of alcohol and other drug use, depression, and social anxiety. While social isolation differs from loneliness, it is common for socially isolated individuals to report feeling sad or lonely or having a lower level of social contact than desired.
• Stress management: While stress is, and should be regarded as, a normal physiological response to changing events in life, prolonged exposure to high-stress levels can be detrimental to a person’s physical and mental health. Particularly, clients who do not have sufficient or positive stress management skills and/or resources often seek counselling support due to its impacts on their emotional and social well-being. It is also common that stress management is an issue masked under other concerns mentioned, as poor stress management can manifest in many domains of life, including health issues, anxiety, and relationship problems.

Whilst most counselling therapies can effectively support clients facing these issues, some may have more ample evidence base for addressing particular issues or clientele than others. When selecting the most appropriate counselling approach to use with clients, counsellors should take into account the type of techniques or approaches that are appropriate for the relevant issues and ensure that they are making evidence-based decisions. We will explore this in more detail in module 9.

What is “The Presenting Problem?”

In this video, Rafael Sharón, psychoanalyst, talks about "The Presenting Problem".

Watch

Check your understanding of the content so far!

A Note on Eclecticism and Integration

Although some counsellors may practice using one specific counselling approach and specialise in this one approach, most counsellors, particularly as they gain more experience, tend to ‘borrow’ and combine techniques from various counselling approaches. This is primarily because one approach is unlikely to be relevant to, and preferable for, all clients and issues. There are two ways of utilising different counselling therapies – eclecticism and integration.

The word “eclectic” means deriving items from different sources. Applied to counselling, eclecticism refers to combining different but complementary counselling techniques taken from different therapy models. On the other hand, integration involves combining one thing with another to form a whole; an integrative approach to counselling is one that not only combines factors from different approaches (i.e., eclectic), but also “work towards developing a new framework” (Reeves & Tebble, 2018, p. 122). The metaphor of a ‘therapeutic soup’ is a useful way to understand this differentiation:

You are more likely to adopt an eclectic approach as you become more experienced in the various counselling approaches. However, it is important not to ‘mix and match’ randomly. The techniques selected must complement each other somehow – counsellors should not mix techniques that counteract each other. For example, care needs to be taken when using techniques from ‘problem-focused’ approaches such as cognitive behavioural therapy in conjunction with post-modern approaches such as solution-focused and narrative therapies due to their differing theoretical orientations (that is not to say that they cannot be successfully integrated – however, it is important to ensure that the techniques used are complementary). Over the next few modules, you will learn more about how some of the techniques of different approaches can be combined effectively.

5 Fast Facts about Integrative Eclectic Therapy

This video introduces five facts about Integrative Eclectic Therapy.

Watch

Check your understanding of the content so far!

Evaluation is important regardless of the counsellor’s theoretical orientation. Evaluation should involve checking that the client is satisfied with the counselling process and strategies being used and that the counselling process is helping the client meet their needs or goals. While the evaluation process can be formal or informal, verbal or written, counsellors must always ensure that they comply with their organisation’s policies and procedures for evaluation. Some organisations may require counsellors to conduct a brief review at the end of each session; others may require an evaluation after a set timeframe (such as every three to six weeks). Evaluation may include:

• A review of the progress made towards the client’s goals.
• Evaluation of and discussion about the effectiveness of specific techniques.
• Evaluation of the counselling relationship (from the client’s perspective).
• Evaluation of the pace of the counselling process.
• Re-evaluation of the termination (final session) date.
• Feedback from the client on what works well for them and what is not.

Evaluation can involve a combination of subjective and objective measures. Some of these are outlined in the following table:

Different theoretical approaches may call for different approaches to evaluation and review (you will learn about these over the next few modules); however, regardless of the counsellor’s theoretical orientation, it is important to regularly evaluate counselling practice in order to improve its effectiveness.

Check your understanding of the content so far!

You have previously learned about the importance of ethical counselling practice. For example, you should recall the importance of:

• Respecting the client’s individuality, values and beliefs.
• Respecting the client’s autonomy (self-determination and independence).
• Safeguarding the client’s well-being (within the boundaries of the counselling relationship).
• Ensuring counsellor competence through a continual process of self-reflection and self-development. This may involve regular supervision and professional development.
• Acknowledging the limits of competency and referring clients.

