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Section Outline

Psychoanalytic theory and how it informed psychodynamic therapy have been pivotal in informing and influencing the nature of counselling and psychotherapy, as well as inspiring the development of a range of other models and schools of therapy. This section outlines the main principles of psychoanalytic and psychodynamic therapy, highlights a number of the key theorists who have contributed to its development, and indicates some of their principal ideas.

Introduction

With any discussion of psychodynamic therapy it is important to begin with psychoanalysis.

Many of the key theories and principles of psychoanalysis still sit at the heart of contemporary psychodynamic practice but, as with all dynamic and changing theories, the practice of therapy within the psychodynamic frame has changed significantly over many years. Some might argue that any discussion of therapy per se must begin with psychoanalysis. As we will discover when we discuss the other key approaches to counselling and psychotherapy, psychoanalysis and some of its core theories have been central to the development of therapy in many forms. This has been either because other approaches have incorporated some key ideas (such as the use of ego states in transactional analysis) and developed them within a different frame, or because new approaches have emerged as a response against some of the philosophical ideas of analysis (such a person-centred therapy and the 'third force' of humanism in psychology). Either way, aspects of psychoanalysis can be found in much of what we do and how we conceptualise the process of therapy, regardless of orientation.

The Development of Psychoanalysis

Sigmund Freud (1856-1939), a neurologist working is Vienna in the 1880s onwards, began to develop an approach of treating his patients' psychological distress through the process of structured and systematic talking about early childhood memories and traumas. He did this primarily through the use of dreams, which Freud argued were the gateway to the unconscious, defined by the Oxford English Dictionary (OED) as, 'the part of the mind which is inaccessible to the conscious mind but which affects behaviour and emotions' (OED, 2012). Freud hypothesised that problems originated from a sexual source and concluded that sexual frustration was at the core of many difficulties. Not all of Freud's contemporaries agreed with his ideas and Freud experienced an early backlash. He was particularly interested in what was then termed 'hysterical illness' (illness without any apparent biological cause). The case of Anna O, a patient being treated by Josef Breur (1842-1925) with hypnosis, with whom Freud worked in Vienna, was an important landmark in the development of psychoanalysis. It was Anna O's ability to talk of past traumatic experiences while deep in hypnosis, resulting in some recovery from her symptoms, that led to the assertion that psychological distress (or hysterical illness) could be treated through the use of a 'talking cure'.

Freud and Breur worked together on these ideas, but Freud later moved away from the assertion that hypnosis was necessary to access repressed thoughts and emotions. The importance of the unconscious remained central to Freud's developing ideas and, in 1899, he published The Interpretation of Dreams, having first used the term 'psychoanalysis' in 1896. Later, in 1901, he published The Psychopathology of Everyday Life and developed further his theories of the personality. He suggested that psychological problems stemmed from conflicts between different aspects of personality, which he termed the id, ego and superego.

Id, Ego and Superego

The premise of different aspects of personality was important in developing ideas about the relationship between the conscious (what we are aware of) and unconscious (what we are unaware of) mind. The different aspects of 'selves' – id, ego and superego – were an important 'next step' in the development of psychoanalytic thinking in that Freud proposed that psychological problems originated from conflict between the different aspects of personality.

The id: primary instincts that drive biological need, including: food, warmth and sex, for example. The id is subdivided into two driving forces: thanatos (the instinct towards death) and eros/libido (the instinct towards life and sex). The desires of the id are either met immediately (the pleasure principle), or may be deferred, thus leading to fantasies of the desire (primary process thinking). The id is an unconscious process.

The ego: develops from the id and is the mechanism by which rational thought, based in the realities and part-conscious thinking, mediates and manages the impulses and drives of the id. The ego facilitates the needs of the id but through a more conscious, process. For example, the ego enables the young infant to recognise that not all impulses and desires are met immediately, or met at all. Freud termed this the reality principle.

The superego: described as 'higher level functioning', the superego is the means by which moral and social standards are incorporated into the personality through learning from early caregivers and then, later, through the development of self. The superego operates at a conscious and unconscious level and is divided into two parts: the conscience (discriminating between good and bad thoughts and behaviours): and the ego ideal (what we wish to become).

In addition to these aspects of personality, another important component of Freud's work was based on his psychosexual stages of development, as outlined in Box 3.1.

While these stages are an important component of classical psychoanalytic therapy, it is not my intention to dwell on them here and more detail can be found in the recommended further reading section. They do not feature as core aspects in contemporary psychodynamic counselling and psychotherapy, but are important to highlight in their development of early psychoanalytic ideas. It is sufficient to note that Freud believed all stages needed to be negotiated successfully for the development of a healthy personality. Aspects of note from these stages include the Oedipus complex, Electra complex, and the development of what Freud termed neurotic anxiety.

More recent development in counselling and psychotherapy has, perhaps, centred on the work of Erik Erikson (1902-1994) and his psychosocial stages of personality development (1950). While Erikson subscribed to many of Freud's theories, including the importance of early experience in the development of the personality and the structures of the ego, he did not agree with the emphasis on infant sexuality. Rather, he asserted that social and environmental factors were significant in development. Erikson's psychosocial stages are outlined in Box 3.2.

Erikson argued that each stage is dependent on the development of the stage that went before it and each is based on the importance of social tasks and the management and negotiation of conflicts. Many view Erikson's stages to have wider application to those proposed by Freud and are easier to integrate into broader ideas of personality, distress and the nature of change.

The Practice of Psychoanalysis

The role of the therapist in the process of psychoanalysis is to bring unconscious material into awareness as a means of helping the client (or analysed) to resolve conflict. Without conflict resolution all that will be achieved is the treatment of symptoms, and if one symptom is treated then another will only replace it (symptom substitution).

The analyst will use a number of therapeutic strategies and skills to facilitate the exploration of unconscious material (Errington and Murdin, 2006, p. 232):

• Basic facilitative skills: empathy, other communication skills
• Interpretation: using Malan’s (1979) triangle of defence (defence of the pain; the anxiety caused; and the defence against the anxiety), and the triangle of transference (past relationship; present relationship outside therapy; the relationship with the therapist), analysts will use interpretations to link two or more points of the triangle
• Boundaries: time, place and 'self' of the therapist
• Blank screen: self-disclosure will be minimal so as to avoid interfering with the exploration of unconscious and transferential material
• Careful attention: attention to the conscious material, but also to the potential for unconscious material (in what is not said)
• Depth and intensity: a great deal of time is required to explore unconscious material, so that analysis will typically take place over several years with a high level of frequency of sessions (minimally once per week)
• Free association: the opportunity for the client to talk about anything that comes to mind, including describing dreams (which will be viewed as an opportunity to explore unconscious material).

Criticisms of Classic Psychoanalytic Theory

As outlined in the introduction to this section, psychoanalysis has been profoundly important in shaping not only the nature and development of contemporary psychodynamic counselling and psychotherapy, but also in shaping, either through the contribution of theory or the rejection of some of the theoretical and philosophical positions of psychoanalysis, many other important approaches. However, psychoanalysis has not been immune from criticism. Freud's theories, rooted in sexual repression, were revolutionary in that they were developed at a time when such ideas were not seen as acceptable. In challenging these societal boundaries many have claimed Freud to be a radical and innovative thinker who, in pushing accepted boundaries, prepared the ground for major philosophical, ideological and practice development. However, the application of psychoanalysis with clients takes many years, with frequent sessions. This makes accessing such therapy very limited; it is available only to those who can fund it, or for the very few referred through health care systems.

Critics have additionally claimed (and continue to do so) that psychoanalysis has no real evidence base and its principles can never be open to scientific scrutiny. It is argued that the principles of psychoanalysis are based in ideas, rather than measurable and quantifiable concepts. Fonagy (2002. p. 287) noted, “There are no definitive studies which show psychoanalysis to be unequivocally effective relative to an active placebo or an alternative method of treatment.”

Historical Development

Contemporary psychodynamic therapy (as opposed to classical psychoanalytic therapy) continues to draw heavily on the early principles and ideas of psychoanalysis, although the early work of Freud has been significantly developed and much of current psychodynamic thinking draws on the work of other theorists, including Jung (1875-1961), Adler (1870-1937), Klein (1882-1960) and Bowlby (1907-1990).

Carl Jung and Freud were close friends and worked together on the development of psychoanalysis for some time. However, Jung did not subscribe to Freud's emphasis on infant sexuality and libido, instead believing there to be other influences on an individual and their experience of distress that worked across the life span (unlike Freud's psychosexual stages. which were early-age specific). Jung developed a number of important ideas integral to the understanding of personality, including developing the ideas of personality difference, including introvert (where a drive and focus rests with a sense of an internal world), and extrovert (where a drive and focus tests with a sense of an external world). Jung's writing on individuation (an integration of self through the resolution of conflicts: a move towards growth) is also important in shaping understanding of personality and change.

Alfred Adler's view was more focused on the individual's strive for power, in response to their early experience of powerlessness in childhood and as a means of avoiding feelings of inferiority, rejecting also Freud's focus on sexual drives. He argued, through his development of individual psychology, that as a means of avoiding inferiority individuals set goals to achieve superiority. He located these ideas in a social context and recognised the important influencing factors of family, relationships and society. By becoming aware of those goals that become self-destructive, Adler believed individuals could make significant positive change.

Melanie Klein is perhaps most strongly associated with her development of the theory of object relations. This view is based on introjective and projective mechanisms, as opposed to Freud's focus on id control and management. Her theories were outlined in her work The Psychoanalysis of Children, published in 1932. In her work she described processes by which she believed young children introject (bring into self) facets of important carers or relationships which, in turn, become influential parts of a developing ego: this process then shapes how the individual relates to the environment and those within it. The concept of splitting refers to problems in ego development when the child has incorporated mixed or conflicting messages from key people (perhaps a loving, but also disconnected parent). The ‘split’ is experiencing someone or something as all good, or all bad (e.g. an ideal therapist who is experienced by a client as encouraging and facilitative can quickly become experienced as neglectful or disinterested in the event of difficulties or disagreements).

Alongside the work of Klein, psychodynamic theory and practice perhaps now draws most heavily on theories of attachment and how insecure attachments can lead to psychological problems. John Bowlby's work on attachment, later developed by Mary Ainsworth and colleagues (1978), is central to the development of attachment theory and its relevance to therapy. It is important to view attachment alongside the concept of dependency. Donald Winnicott (1965, p. 84) described three forms of dependency: the absolute dependence of early infancy; relative dependence; and 'toward independence'. How the process of dependency has been experienced will partly inform the experiences of attachment. Ainsworth outlined the following forms of attachment following child observations:

• Secure: confidence in the security of the relationship and presence of carer
• Insecure-ambivalent: child remains angry and distressed on the return of the carer
• Insecure-avoidant: child does not miss the carer and does not initiate contact on their return
• Insecure-disorientated: child becomes immobilised or ‘frozen’ on separation.