The following table reviews some of the key legal and ethical principles underpinning counselling practice and outlines how they apply to the counselling process and practice. Remember that these principles remain important regardless of which theoretical approach a counsellor may be practicing from – they serve to protect the rights and wellbeing of clients, counsellors, and counselling organisations.

As you should recall from previous modules, taking notes and keeping records are vital to counsellor responsibilities. Client session notes act as a memory aid, enhance the effectiveness of the counselling process by avoiding repetition and reminders, and provide continuity for the client’s counselling process. While exact record-keeping practices will vary between organisations and between different theoretical orientations, counselling records generally include the following:

Counsellors using a particular counselling approach may also have specific practices concerning documentation and record keeping. For example:

• An important CBT practice is homework (i.e., tasks for clients to complete in between sessions), so a CBT counsellor may review and reflect on the details of any thoughts, records or behavioural experiments with the client to evaluate and inform the counselling directions.
• Counsellors who practice the ACT approach often use various worksheets to assist clients in reflecting and facilitating actions. Copies of the completed worksheets are typically included in the client records.
• Many person-centred therapists choose not to take notes during sessions as they feel it takes away from being fully present with a client; however, it is important that at least an outline of the session is completed and filed. Person-centred counsellors may like to include their own feelings and responses about the session to monitor whether they are practising empathy, congruence and unconditional positive regard.

These approach-specific practices will be explored in more detail in the respective modules following this module.

Check your understanding of the content so far!

Last but not least, and regardless of their theoretical orientation, all counsellors must critically reflect upon their work with clients and engage in appropriate personal and professional development activities.

The importance of regularly reviewing and updating your skills cannot be overemphasised.

Counsellors should ideally use as many of the strategies listed as often as possible to maintain a professional and ethical approach to their counselling work.

Different counselling therapies may emphasise particular aspects of self-development. For example, while all counsellors must engage in the ongoing development of skills to remain competent and meet professional standards, person-centred counsellors must monitor themselves and be aware of any internal factors that may impact their ability to express empathy, congruence, and unconditional positive regard. Person-centred counsellors may include the following questions as part of the self-reflection process:

• Can I be aware and accepting of my own feelings?
• Can I experience positive attitudes toward others and show warmth, care, interest and respect?
• Can I receive and accept this client as they are?

An important aspect of the self-reflection process is monitoring how comfortable you are using a particular counselling approach or technique. For example, you may become aware that you are not confident or convincing in using a particular technique. This may be due to personal reasons. For example, you may not agree with the theoretical principles underlying a counselling theory, or it may clash with your belief system, or you may feel uncomfortable with the emotional and personal requirements of a particular approach. Alternatively, you may feel that you do not understand the counselling theory sufficiently or lack the skills or knowledge required to use it competently. It is important to monitor your comfort levels during sessions and engage in self-reflection after sessions to identify any personal and professional issues affecting your practice and address these through either personal therapy, supervision, or professional development.

Check your understanding of the content so far!

In this section of the module you learned about a range of critical considerations that counsellors must keep in mind regardless of their theoretical approach. As you begin implementing specific counselling approaches and techniques remember to keep these considerations in mind in order to help ensure effective counselling practice.

In the last section of the module you will begin your in-depth exploration of specific counselling theories by learning about the person-centred approach to counselling.

Corey, G. (2017). Theory and practice of counseling and psychotherapy (10th ed.). Thomson Brooks/Cole.

Geldard, D., Geldard, K., & Yin Foo, R. (2022). Basic Personal Counselling: A training manual for counsellors. (9th ed.). Cengage Learning.

Nelson-Jones, R. (2014). Personal counselling and continuing professional development. In Practical counselling and helping skills (6th ed.). Sage Publications.

Reeves, A. (2018). Becoming a counsellor or psychotherapist. In A. Reeves (Ed.) An introduction to counselling and psychotherapy: From theory to practice (2nd ed.) (pp. 29-54). Sage Publications.

Reeves, A., & Tebble, G. (2018). Integrative and pluralistic approaches. In A. Reeves (Ed.) An introduction to counselling and psychotherapy: From theory to practice (2nd ed.) (pp. 119-134). Sage Publications.