Attachment is an important aspect of psychodynamic therapy in that it provides an important opportunity for the therapist to work with relational and transferential dynamics – working with early childhood experiences and patterns of behaviour that have formed as a consequence. However, attachment theory is not exclusively a psychodynamic model and has relevance for other approaches. Finally, Erikson, who we have already briefly discussed, offers important ideas and insights into psychodynamic therapy.

Key Theoretical Principles

Psychodynamic ideas work on the premise that much of human experience takes place unconsciously in the unconscious part of our thinking, containing thoughts, feelings, ideas and drives, and that early important relationships with caregivers are influential in the processing of emotional wellbeing problems in those early relationships can lead to emotional difficulties later. However, while early psychoanalytic thinking was important in shaping ideas of personality, including the functions of the id, ego and superego, a much greater emphasis is now placed on a relational, social and environmental context of people.

The importance of the unconscious remains central in much of the thinking, but theories of attachment, object relations, and power and motivation are important also. While there remains disagreement about the particular focus or emphasis of psychodynamic theory (with different 'schools' holding different positions), there is much more common ground.

The Nature of Therapeutic Change

The nature of change focuses on work with unconscious processes that are represented in a variety of ways, including drawing on theories of attachment and object relations. Clear assessment of problems is important at the outset to enable the therapist to understand how difficulties are experienced and presented. This can provide invaluable information in formulating ideas and early speculations. Such information will include taking a careful history of family formation, relationships and early experiences so as to give insight into possible patterns of behaviour or relating.

By setting clear boundaries of time, space and relationship, the therapist is able to work more effectively with transference and possible resistance dynamics as they present in the relationship, as well as exploring defence mechanisms. This requires commensurate skills given that anything the therapist brings to the relationship has the capacity to change and influence it. The careful management of therapeutic space and boundaries provides a better opportunity for therapist interpretation to help bring unconscious dynamics into conscious awareness, thus enabling the client to move towards change. Segal (2012, p.273) states that the understanding of the therapist includes, 'the capacity to face unpleasant, destructive, shameful feelings as well as deeply loving ones, in themselves as well as the client'.

Working in Context

Psychodynamic counselling or psychotherapy, unlike psychoanalytic therapy, is not necessarily long-term and is therefore much more accessible. Psychodynamic therapists can be found in a wide range of settings including health and social care, education, third sector and in independent practice. Like other modalities there have been developments in brief models of psychodynamic work, which allows for its delivery in a wider range of settings. Models of delivery have been developed for working across the age span and with a range of client groups, and also with a range of presenting problems. Psychodynamic approaches are included in treatment guidelines for moderate to severe depression, as well as other mental health problems.

Research Profile

Cooper (2008, p. 164) notes, ‘Psychodynamic therapies are well-supported by the evidence on the importance of the therapeutic alliance, as well as research linking the use of interpretations to positive outcomes. However, frequent use of transference interpretations tends to be contraindicated by the research.’ Abbas et al. (2006) notes that short-term psychodynamic therapy seems to be effective for a range of common problems with mild to moderate benefits lasting into the medium and longer term. Cooper (2008) outlines a number of other studies that demonstrate the effectiveness of psychodynamic therapy with a range of client problems.

Section Outline

The humanistic therapies are widely practised, particularly in the UK, with more than half of BACP's 40,000 membership identifying themselves as humanistic practitioners. This section considers some principal models, outlining key theories, philosophical assumptions, primary principles of practice and key skills associated with working from that orientation.

Introduction

As was outlined in Chapter 1, the humanistic movement began to gain prominence in the 1940s and 1950s in the United States. At that time the field was dominated by psychoanalytic approaches and behaviourism. Psychoanalysis was particularly strong following the early work of Freud and his associates. While these early psychotherapy developments represented a 'turn away' from mainstream psychiatry and medicine, they were still closely allied to it and worked on philosophical assumptions of disorder and treatment.

The humanistic approaches, in contrast, rejected a number of important philosophical parameters of psychoanalysis and behaviourism and, in doing so, opened a new approach to the psychological therapies. The humanistic approaches, for many, represented for the first time a very real alternative to existing ideas and beliefs. Informed by humanistic psychology, the philosophical principles were quite startling for that period. They gained further momentum in the 1960s and 1970s, perhaps reflecting (and some would argue, leading – in their field) social movements at the time. Humanistic psychology evolved from phenomenological and existential thinking, with key writers such as Heidegger (1889-1976), Merleau-Ponty (1908-1961) and Sartre (1905-1980). It was in the 1950s that three psychologists, Carl Rogers (1902-1987), Abraham Maslow (1908-1970) and Clark Moustakas (b. 1923) met in Detroit in the United States to develop what was later called the 'third force' in psychology (the first being psychoanalysis, and the second behaviourism). Maslow's concept of self-actualisation was profoundly important in helping to shape wider ideas around humanistic psychology and then psychotherapy. His 'hierarchy of needs' is outlined in Figure 3.1.

FIGURE 3.1 - Maslow's hierarchy of needs

• Self-actualisation - morality; creativity; spontaneity; problem-solving: lack of prejudice
• Esteem - self-esteem; confidence; achievement; respect of others; respect by others
• Love/belonging - friendship; family; sexual intimacy
• Safety - security of: body; resources; health; family; morality
• Psychological - food; water; sleep; shelter; warmth

Maslow (1968, p. 10) wrote, ‘Human nature is not nearly as bad as it has been thought to be... It is as if Freud supplied us with the sick half of psychology and we must now fill it out with the healthy half.’ This statement typifies the underpinning philosophy of humanistic thinking, that while, in the view of Maslow, psychoanalysis attended to the 'sick' half – disorder and treatment – humanistic psychology instead attended to the 'healthy' half – growth, potential and self-actualisation. It is the premise and assumption of growth, human potential and move towards self actualisation on which humanistic therapies are based.

A number of key theories fall within the humanistic-existential school paradigm. I will briefly fonts on three of the most widely practised:

1. Person-centred (Rogers)
2. Gestalt (Perls)
3. Transactional analysis (Berne).

Historical Overview

Zimring and Raskin (1992) (outlined in Tudor et al., 2004) suggest that the development of person-centred therapy can be viewed across four distinct periods. This development begins with a talk by Rogers in 1940 entitled 'Some newer concepts of psychotherapy at the University of Minnesota', during which he began to introduce some of the earliest ideas. During this period Zimring and Raskin note how Rogers began to focus on what were to become important therapist qualities: responding to feelings rather than focusing on content; and the therapist's acceptance of both positive and negative feelings. The second period, in the 1930s, saw the publication in 1931 of Client-Centred Therapy and further work by Rogers on the nature of therapeutic change and the development of the six ‘necessary and sufficient conditions’ for change to occur.

The third period, in the 1960s, saw Rogers publishing On Becoming a Person, in which he began to focus even more on the relational aspects of therapy and the importance of the nature of experiencing and being. Finally, the fourth period, from the 1970s and beyond, saw Rogers further developing core theoretical concepts with the steady emergence of ‘person-centred therapy’ as the dominant term for the approach.

The impetus for the development of person-centred practice for Rogers came from his own experience of having been a client, and his views of the predominant theories of the time, behaviourism and psychoanalysis. For Rogers, behaviourism represented a reductionist approach to human personality: individuals, in developing entrenched ways of being from experience, were essentially helpless and unable to make significant or meaningful change. Whereas psychoanalysis, he believed, constructed people as always driven by basic biological drives, never free from these primitive instincts and behaviours. Additionally, it was his view that psychoanalysis essentially focused on the negative aspects of human behaviour, always driven by destructive impulses. Whether his perceptions were accurate about those approaches at that time, Rogers instead focused on his view that individuals, given the right conditions, had the capacity to change and move towards a position of health and growth.

It is worth noting that many writers have criticised person-centred therapy for being very light on theory and suitable only for those with mild psychological problems. Koval (1976, p. 116) wrote that ‘Rogerson treatment works best where the person doesn't have to go very deep ...’. However, others have refuted such charges, with Mearns and Thorne (2000, p. x) stating:

Underlying Assumptions

According to Casemore (2011), person-centred therapy draws on three primary philosophical beliefs: humanism, existentialism and phenomenology. Humanism is based on the belief that each individual has the potential for growth and development with self-actualisation a fundamental human drive. That said, the move towards self-actualisation is more a process rather than an end-point, with individuals engaged in a search for meaning and importance, rooted in a belief of dignity and self-respect. Existentialism informs person-centred therapy through its assertion that we all possess free will and make choices based on our beliefs and experiences. Casemore (2011, p. 7) outlines six primary concepts that underpin existentialism:

• Humankind has free will
• Life is a series of choices, creating stress
• Few decisions are without any negative consequences
• Some things are irrational or absurd, without explanation
• If one makes a decision, he or she must follow through
• The only important meaning which can be attached to life is that which I give to it

Essentially, with free choice comes responsibility: individuals are free to make their own choices, but with those choices come responsibility and consequence, which must be dealt with.

Phenomenology, developed by Husserl in the early 20th century, asserts there is no one, single reality but rather reality is constructed through our own individual experience. That is, my experience of an event or situation may be very different to another's, even if the situation was the same for both. We therefore must pay careful attention to an individual's account of their reality to begin to understand it fully. As Casemore (2011, p. 9) states, a phenomenological approach to therapy entails ‘noticing all the events, feelings, experiences, behaviours, words, tones of voice and anything else that we see or hear, as they are in the moment and not interpreting them on the basis of our past experiences’. In person-centred terms this demands the therapist stays in the frame of reference of the client, as any interpretation of the client's experience would, undoubtedly and unavoidably (because of phenomenological assumptions), be framed within the therapist's own reality.

Key Theoretical Principles

Person-centred therapy is based on the assumption that human personality is positive, with the belief that all people are potentially fully functioning (i.e., someone with a positive self-concept, who is healthy and capable of development through new experiences and potential). Individuals experience conditions through their lives, which are informed by a judgement of what is worthy and what is not. People learn that their acceptability to others increasingly becomes conditional (e.g., I am only lovable if I am ‘good’); conditions of worth shape an individual's view of themselves. Purton (2004, p. 4) describes conditions of worth where an individual ‘denies or distorts their own felt needs so as to develop a self-concept which fits the “conditions of worth” of those around them. The therapist's unconditionality in the relationship is therefore essential as a reparative factor.

Regardless of previous harm or the effects of conditions of worth, each individual retains the potential for growth and thus move towards their organismic (real) self. Within this frame it is believed that every individual retains the potential for change: each individual has an actualising tendency, a motivation for self-development and growth. Self-experience can only be healthily processed cognitively and emotionally by the individual whose experience it is (the principle of phenomenology). Organismic valuing recognises the potential for good for individuals to engage with and experience activities and behaviours they enjoy.

The Nature of Therapeutic Change

The nature of the relationship is fundamental to the nature of change in person-centred therapy. The person and being of the therapist is essential here in creating the right conditions for change to take place. Person-centred theory asserts that the circumstances for change to take place need to be present. The core conditions of any relationship must not only be present, but must be communicated by the therapist so that the client experiences them. The therapist needs to empathically understand the client's experience from the client's frame of reference, and must communicate that empathic understanding. The therapist must experience unconditional positive regard for the client, in that they must be accepting and non-judgemental, and communicate unconditional positive regard; finally, the therapist must be congruent with the client, so that the client is able to experience the true self of the therapist in context of the therapeutic relationship. Person-centred therapists do not work from a professional facade of being, nor a position of expertise, but rather with a willingness and capacity to meet with the client where the client is, emotionally, experientially and psychologically.

Rogers (1959, p.213) set out six ‘necessary and sufficient conditions’, within which the three 'core' conditions are embedded, for therapy:

1. That two persons are in contact
2. That the first person, whom we shall term the client, is in a state of incongruence, being vulnerable, or anxious
3. That the second person, whom we shall term the therapist, is congruent in the relationship
4. That the therapist is experiencing unconditional positive regard toward the client
5. That the therapist is experiencing an empathic understanding of the client's internal frame of reference
6. That the client perceives, at least to a minimal degree, conditions 4 and 5, the unconditional positive regard of the therapist for him, and the empathic understanding of the therapist.

Person-centred therapy is non-directive (its first, original name) in that, unlike many other therapies, the therapist does not set the goals, focus nor direction of therapy. Instead, the client's emerging experience in the moment is the driving focus of the work. As we have outlined previously, the therapist's role is not to interpret the experience of the client (for that would take them away from the client’s frame of reference). With the communication of the core conditions, therapeutic change occurs during moments of self-acceptance and integration and the client's increasing awareness of conditions of worth that inhibit growth and the process of self-actualisation.

Working in Context

Person-centred therapy is widely practised in the UK and in Europe, but has been less of an influence in the United States over recent years. In the UK, person-centred therapy can be found in a wide range of contexts, including health, social care, education, third sector and in independent practice. As will be discussed in more detail in Chapter 12, its presence in some health care settings is threatened with only a peripheral presence in the treatment guidelines for psychological therapies for depression, with CBT, interpersonal and psychodynamic approaches having greater prominence. However, the humanistic movement remains very strong and is important in continuing to challenge the increasing medicalisation of human experience and the ever-growing development of diagnostic categories of mental disorder.

Person-centred therapy remains a dominant force in training, with many and varied training programmes in person-centred therapy continuing to be very active and influential. The principles of person-centred therapy, and certainly the concept of the ‘core conditions’ have been widely accepted not only by other therapeutic modalities but by other disciplines, such as nursing, social work and mental health. However, some have expressed concern by what they consider to be a misuse of the concepts and ideas of person-centred therapy. Merry (1996, p.507) wrote, ‘I am troubled by ... the way "person-centred" is becoming widely used to describe situations which do not do justice to the spirit or the original meaning of the term ...’

Research Profile

A study by Stiles et al. (2008) noted that person-centred therapy is as effective as psychodynamic therapy and CBT for a wide range of problems when analysing data from UK primary care settings. Additionally, there is evidence for efficacy of person-centred therapy for mild to moderate depression in adults and young people (King et al., 2000; Gibbard and Hanly, 2008). An increasing number of qualitative studies are being published that further demonstrate the value and benefit to clients of person-centred therapy.

Historical Development

Like person-centred therapy, gestalt therapy began to gain prominence in the 1950s with the emergence of the ‘third force’ of humanistic psychology in the United States. Developed by Frederick (Fritz) Perls (1893-1970), Laura Perls and Paul Goodman, gestalt therapy emerged as a new model with the publication of Gestalt Therapy: Excitement and Growth in the Human Personality in 1951, although Fritz Perls had previously published Ego, Hunger and Aggression, which outlined fundamental beliefs that were later to be incorporated into the therapeutic approach. Perls originally trained in medicine in Germany and qualified in 1921 before training as a psychoanalyst. Laura Perls worked with Kurt Goldstein and studied gestalt psychology, while Goodman was a philosopher.

For many years and, still for some today, gestalt therapy was associated with the particular unique style of its co-founder Fritz Perls who, in the 1960s, embarked on a number of large demonstrations of particular techniques. From that point gestalt has been synonymous with the use of particular therapeutic exercises, experiments and techniques (Mackewn 1997). The ‘empty chair’ exercise (where the client is invited to engage in a dialogue with aspects of their ‘self’) remains strongly associated with a gestalt approach. While some may still use this particular technique, gestalt has evolved considerably over the last 30 years, adopting an increasingly relational focus, adapting to the changing needs of clients and services (Parlett and Hemming, 1996; Yontef, 1991).

‘Gestalt’ is a German word without a direct translation into English. The OED (2012) defines gestalt as ‘an organized whole that is perceived as more than the sum of its parts’, and gestalt is generally taken as meaning pattern, configuration or form. In the same way as person-centred counselling, gestalt and gestalt psychology may be said to draw on three primary aspects: phenomenology and existentialism; Eastern religion; and drama and movement (Ellis and Leary-Joyce, 2000). Phenomenology emphasises the importance of experience being seen as subjective, rather than an objective process, in that each individual experiences their own, unique view of their world. Existentialism, as was previously outlined in the section on person-centred therapy, highlights the importance of choices and individual responsibility. Eastern religions, such as Taoism and Zen, emphasise the importance of being and experiencing in the moment. Drama and movement was an important influence on Fritz Perls, who was interested in the work of Moreno’s psychodrama approach.

Underlying Assumptions

Gestalt is based on an assumption of holism, in that it is impossible to understand self through the interpretation or exploration of one part, given that the whole is greater than the sum of the individual parts. As well, the focus of therapy is about the configuration of the whole self and how it relates to its world/environment. We cannot be understood as separate from our environment (relationships culture, family, class etc.) and must therefore be seen as in relationship with our environment through our means of being in contact with it. As per the humanist tradition, each individual retains the potential for growth and self-actualisation. Perls (1969, p.31) wrote: ‘Every individual, every plant, every animal has only one inborn goal — to actualise itself as it is.’

The core of gestalt is awareness, and helping to increase a client's awareness through the therapeutic process. Awareness in this instance would go beyond simply an intellectual awareness, but would also include an 'organismic experienced awareness' (Ellis and Leary-Joyce, 200, p. 339). The ‘here and now’ experience of contact is essentially important, and gestalt therapists work to facilitate a client’s ‘here and now’ experience and their contact with their environment. Growth occurs as we achieve contact with our environment, with different needs becoming ‘figural’ (everything in the environment that is the focus of attention) and returning to ‘ground’ (the environment surrounding the figure) as they become more or less important.

Gestalt therapy draws heavily on the work of Buber (philosopher) and his concepts of I-thou and I-It contact. I-thou (being as present as possible to another relationally) and I-It (where there is some goal or purpose to the meeting; that is, where the meeting moves beyond simply being in psychological and emotional contact). Human connection in therapy works toward an I-thou contact, although both I-thou and I-It are important for living in the world.

Key Theoretical Principles

Field theory is important in gestalt in working with awareness and how the client experiences their world and the meanings they attribute to it. Joyce and Sills (2001, p. 24) identity three important aspects of ‘phenomenological investigation’:

• The internal world of the client
• The external world or environment (including the therapist)
• The ever-changing relationship between them.

Taken as a whole they describe this as ‘the field’. Field theory was first developed in psychology by Kurt Lewin (1952). He asserted that the relationship between the person and the environment was essential, and this is a key tenet of gestalt therapy. Clarkson (1999, p. 9) states that ‘human beings can be understood only within the system of which they are a significant component part. A gestaltist would always work within the matrix of the person with needs in a sociocultural context’. Mackewn (1997, p. 49) offers a useful overview of field theory as it relates to gestalt therapy, summarised here:

• People cannot be understood in isolation but only as part of their sociocultural background.
• The field consists of all the ‘interactive phenomena’ of the individual and the environment.
• Human behaviour cannot he linked to any one cause but rather from the relationship between events in the field.
• Individuals constantly change their perspective of the field as they experience it differently.
• Some aspects of the field come into focus, while others move into the background.
• Individuals attribute their own meaning to events and experiences and by doing so contribute to creating their own experience (they ‘co-create the field’).
• Behaviour and experience happen in the present and can only be explained in relation to the present field.
• As all aspects of the field are ‘interconnected’, a change in one part will influence the whole field.

The gestalt cycle of experience (or formation and destruction cycle) is another key concept in gestalt, and a useful metaphorical means of illustrating contact and loss of contact with the environment. It assumes that healthy human experience is based on the formation of figure (needs) against the ground (environment) in a responsive and free-flowing way. However, problems occur when this process is disrupted. Early human relational experience is assumed to be important in setting patterns in this process. The cycle of awareness is illustrated in Figure 3.2.

The terms in brackets in Figure 3.2 represent what Perls called ‘neurotic mechanisms’ or ‘contact boundary disturbances’, which limit an individual's contact with their environment at all experiential levels. We can consider each of the ways in which contact with our environment can be disrupted:

• Desensitisation is the way in which we can disconnect from both our environment and ourselves: not experiencing feeling, physical sensation, taste, sex etc. We do not experience a healthy sense of our sensitised experience of our world.
• Deflection is the means through which we ‘turn away’ from positive contact with our environment.
• Introjection is where ideas, beliefs, attitudes or other negative aspects from our environment are taken in (‘swallowed’) without question or assimilation.
• Projection is the mechanism through which beliefs, attitudes, ideas or other negative aspects are attributed to others or other aspects of our environment.
• Retroflection is the process of turning ‘back in’ on ourselves, thus to avoid full contact — avoiding expressing our experience for the risks it might bring.
• Egotism is an excessive preoccupation with our own thoughts, feelings or behaviours (akin to an ongoing internal self-commentary).
• Confluence is the loss of boundaries between self and environment, including other people.

FIGURE 3.2 - The Cycle of Awareness

The Nature of Therapeutic Change

Gestalt therapy draws on a number of therapeutic strategies that aim to increase an individual's awareness. This includes awareness of the body and physical awareness, the language the client uses, and the nature and form of contact they have with their environment. The therapist may also encourage ‘experiments’ occasionally in which clients will be supported to try out new ways of being, different discourses, or ways of being with their environment, e.g. increasing sensation if the client is desensitised.

The therapist will pay particular attention to the client's way of being in the world, and in relationship with the therapist. In this way the nature and form of the therapeutic relationship will be extremely important in gestalt therapy, with the therapist working to be fully connected with the client in a meaningful and relational way. Gestalt therapy is based on the premise that change occurs with greater awareness. As Beisser (1970, p. 88) states: ‘Change occurs when one becomes what he is, not when he tries to become what he is not’.

Working in Context

Like person-centred therapy, gestalt therapy can be found in a wide range of contexts, including health and social care, education, third sector organisations and in independent practice. Again, consistent with other humanistic approaches to therapy a dearth of scientifically accepted evidence means its position in health care settings is becoming more peripheral, with a move instead towards approaches such as CBT, with a strong, quantitative evidence base.

Research Profile

As stated, research has not been a primary driver in the gestalt world for many decades, with only relatively recent moves towards developing an evidence base. A study by Strumpfel and Goldman (2002) demonstrated that gestalt was as effective as CBT and person-centred therapy when working with clients who were depressed, with some phobias and other problems.

Historical Development

Transactional analysis (TA) was founded in the 1950s by Eric Berne (1910-1970), a psychiatrist with training in psychoanalysis. With roots in a psychoanalytic tradition, TA now has firm roots as a humanistic approach. Berne was influenced by the work of Paul Federn, his training analyst, whose ideas of a system of ego psychology was particularly important for Berne's later work. As well as Federn, Berne was also strongly influenced by the work of Erik Erikson, who introduced Berne to the concept of the social and developmental influences on personality.

A key point in the development of TA was the rejection of Bernes application for membership of the San Francisco Psychoanalytic Institute in 1956, which then prompted Berne to undertake further work on his own theories. By 1958 all the primary aspects of what was to become TA were published in various articles and papers. Initially developed through these various papers and ideas, TA assumed a more coherent form, in 1961 when Berne published Transactional Analysis in Psycho-therapy. It developed a more popular appeal with Berne's publication in 1964 of his mainstream text, Games People Play, which introduced some of the basic principles of TA to a wider population. TA is now an established model within counselling and psychotherapy and continues to develop.

Underlying Assumptions

Similar to other humanistic approaches, TA assumes that all individuals have a basic drive for health and growth. It is assumed that each individual is able to think and take full responsibility for their own actions but that decisions people have made can be changed (through ‘re-decision’ work) and people can be responsible for their own destiny. Such decisions may be conscious and in awareness, but may also be unconscious or out of direct awareness.

Autonomy is a goal for individuals — this does not necessarily mean individual and isolating autonomy, but one that includes and is dependent on others to achieve. Awareness is central to the work of TA, encouraging individuals to live in the moment and to perceive it without interruption through rumination and moving away from a here-and-now experience. Like person-centred and gestalt approaches, TA stresses the importance of spontaneity, the validity of individual experience and how people construct their own worlds, and personal autonomy and responsibility, believing that change is possible. Finally, Berne proposed a third ‘instinct’ – physis (creative instinct) – to build on the instincts proposed by Freud, namely thanatos (death instinct) and eros (sexual instinct).

Key Theoretical Principles

One of the central concepts of TA is that of the three ego states: parent, adult and child. Clarkson (1999, p.222) defines ego states as ‘the subjectively experienced reality of a person’s mental and bodily ego with the original contents of the time period it represents. The three ego states, as depicted by Berne, are detailed in Figure 3.3.

Here the parent (P) ego state contains two aspects: the nurturing parent and the controlling parent. The parent ego state represents past experiences in that it draws on the patterns of behaviour and parent style as experienced in childhood. The nurturing parent represents the parent that was unconditionally caring and supportive, while the controlling parent represents the disciplinarian and restricting parent. The child (C) ego contains two aspects: the free child and the adapted child. The free child is playful, happy, adventurous and explorative but is able to access sad and painful feelings too, while the adaptive child (often responding to the controlling parent) is managed, passive and overly focused on ‘good’ behaviour. The child ego state also draws on past experience, including feelings, thoughts and behaviours related to our own experience of childhood. The adult (A) ego state, represents adult virtues, such as autonomy, clear thinking and ‘here and now’ responses.

Transactions occur between individuals originating from particular ego states. In Figure 3.3, where 1 represents one person and the ego states in panel 2 represent another, we can draw lines between them to illustrate transactions. For example, we may find ourselves responding to another from a controlling parental position (‘I wish you wouldn’t do that, it is really irritating’) that might trigger an adapted child response from another (‘I’m sorry, I won’t do it again’). Transactions can occur from any of the three primary ego states (and the two sub-divided ones) and trigger responses in another from particular ego states, depending on how the transaction, or communication, has been experienced by them. This constitutes a simple and helpful diagram to use in counselling and psychotherapy in that it quickly illustrates the co-defined process of communications and how our communications can be influential for another.

FIGURE 3.3 - Three Ego States (for details, see text)

Other important aspects to TA theory are psychological games, which describe repeating patterns of behaviour leading to familiar self-deprecatory feelings. Such behaviours are energised by ‘unfinished business’, and such games reinforce an individual’s ‘scripts’. Scripts are unconscious life plans, usually set down in early childhood, which are formed in response to external influences and a subsequent sense of internal vulnerability.

The Nature of Therapeutic Change

Berne (1966) outlined eight ‘therapeutic operations’ fundamental to TA. They are outlined in Tudor and Sills (2012, p.338) as follows:

1. Interrogation or enquiry – inviting the client to talk about him/herself
2. Specification – categorising and highlighting certain relevant information
3. Confrontation – using previously specified material to point out inconsistencies; often this has the purpose and effect of disconcerting the client's Parent, Child or contaminated Adult
4. Explanation – explaining a situation with a view to strengthening the client's Adult
5. Illustration – using an anecdote, simile or comparison to reinforce a confrontation or explanation
6. Confirmation – using new confrontations to confirm the issues and patterns that emerge in the client's discourse
7. Interpretation – offering ways of understanding a client's underlying motives, designed to stabilise the client's Adult control and ‘deconfuse’ the Child
8. Crystallisation – making summary statements to help the client make autonomous choices.

Lister-Ford (2002) outlines several distinguishing characteristics of a TA therapist, which need to be present for therapeutic change to be facilitated:

• The pursuit or autonomy in self and others
• Respect for self and others – ‘I'm OK, you're OK
• Personal responsibility and self-knowledge
• A humanistic stance
• Open communications
• Avoiding psychological games
• Cooperative
• Emotionally literate
• Making clear contracts.

The process of therapeutic change in TA is outlined by Berne, and detailed by Tudor and Sills (2012, p.338) as:

• Social control: the control of dysfunctional behaviours
• Symptomatic relief: the personal relief of subjectively experienced symptoms
• Transference cure: when the client can stay out of their script, as long as the therapist is around either literally or ‘in their head’
• Script cure: by which the person’s own Adult ego state takes over the previous role of the therapist and the person makes autonomous decisions.

Working in Context

TA is a widely used approach in counselling and psychotherapy, albeit not in the same numbers as person-centred, and has continued to develop both in theory and practice. Traditional models of TA, drawing on the original theories and ideas of Berne, are increasingly supplemented by a relational TA, which focuses more attention on the nature of the relationship between therapist and client, as in many of the other humanistic traditions.

Again, like person-centred and gestalt, TA can be found in many of the mainstream contexts for counselling and psychotherapy, but is not generally cited as a treatment of choice in treatment guidelines for many of the primary mental health conditions, thus making its use in health care settings more peripheral to cognitive-behavioural and psychodynamic therapy.

Research Profile

The research evidence for TA over the years has been patchy, with comparatively few empirical studies. The last decade has seen the emergence of a research culture within TA, with an increasing number or qualitative, case study and quantitative papers being published.

Section Outline

Cognitive behavioural approaches have become a dominant force in UK therapy provision, particularly within health care settings for the treatment of anxiety and depression. This section considers the development of cognitive-behavioural therapy, from an integration between behavioural and cognitive approaches, through to current practice.

Introduction

It is important to understand that what we now term as ‘cognitive-behavioural therapy’ (CBT) is an integration of several approaches to personality and the development of psychological difficulties. To understand that integration and to appreciate its current application in practice, it is helpful first to deconstruct the model and look a little more at its constituent parts: behaviourism and behaviour therapy, and cognitive theories and their application in therapeutic settings. Of course, CBT is not simply a bringing together of these two distinct parts, but drawing on the principles of the two that CBT has continued to evolve, through, practice experience and empirical research, into the forms in which it is currently practised. It is also important to note that other developments in the UK, such as the Improving Access to Psychological Therapies (IAPT) programme, have furthered the approach to psychological difficulties and the delivery of treatments in primary care settings (Robinson et al., 2012). CBT is not a single model of therapy, applicable to all clients in all situations. This has been one of the criticisms incorrectly levelled at CBT, that its ‘one size fits all’ approach to the complex nature of human problems will, inevitably, fail to meet the needs of many, or (at best), simply focus on symptom reduction (House and Loewenthal, 2008). CBT is as much based on the development of a therapeutic alliance as it is in a psychodynamic or humanistic approach. The success of therapy will be, at least partly, informed by the nature of the therapeutic process, and not simply the application of particular theoretical ideas, as some suggest.

Behaviourism and Classical Conditioning

The birth of behaviourism can probably be traced back to the work of Ivan Pavlov (1849-1936), a Russian physiologist. He is credited with the development of theories of classical conditioning, one of the central tenets of behavioural explanations of psychology and, later, behaviour therapy (developed in the 1960s) and CBT. Classical conditioning describes a process whereby ‘if a stimulus produces a response, it can be paired with another stimulus and the second stimulus will produce the same response’ (Kinsella and Garland, 2008, p. 187). This was most clearly demonstrated in Pavlov's well-known experiment (Pavlov's dog) in which dogs salivated in response to the presentation of food (unconditional stimulus = food; unconditional response = salvation). The food was paired with a bell (i.e.., a bell was rung on the presentation of food), so that the dogs began to associate the bell with the likelihood of food; the bell alone then led to the dog salivating (conditioned stimulus = bell; conditioned response = salivation). This experiment demonstrated the process of learning (classical conditioning is an important concept in learning theory, alongside operant conditioning, habituation and modelling). Clinical conditioning has particular relevance when applied to understanding the development of psychological problems, in that if the environmental stimulus is changed, problems can be treated. Classical conditioning can also help explain the development of phobias (conditioned stimulus = spiders, for example: conditioned response = fear and anxiety).

Operant Conditioning

B.F. Skinner (1904-1990), developing the earlier work of American psychologist Edward Thorndike, used the term operant conditioning to describe a process whereby a ‘response is altered as a result of its consequences ... the consequence of the reward will increase the behaviour and that of punishment reduce it’ (Kinsella and Garland, 2008, p.187). Essentially, if a reward (positive reinforcer) is present every time a task is completed (behaviour), it is more likely the task (behaviour) will be repeated. If a punishment (negative reinforcer) is present, the task (behaviour) is less likely to be repeated. As Joseph (2010. p. 77) states, ‘operant conditioning explains the persistence of the maladaptive behaviour and classical conditioning explains the formulation of the behaviour in the first place’. Mowrer's (1947) two-factor theory of fear and avoidance is outlined thus by Joseph (2010, p. 77): ‘fear is acquired through classical conditioning (first factor) and maintained through operant conditioning via negative reinforcement (second factor) as the person avoids his or her fear’.

Habituation

Habituation simply means that if someone is repeatedly exposed to a stimulus, the level and intensity of the response will reduce. We can probably think of many situations in our own lives where we might identify the process of habituation. If a house alarm goes off we may initially pay careful attention to it. If it goes off subsequently and repeatedly, however, our response will wane until we eventually ignore it, or do not hear it. The concept of habituation has been used in work with phobias, anxiety disorders and obsessive-compulsive disorder (OCD), for example, where a repeated exposure to the feared stimulus can lead to a reduced anxiety response.

Modelling

The concept of modelling (Bandura, 1969) refers to the increased likelihood of adopting a behavioural/emotional response having observed that response to a given stimulus in another person. We might consider, alongside the other concepts outlined, the importance of modelling in the development of phobias. If we assume we are not born with a fear of small house spiders, modelling might play an important role in the development of the fear in having witnessed the fear of spiders in others.

Behaviour therapy, therefore, based on the concepts of learning theory and, in particular the role of classical and operant conditioning, aims to reduce and eradicate symptoms, to help the individual develop new behaviours as well as changing the experience of environmental reinforcers. One means by which this is achieved is through systematic desensitisation, which is associated with Joseph Wolpe (1915-1997), although Wolpe used the term systematic desensitisation to describe a process that had already been successfully used to treat children, outlined by Jones (1925). This can be described as a process of steady and managed exposure to a feared stimulus following a period of relaxation training. For example, once an individual is taught to increase their sense of relaxation, they are exposed to a low level of the feared stimulus (having first been enabled to identify situations or events that cause different levels of difficulty) in a controlled way until no response is experienced (through the process of habituation). This is then repeated with a higher level of the feared stimulus until no response is experienced, and continued until the stimulus does not trigger the response. Other techniques based on the principles of classical conditioning include flooding (exposure to high levels of the feared stimulus) until extinction of the response occurs, and aversion therapy, involving pairing an unpleasant consequence with an unwanted behaviour to reduce frequency.

Cognitive Therapy

While behaviourism is clearly rooted in the process of learning, much of the research in the development of the concepts outlined was conducted in animal behaviour experiments. What may happen with animal behaviour may not always be extrapolated to human behaviour, as Kinsella and Garland (2008, p. 187) state with reference to the concept of operant conditioning: ‘because of [human] cognitive abilities they are more likely to question the necessity of continuing the behaviour or the desirability of the reward’. The development of cognitive approaches to understanding human distress therefore aimed instead to look at thinking processes that might influence behaviour and emotional responses. The two principal writers in the development of cognitive therapy were Aaron T. Beck (b. 1921) and Albert Ellis (1913-2007).

Beck's cognitive therapy asserts that the processes of thinking influence, and are also influenced by, emotional difficulties. Therefore, if thinking processes can be changed through the process of therapy a reduction in the emotional difficulties may result. As outlined by Sanders and Wills (2005, p. 3), ‘While clients may well come to therapy asking for help with their negative thoughts, more often they come because they are feeling bad. Despite its focus on thinking, cognitive therapy is actually all about reaching and working with emotion.’

The original model of cognitive therapy was outlined in two key publications, Cognitive Therapy and the Emotional Disorders (Beck, 1976) and Cognitive Therapy of Depression (Beck et al., 1979). If a person can be supported through therapy to change the way they think about a situation, they can influence the way they experience the situation and thus facilitate emotional change. For example, Beck suggested that people experiencing depression typically think about themselves in ways that accentuate the negatives, having developed such patterns of thinking when young. Essentially, Beck argued that underlying emotional difficulties were illogical thoughts and maladaptive ways of experiencing the world.

Cognitive therapy is essentially based on the assumption that, as humans, we interact with our environment through the process of thinking, interpretation and evaluation. In turn, these are linked to our feelings and behaviour (as well as our physical wellbeing, as has increasingly been acknowledged). Cognitions are available to us knowingly, that is, they are conscious (and thus cognitive therapy does not work with the unconscious in the way psychoanalysis would). Beck described three types of cognition: information processing, automatic thoughts and schema. Information processing describes how individuals constantly receive information from within themselves (body experiences), and their environment. Automatic thoughts represent an individual's internal dialogue that occurs in an unplanned way, while schema describes ‘hypothetical cognitive structures which act as templates to filter incoming information’ (Mytton, 2012, p. 287). Schemas are the core beliefs and views of the world an individual develops when young that help them to function in their life by filtering out unnecessary information and creating an internal ‘map’. There are recent developments in schema therapy that try to help people restructure fundamental, core beliefs through an integration of cognitive-behavioural therapy, object relations, gestalt and, most recently, mindfulness-based approaches (Rafaeli et al., 2010).

Beck outlined a number of illogical ways of thinking, some of which are described in Box 3.3.

Cognitive therapy relies on a strong therapeutic alliance between therapist and client and emphasises the importance of relational dynamics as well as the behavioural and/or cognitive aspects of the client's presentation. Cognitive therapy begins with the therapist helping the client to understand the model of therapy (especially concerning the place and importance of cognitions in their distress). Clients then facilitated to begin to identify problematic cognitive processes and are supported by their therapist to challenge and re-structure this thinking, trying new thoughts and ideas in response to given situations.

Rational Emotive Behaviour Therapy

Previously known as rational therapy, then rational emotive therapy, rational emotive behaviour therapy (REBT) now incorporates a behavioural and cognitive aspect to its approach. Albert Ellis, an American psychologist and psychotherapist originally developed rational therapy in 1955. Like Beck, he was disillusioned with psychoanalysis and developed an approach that focused on a client’s emotional and thinking disturbances. The key principles of REBT (adapted from Dryden, 2012) include that rational beliefs contribute to the core of psychological health. Conversely therefore, irrational beliefs are considered to be at the core of psychological distress and are represented as inconsistent with the individual’s actual reality, rigid, extreme and self-defeating.

The four types of rational belief are: non-dogmatic preferences; non-awfulising beliefs; high frustration tolerance beliefs; and acceptance beliefs. REBT works on an ABC approach to therapy (A = aspect of the situation the person focuses on; B = beliefs (rational or irrational); and C = consequences). If A represents irrational beliefs then psychological disturbance is likely. If A represents rational beliefs then psychological health is likely. Individuals are seen to have both rational and irrational beliefs and, with work, all have the capacity to identify, challenge and change irrational beliefs. Finally, many irrational beliefs are learnt from parental disturbed behaviour or other unhelpful experiences. Box 3.4 shows the examples offered by Dryden and Neenan (2006, p. 2-3) for the four types of rational and irrational beliefs.

REBT does not have a particular theoretical position on the nature and form of disturbance, but instead sees psychological distress as a consequence of an individual's views formed in response to events. The role of the REBT therapist is to help clients consider their own part in distress and consider ways in which they may begin to think about events differently.

Given an assumption that, with insight, individuals are able to take control over their lives, the role of the therapist is to facilitate that process. This might involve periods of challenge. There is an acknowledgement that the qualities of the therapist (e.g. warmth, acceptance) are important; however these are not seen as integral to the process of change. The process would instead focus on identifying irrational beliefs, questioning and challenging irrational beliefs until the individual is able to see them as false and unhelpful (in contrast to their rational beliefs), and then working to integrate newly formed rational beliefs into their cognitive structure.

Cognitive Behavioural Therapy

Gilbert has suggested there are at least 16 different approaches to CBT (Gilbert, 1996, cited in Kinsella and Garland, 2008), each placing a different emphasis on behavioural, cognitive and/or interpersonal factors to the provision of therapy. The truth is there are probably many more, given that how therapists integrate different aspects of behavioural and cognitive theories and approaches to therapy will vary greatly. Wills (2005) notes, however, that common to the different styles of CBT is the importance of the relationship, placing emphasis on empathy, warmth and genuineness (akin to the core conditions of empathy, congruence and unconditional positive regard in person-centred therapy).

The development of CBT has been heavily influenced by its application with particular problems and presenting issues, such as depression and anxiety. Practitioners have sought to place different emphasis on aspects of the approach depending on the type of difficulties experienced by clients, but also more specifically on the particular needs of individual clients as they present for therapy. In that sense, CBT can be seen as a particular bespoke approach to working with clients, with an emphasis on individual therapy plans targeted at specific problem areas, albeit within a wider behavioural and cognitive frame. For example, while the emphasis may vary, the ideological, philosophical and theoretical stance of CBT would not place great emphasis on an in-depth exploration of an individual's psychodynamic history, other than to identity sources of schematic problem and behavioural difficulty nor would it seek to work with unconscious processes. Claringbull (2010) suggests some common concepts inherent within CBT, outlined in Box 3.5.

There are a number of particular developments ornate within CBT. Acceptance and commitment therapy (ACT; Hayes et al., 1999) uses CBT techniques and mindfulness together with strategies for commitment for behaviour change. The aim is to facilitate a healthier experience of memories, thoughts, feelings and physical sensations through the use of experiential exercises, metaphor and paradox. The intervention stresses the importance of being in the moment and experiences thoughts and feelings as such.

Cognitive analytic therapy (CAT), developed by Ryle (1990), draws on cognitive and analytic theories and is time-limited. The shorter-term focus of CAT is achieved through the use of some cognitive therapy techniques, including setting of goals and Socratic questioning. Socratic questioning in CBT is an important approach that facilitates a deeper and particular type of thinking. Sanders and Wills (2005, p. 109), drawing on the work of Pakesky (2004a, 2004b), outline four related stages of Socratic questioning:

1. Asking informational questions to uncover information beyond the client's current awareness
2. Accurate listening and empathic reflection
3. A summary of information discovered
4. Asking synthesising questions which help apply the new information discussed to the client's original thought or belief.

Other approaches include compassion focused therapy (CFT; see later in this chapter for a brief discussion of CFT) and dialectic behavioural therapy, amongst others.

Criticisms of CBT

Despite a strong evidence base for its efficacy across a wide range of difficulties, and its being recommended as the treatment of choice for many presenting problems in treatment guidelines, CBT has attracted a great deal of criticism during the last two decades, and particularly following Layard’s (2003) 'wellbeing and happiness' agenda that led to the development of IAPT services and the implementation of adapted CBT approaches (Mytton, 2012). Some feel the research evidence is overstated in its claims (White, 2000), while others argue that the findings of CBT and its application in practice are overly simplistic (Small, 1996). Joseph (2010) notes, however, that the increasing adaption of the medical discourse and psychiatric approaches to understanding and describing human distress, as seen in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (2000, currently in consultation for a 5th edition), have been important in the increasing acceptability of CBT to the scientific community.

Section Outline

Integrative ways of working draw on a number of models to bring about a new integration of approaches. Typically, an ‘integrative practitioner’ will work with theoretical assumptions and principles of practice informed by several approaches. Working ‘pluralistically’ takes the idea of integration a stage further. This section considers the differences between integrative and pluralist ways of working and discusses the implications for practice.

While for many years the major counselling and psychotherapy approaches were adopted in a purist way (i.e., each delivered without being informed by another predominant model), there has over recent years been a move toward an integration of different ideas and principles. Such an approach has attracted several different terms, including eclecticism, integration, a synthesised approach and, most recently, pluralistic approaches (though the writing on pluralism differentiates it from integration, rather than simply offering a new name for the same concept). The critics of integrated approaches suggest that important perspectives on personality are lost, and that therapy becomes intervention-based rather than relational-driven. In contrast, the proponents of integrative therapy argue that, when considering the sheer range of client problems that counsellors and psychotherapists can encounter in practice, it is never appropriate to take a ‘one size fits all’ approach to supporting people in distress: integration, they argue, offers a mechanism by which the most helpful aspects of theoretical approaches can be brought together to form a new model.

Definitions

The OED (2012) defines eclectic as, ‘deriving ideas, style, or taste from a broad and diverse range of sources’, while integrate is defined as, ‘combine (one thing) with another to form a whole’. Synthesis is defined as, ‘the combination of components or elements to form a connected whole’. From the definitions here we can we that integrative and synthesis essentially describe a similar process, even though they have been used in a differentiated way in the literature. More significant is the distinction between eclectic and integrative.

There are a number of reasons why an integrative approach may be preferred over a more purist one. Messina (2005, cited in Antis, 2011) offers the following:

1. The proliferation of therapies
2. The inadequacy of a single therapy relevant to all clients and problems
3. External socioeconomic realities (e.g. insurance protection)
4. The popularity of short-term, prescriptive, problem-focused therapies
5. The paucity of differential effectiveness among therapies
6. Recognition of therapeutic commonalities’ major role in therapy outcomes
7. The development of professional societies aimed at integrating psychotherapies.

Norcross and Goldfried (2005, p. 8) outline general ‘routes’ to integration as follows:

1. Common factors: some have suggested there are common factors across the counselling and psychotherapy models that contribute to their effectiveness. By drawing together these common factors there is potential to develop an effective integration, although some aspects may be theory dependent and thus diluted if used out of context.
2. Technical eclecticism: in which therapists use particular approaches or interventions in response to clients’ problems and needs, without necessarily doing that in a coherent way.
3. Theoretical integration: where the hope is that the new whole will be better than the individual constituent parts. An example of theoretical integration would be cognitive analytic therapy (Ryle and Kerr, 2002), where psychodynamic theory, including object-relations theory, is integrated with a cognitive-behavioural approach.
4. Assimilative integration: works on the basis that any counsellor or psychotherapist will train in one particular approach and have a theoretical and practice grounding in it, but through practice and experience will begin to assimilate new or different approaches to complement existing skills and knowledge. However, an increasing number of integrative training courses do not rely on a 'base' model, but instead encourage trainees to develop an integrative approach as their core model.

Eclecticism vs Integration

A metaphor I have heard on several occasions (and sadly cannot attribute) is that of a therapeutic ‘soup’. Each model of therapy represents individual ingredients or a set of ingredients. Each can be nourishing of itself and is not necessarily dependent on other ingredients being added. However, it is possible to take particular ingredients and put them together to make a new whole. Eclecticism might correspond to all the ingredients being put together in a pot; they still exist in their constituent parts and can easily be identified as such. While they do make a new ‘whole’, it is more to do with them being collected together rather than anything more. Integration would correspond to a careful selection of ingredients brought together and put through a liquidiser; all of the ingredients are still present, but they have been closely adapted into something new. Of course, great care has to be taken in the selection of ingredients, as some simply do not work together.

The challenge of integration is to make a careful and thoughtful selection of ideal principles, philosophical assumptions and interventions that can work together in a new, integrated theory or approach. The critics of eclecticism argue that, unlike integration, eclecticism instead brings together different parts in a more ad hoc style; that is to say, with particular thought as to how they work together or how they might be held together in a new, cohesive whole. On this view, eclecticism might be thought of as like trying to fix a broken piece of furniture with a range of different screwdrivers and hammers, simply trying them all until one seems to work. Unlike broken furniture, of course, vulnerable and distressed clients attending counselling and psychotherapy take great personal risks in trusting the therapist and would hope their counsellor and psychotherapist wouldn’t simply go through the toolbox until they find something that works. Doing so runs the risk of causing further harm along the way.

The ‘ingredients’ for integration go beyond the essential components of different counselling and psychotherapy models. In addition, the counsellor or psychotherapist’s particular personal and professional experiences, working context, client presentations and expectations, and training, will inform the ‘blend’ of integration. Fundamentally, the philosophy behind integration is that no single approach has the answer for all clients and that, though two or more approaches have something to offer separately, they have even more to offer when combined.

McMahon (2000, p.118) offers an outline of using integrative therapy with a client:

1. The counsellor or psychotherapist will, like all therapy, need to develop a sound working relationship with the client, ‘building rapport and establishing core values’ (p. 118).
2. During this early process the therapist will be looking out for client strengths and also points of struggle or vulnerability.
3. An assessment will inform both the therapist and client as to the potential value and efficacy of therapy and, if deemed appropriate, a contract will be agreed.
4. Both therapist and client will keep an eye on agreed goals so that changes in emphasis can be monitored and responded to.
5. The integrative counsellor or psychotherapist has no predetermined approach or theoretical perspective through which to view the client's difficulties, but rather will allow themselves to be informed by the client's problems and place a different emphasis on their approach depending on this. A therapist working from a more purist frame may follow the similar steps, but will ultimately approach the ‘tasks’ of therapy from their preferred position, whether that be cognitive-behavioural, psychodynamic, person-centred, or so on.

As McMahon states: ‘There is no set format for a typical session in integrative counselling, which will vary according to the needs of the client, the stage of therapy and the particular approach or techniques being employed by the counsellor’ (2000, p. 121).

Pluralistic Approaches

Cooper and McLeod (2010, p. 7-8) define pluralistic counselling and psychotherapy as based on ‘the assumption that different clients are likely to benefit from different therapeutic methods at different points in time, and that therapists should work collaboratively with clients to help them identify what they want from therapy and how they might achieve it.’

Cooper and McLeod (2010, p. 9) argue that a pluralistic approach to counselling and psychotherapy differs from an integrative approach on the following grounds:

1. A pluralistic approach is not just a practice, but a way of viewing therapy as a whole
2. Pluralism is not one combination of methods or theories but has ‘the potential to embrace an infinite variety of theories, practices and change mechanisms’ (p. 9)
3. Places emphasis on ‘tailoring’ (p. 9) each session of therapy to the client
4. Dialogue around the goals, tasks and methods of therapy based within the formation of maintenance or a collaborative therapeutic relationship
5. There is no one set of factors that determine therapeutic change for all clients
6. Puts emphasis on the client as the agent of change
7. Introduces a framework for thinking about, researching and practising therapy.

We see here that integration is seen to be a more static entity, given that a counsellor or psychotherapist will integrate different models of therapy into a new approach embedded within their personal style. The needs of the client will bring a different focus or intervention, but it will still be in the context of the nature and form of the integration. Pluralism instead offers something that is perhaps more fluid and responsive to the client’s needs; engages the client as an active and equal collaborator in their own therapy; is more responsive to the changing needs of the client; and forms a negotiated approach in which the client has an important investment. This may ring true for some purist approaches too, but again the therapist will still be coming to the work from a certain frame (as opposed to coming from where the client is at, emotionally and psychologically). Even though integrative approaches have been in place for some time, the new challenges of pluralism take those steps even further and task the therapist with giving away more of their power and expertise, in the tradition of humanistic psychology.

Section Outline

Beyond the four principal schools of counselling and psychotherapy lie a number of approaches and techniques, often allied to existing schools, but also drawing on alternative ideas and approaches. This section outlines a number of associated ways of working and considers their relevance for contemporary practice.

The four principal schools of counselling and psychotherapy–psychodynamic; humanistic-existential; cognitive-behavioural; and integrative and pluralistic – all hold within them particular theories and styles of therapy informed by both practice and philosophy. There are some other approaches to therapy increasingly used in mainstream counselling and psychotherapy services, some or which may be positioned within one of the four principal schools, while others sit slightly apart. Some of these therapies might not constitute a first training in counselling and psychotherapy (such as EMDR, for example), but rather might be followed up after a core training. In this section we briefly discuss the following in turn:

• Eye movement desensitisation and reprocessing (EMDR)
• Solution-focused therapy
• Mindfulness-based cognitive-behavioural therapy / mindfulness-based stress reduction (MBSR.)
• Companion-focused therapy
• The skilled helper model.

Eye Movement Desensitisation and Reprocessing

Eye movement desensitisation and reprocessing (EMDR) was developed by Francine Shapiro in the late 1990s and early 2000s to help working with trauma. While it is used with other presenting problems, trauma remains its primary focus. The key principles of EMDR are outlined in Box 3.6.

Treatment is conducted over eight phases, and repeated as necessary. The phases of treatment are as follows.

• Phase I: History and treatment planning
  The therapist takes a client history and a treatment plan is discussed and outlined. Specifically, potential areas for EMDR are identified.
• Phase II: Preparation
  Clients are encouraged to identify a ‘safe place’ (i.e., image or memory with positive associations) to help with self-support during, or after, sessions.
• Phase III: Assessment
  A negative cognition is identified – a negative statement about the self usually triggered when thinking of the trauma – and a positive cognition – a positive self-statement – to counteract the negative one. Additionally, the client is encouraged to identify particular responses, such as emotions (e.g. anger) and other responses (e.g. cold hands, butterflies in the stomach).
• Phase IV: Desensitisation
  The client is asked to focus on the image they have previously been encouraged to bring to mind, the negative cognition and the distressing emotion or body sensation. The bilateral stimulation is undertaken (eye movements, tapping, tones, etc. – it is believed that bilateral movements help ‘re-wire’ the processing of memories). The client is then asked to report briefly on what has come up for them (e.g. a thought, feeling, or physical sensation). The client will occasionally be asked to focus on the thought, but may be asked instead to focus on the original target memory. The client is occasionally asked to report their current level of distress using the Subjective Units of Disturbance (SUDS) scale. The desensitisation phase usually ends with a SUDS score of 0 or 1.
• Phase V: Installation
  The client is asked about the positive cognition, if it is still valid, and build on it. Treatment continues and the client’s position measured using a Validity of Cognition (VOC) scale until they reach the maximum score of 7 (ideally), or 5 or 6.
• Phase VI: Body scan
  The client is asked if they experience any physical pain, stress or discomfort when they think of the target memory. If so, further reprocessing will take place. If not, treatment can move on to the next phase.
• Phase VII: Closure
  This is used at the end of each treatment session to ensure the client is able to function safely and appropriately when they leave.
• Phase VIII: Re-evaluation
  This takes place at the beginning of each new session where the client is invited to review the previous week and discuss any new problems or experiences. The level of disturbance of previously targeted memory is assessed.

Solution-Focused Therapy

Solution-focused therapy originated at the Brief Family Center in the United States in the 1960s. Originally located as part of family and systemic therapy, solution-focused therapy has been further developed for work with individuals. It focuses on clients’ existing resources and strengths. Its key assumptions include the following (taken from O'Connell, 2012, p. 393):

• Clients have ideas about their preferred futures
• Clients are already carrying out constructive and helpful actions (otherwise things would be worse)
• Clients have many resources and competencies, many of which go unacknowledged by themselves and by others
• It is usually more helpful to focus on the present and the future. The past can be useful as a source of evidence for prior successes and skills
• It can be useful to find explanations for problems, but it is not essential, and in some cases this quest can delay constructive change
• Constructing solutions is a separate process from problem exploration
• The ‘truth’ of a client's life is negotiable within a social context. Fixed objective ‘truths’ are unattainable. There are many truths about the client’s life.

The role of the therapist is to facilitate change through the process of engagement with the current situation, resources and coping mechanisms. O'Connell (2012, p. 394) outlines a number of specific strategies. including:

• Pre-session change: clients are encouraged to notice what they have coped with and how they have managed between making initial contact for therapy and therapy commencing
• Problem-free talk: clients are encouraged to talk about themselves and their interests without focusing specifically on their ‘problems’, thus highlighting important information for therapy
• Listening to evidence of client’s strengths, qualities and skills: the therapist pays careful attention to the client’s strengths, qualities and skills, and brings these to the client’s attention at suitable times during therapy
• Building on exceptions: clients are encouraged to focus and explore those times when they are coping more effectively, thus further highlighting coping strategies and existing strengths
• The ‘miracle question’: helping clients to consider life without the problem. The question, as originally outlined by de Shazer et al. (1988) was ‘Imagine one night when you are asleep, a miracle happens and the problems we’ve been discussing disappear. As you were asleep, you did not know that a miracle had happened. When you wake up what will be the first sign to you that a miracle has happened?’
• Scaling: the therapist asks the client to measure progress on a scale of 0-10 and consider what needs to happen (and how the client can influence) a move up the scale (the higher being more positive)
• Feedback: each session finishes with feedback to the client, including negotiating in-between session tasks
• Tasks: noticing what works and what doesn’t, and continuing to do those things that help.

Mindfulness-Based Stress Reduction/ Mindfulness-Based CBT

Mindfulness-based CBT (mCBT) was developed by Zindel Segal, Mark Williams and John Teasdale, based on the work by John Kabat-Zinn and mindfulness-based stress reduction (MBSR). Kabat-Zinn developed MBSR at the University of Massachusetts Medical School in the 1970s as support for patients with chronic pain, hypertension, cancer, depression, anxiety, gastrointestinal disorder, and panic. The course runs for eight two-and-a-half-hour sessions, plus an all-day session, and draws heavily at a philosophical level on Buddhist teachings and meditation. However, MBSR is not Buddhist-based and thus is accessible to everyone, regardless of their spirituality or faith. MBSR teaches people moment-to-moment non-judgemental awareness of self in relation to environment, with evidence suggesting an increase in self-awareness and a significant reduction in anxiety, panic and depressive symptoms.

Segal, Williams and Teasdale developed mCBT specifically for the treatment of depression. Mindfulness-based CBT has been recommended by NICE for relapse prevention in depression and there is a growing evidence base as to its efficacy. Again, like MBSR, mCBT is structured around group work over eight two-and-a-half-hour sessions to help clients develop the capacity to respond to negative events rather than react to them.

Compassion-Focused Therapy

Compassion-focused therapy (CFT) was developed by Paul Gilbert (2010), drawing on Buddhist principles of compassion and self-care. While all counselling and psychotherapy needs to be conducted compassionately, the distinctive aspect of CFT is that it uses compassion as a central tenet and encourages clients to become self-compassionate. CFT draws on a range of other modalities, including cognitive-behavioural therapy. It was developed for people with chronic, long-term, complex mental health problems where self-criticism and shame are deeply embedded, originating from abusive and harmful upbringings.

Gilbert et al. (2008) noted in a study that when participants experienced feelings of calmness, wellbeing, contentment and safety they experienced measurably lower levels of depression, anxiety and stress. Gilbert (2010) suggests there are different types of positive feelings: some higher-energy feelings that are related to excitement, success and achievement; and resting-energy feelings, such as calmness, peace and a sense of safety. CFT focuses on the calmer level feelings to help the client acquire and develop a capacity for self-compassion.

Gilbert (2010, pp. 5-6) states that as CFT is a ‘multimodal’ therapy, it uses a wide range of intervention styles, including:

• Socratic dialogues
• Guided discovery
• Psycho-education
• Thought, emotion, behaviour and ‘body’ monitoring
• Behavioural experiments
• Exposure
• Mindfulness
• Learning emotional tolerance
• Making commitments for effort and practice
• Expressive (letter) writing
• Learning to understand and cope with emotional complexities and conflicts.

The Skilled Helper Model

The skilled helper model was originally developed by Gerard Egan (b. 1930) in the mid-1970s. Being positioned within a more integrative school of counselling and psychotherapy, the model allows for therapists to use a number of skills and interventions within a goal-centred structure of helping. The key principles of the skilled helper approach are outlined in Box 3.7.

Egan uses the mnemonic SOLAR to outline the five key skills helpers must demonstrate in working with clients:

• Sit facing the client squarely
• Maintain an Open posture
• Lean towards the client
• Maintain Appropriate eye contact with the client
• Be Relaxed to facilitate the quality and comfort of the sessions.

The model is structured over a number of stages (problem definition, goal-setting and action planning) as follows:

• Stage One: Explore the client’s existing situation
• Stage Two: Help the client establish aims and goals
• Stage Three: Help the client develop strategies.

While the skilled helper approach is presented by Egan in a clearly delineated fashion, the actual implementation of the model with clients is likely to be much more fluid, with dialogue moving between and across the different stages depending on the focus of work, and allowing for a linking between different narratives and accounts of difficulties.

Section Outline

There are a number of skills and interventions specific to different models of therapy. However, there are also some skills relevant to all types of approaches that help the counsellor and psychotherapist to engage clients and develop and sustain relationships. Different approaches place slightly different emphases on the ways in which the skills are implemented (concerning their frequency, for example), but all approaches integrate these skills into their core theoretical model.

We have discussed in previous sections of this chapter how specific models of therapy adopt preferred interventions and skills. It would very unusual, for example, to find a psychodynamic practitioner (where the emphasis is on therapist abstinence to facilitate the transferential process) to set homework, whereas a cognitive-behavioural practitioner might. Likewise, interpreting a client’s thoughts, comments or behaviour, as would happen in psychodynamic therapy, is very unlikely to take place in person-centred therapy (where the emphasis is on the client’s frame of reference and understanding, not the therapist’s). We may say that there are particular tools or approaches that are quite model-specific and not easily transferable because of philosophical incompatibilities.

There are, however, a number of micro-skills that cross the divisions of modality and are used by most therapists, most of the time. Each approach might place a different emphasis on particular skills (e.g. person-centred counsellors are less likely to use questioning than a cognitive-behavioural or psychodynamic counsellor), but the use of questions would not he prohibited by the model (despite the persistent myth that person-centred counsellors are ‘not allowed’ to use questions). Before we begin to consider some of these skills, however, we need to reflect further on what it is that makes an effective counsellor or psychotherapist.

Definitions: Skills, Qualities and Competence

The OED (2012) defines being skilled as ‘trained to do a particular task’. Certainly one of the aspects of counsellor and psychotherapy training is to facilitate the acquisition and development of skill to enable competent practice. The OED defines competence as, ‘the ability to do something successfully or efficiently’. We might therefore assume that a ‘good’ counsellor or psychotherapist is one who has the ability to ‘do a particular task successfully and efficiently’. While few would dispute the assertion of this statement, it is rather two-dimensional and does not fully reflect the full essence of being a therapist. We might train a therapist to use questions ‘efficiently and effectively’, but that would not necessarily enable them to do it compassionately, or empathically, or with care. Similarly, a surgeon might be well-trained to conduct an operation ‘successfully and efficiently’', but there is more to being a successful surgeon that safely wielding a scalpel; we might also judge ‘success and 'efficiency’ by the surgeon’s capacity to talk to patients, to reassure them and to explain, clearly and accessibly, the procedure they are about to undertake.

Thus, there is something about the qualities of a therapist that acts as an important context for the application of skills. The OED defines quality as, ‘a distinctive attribute or characteristic possessed by someone or something’. In defining an effective counsellor or psychotherapist we are assuming they possess:

• the appropriate qualities to undertake their role
• the appropriate level of training to undertake their role
• the ability to deliver their role using key skills.

When these three aspects are taken as a whole, we might assume that a therapist is competent. McLeod (2009, p. 613) states that it is ‘essential to view counsellor competence as a developmental process’.

• He suggests a ‘composite model consisting of seven distinct competence area’ (p. 613). These are:
  • Interpersonal skills
  • Personal beliefs and attitudes
  • Conceptual ability
  • Personal ‘soundness’
  • Mastery of technique
  • Ability to understand and work within social systems
  • Openness to learning and inquiry.

^{(McLeod, 2009, p. 613)}

In general terms I might also add to this list:

• Capacity to self-reflect
• Willingness to be open to challenge from others
• Ability to identify personal areas of competence
• Capacity to identify limits of competence, or when competence is temporarily impaired.

McLeod’s seven areas of competence include the sound acquisition of knowledge and the capacity to understand and apply relevant theory and interventions. Additionally, interpersonal qualities and personal beliefs and attitudes are an important aspect of being a therapist. These might include:

• Honesty
• Being empathic and warm
• Being interested in the wellbeing of others
• Being non-judgemental
• Respecting and accepting of others, and of self
• A commitment to self-awareness and self-development
• Integrity and a willingness to think ethically both personally and professionally
• An ability to communicate interest and attentiveness
• Capacity to hold a sense of hope
• Flexibility.

These are the types of qualities referred to earlier as an important context for an effective counsellor or psychotherapist. A therapist, therefore, might have the ability to learn skills and interventions and deliver them effectively and efficiently, yet without the types of personal qualities outlined above, their work will be experienced as mechanistic rather than fluid and relational.

The final aspects of this discussion related to the definitions offered above are centred on efficiency. The OED defines ‘efficient’ as ‘achieving maximum productivity with minimum wasted effort or expense’. In counselling and psychotherapy terms, the idea of ‘productivity’ might be defined in terms of ‘successful outcomes’. Yet (as is discussed later in this book) a client’s definition of a ‘successful outcome’ might be very different from that of the therapist which, in turn, might be very different again for the employing agency. Consider the three brief scenarios in Boxes 3.8 to 3.10.

In each of these scenarios the measure of ‘successful outcome’ will be different. For Alan, success will constitute learning to live with bullying, whereas for his counsellor it might be to make a stand, while the employer will want Alan to be effective in his work. Janine does not wish to leave her partner and so, while understanding the devastating impact of domestic violence, may define successful counselling in terms of learning to cope. ‘Success’ for the counsellor might he for Janine to make a decision to get out of the relationship. Finally, for Jacob ‘success’ might consist of having the confidence to leave his course; however, for the university—focused on retaining students—this would not be a ‘successful’ outcome.

Skills

A therapist may be warm and empathic, but without the right skills might not be able to effectively communicate that to the client. The skills of counselling and psychotherapy therefore, remain integral to the effectiveness of the therapist.

It is important to make a distinction between counselling and the use of counselling skills. Amis (2011, p. 113) defines counselling as ‘Agreed, structured and contracted sections with a trained counsellor. The core objectives are supporting the client and working towards change with the use of counselling skills’. She defines counselling skills as ‘a range of communication skills varying in difficulty that are used in general interactions or more skillfully in the caring professions’. Amis’ distinction concerning the context in which the skills are used (whether within the context of a general ‘helping’ role, or instead within an agreed and structured therapeutic relationship) is helpful. Many helping professionals, such as nurses, social workers or teachers, for example, will undertake counselling skills training. Amis is right in citing counselling skills as ‘communication’ skills, as counsellors and psychotherapists cannot claim communication as a unique selling point given that as relational beings, humans communicate all the time (with greater or lesser effectiveness). However, counselling skills might consist of communications skills that are enhanced and developed. Nurses, social workers and teachers, for example, can find their work enhanced by developing their core communication skills.

Many of the chapters in this book discuss counsellor and psychotherapist skills, including: contracting, establishing contact, evaluation and reviewing, working with specific presentations and recognising and working with relational dynamics.

Inskipp (2012) distinguishes between ‘inner’ and ‘outer’ skills as shown in Figure 3.4.

FIGURE 3.4 - Inner and Outer Skills

Whether counselling skills should be taught specifically, or be more integrated into learning is a disputed point. Ivey (1971) argues in support of the specific learning of skills, while Geldard and Geldard (2005) instead propose a more integrated approach to learning. Different courses will approach this question based on the personal preferences of the trainer and the modality being taught. It is, however, helpful to have a clear view as to which skills constitute micro-skills (as opposed to macro-skills that consist of the wider skills of therapeutic practice covered elsewhere in this book). Amis (2011, pp. 111-12) offers the following list of micro-skills:

• Active listening: the capacity to hear the detail of what the client is saying, how they are saying it and what they are not saying
• Attending: noticing the presentation of the client during the session, such as pauses, hesitations, and other communications
• Empathy: to see the world through the client’s perspective: taking an ‘as if’ position
• Unconditional positive regard: accepting of the individual unconditionally, but not necessarily condoning everything they say or do
• Congruence: the capacity and willingness to be open and honest with the client about how they are being experienced in the session (but not about the therapist’s own thoughts and opinions)
• Summarising: to encapsulate briefly the main and salient points of the client’s narrative
• Paraphrasing: to summarise, often using some of the client’s words, particular aspects or sections of their narrative so they are able to check meaning and inaccuracies
• Challenge: the capacity and willingness to challenge a client’s position or perspective to help the client move from a position of being stuck with something. This can include empathic challenge
• Advanced empathy: taking empathy to the ‘next level’ by connecting with the unspoken meaning of the client’s narrative
• Encouraging strengths: highlighting areas of particular competence or ability
• Highlighting conscious or unconscious interactions/‘edge of awareness’: highlighting aspects of the client’s behaviour, thinking or feeling that might be beyond the client’s immediate knowledge or understanding and bringing it from their edge of awareness into the ‘now’
• Reflection: offering back to the client, in their own words, specific sections of their narrative so they can be encouraged to reflect on meaning and intention
• Exploration: perhaps using questions and other skills, encouraging the client to ask questions from their perspective or narrative
• Non-verbal: eye contact, position, breathing etc. and what they communicate to the client
• Silence: allowing quiet time for reflection, or for the client or therapist to be fully present in the space — can be unsettling for therapists, particularly when new to practice
• Focus: bring particular aspects of the client's narrative or presentation to their attention.

Let us now look at some of these key skills in action, using in each case a short passage of therapy transcript to illustrate them. These are also available in a PowerPoint presentation on the companion website.

Attending

Here the therapist not only reflects back to the client the expression about not knowing how ‘she will react’, but also highlights the client’s pauses and hesitations (which are linked to their concerns).

Empathy

The therapist here introduces the word ‘overwhelming’ to characterise their sense of how this might feel for the client, seeking to understand the situation from the client’s perspective. The client hears this as strongly affirming their experience.

Congruence

The therapist here takes a risk in naming the client’s experience as ‘frustration’, which could easily be experienced by the client as critical. However, by linking it to the possibilities of the client's experience too (‘I wonder if that means anything for your experience?’) the therapist creates an opportunity for the client to explore and clarify their own process a little more. Congruence always needs to concern a dynamic within the relationship, rather than merely the therapist’s own views on life.

Summarising

The therapist offers a summary of the client’s narrative, using in the process non-verbal (paralinguistic) sounds (sighing) and implied meaning (‘I know I sound horrible’) in what the client is saying. The summary includes more than just the words. This helps the client begin to explore a wider issue of self-judgement.

Paraphrasing

The therapist paraphrases the client’s narrative, sometimes using the client’s words and phraseology to do so. This provides the client with an opportunity to reflect on the meaning and implications of what they are saying and to move forward with their exploration.

Challenging

The therapist offers a direct challenge to the client’s position by referring to things they have said previously. This is different to trying to make the client feel better (e.g., I’m sure you can organise things well. I’m sure you can!) which never has any real benefit.

Advanced Empathy

The client tentatively begins to talk about feelings that lead to guilt and shame (‘. . . there’s a part of me. . .’) but find them too hard to express. The therapist picks up on this and, from an empathic position, helps the client begin to name the feelings (“. . . might be a part that feels relief. . .’) and then acknowledges how ‘difficult’ it is to have such feelings. The client hears this ‘permission’ to name the difficult feelings.

Encouraging Strengths

The therapist, using reflective skills, highlights the difficulty of the client’s situation but then encourages the client by referring back to a previous session when they had talked about what the client does to take care of herself. This encourages the client to recall these things and begin to draw some strength from them – this immediately begins to help with a sense of depletion, although those feelings are acknowledged too.

Highlighting Conscious or Unconscious Interactions/ ‘Edge of Awareness’

The client has not made any links himself concerning the arguments he has in relationships. The therapist tentatively offers a link – not in a way that interprets the client’s narrative, but rather as a way of holding similarities together for the client to reflect on them. This has a profound impact on the client, who suddenly begins to make connections.

Reflection

The therapist uses the client’s narrative without adding anything new: they just reflect the words back for the client to hear. This helps the client to make more sense of their experience and move forward, in this instance to a sense of being ‘smothered’ by their hopelessness.

Exploration

While the exploration here doesn’t lead to any new insight or resolution, it does provide the client with an opportunity to be more specific about how they feel about their body. This extra detail may be important for the client and therapist to use in subsequent sessions.

Focusing

The client names an important area of concern and then becomes distracted by the thought of living in the city. It would be easy here for the therapist to follow that line and miss the issue about the job. Here, however, the therapist focuses the client, which helps the client be more specific about what it is they find difficult. The issues of moving may return in subsequent sessions.

Summary

The above passages demonstrate generic micro-skills in action. While some might appear to overlap a little (and they probably do, as in the case of summarising and paraphrasing), there are subtle differences. However, their common intention is to facilitate the client’s self-exploration. They require practice and sometimes they won’t work. Knowing how best to make use of these skills can also be challenging. Over-using particular skills can be unhelpful as this can undermine the emotional potency. I have given examples elsewhere (Reeves, 2010a) of an overuse of reflective skills with suicidal clients, where there can be a need for explorative skills to help the client consider their experiences in more detail.

These generic sills can be rendered unhelpful and meaningless if used without compassion, integrity and warmth. Imagine any of the therapist statements above if delivered coldly or without feeling: their intention would be lost and the client is likely to feel, at best, untouched and, at worst, misheard and misunderstood. Fundamentally these micro-skills help the therapist communicate their understanding of, and connection with, the client. In these circumstances, with a therapist demonstrating the personal qualities already outlined, the therapeutic relationship can be profoundly powerful in helping the client to move away from a position of despair or hopelessness.