by Maeve Dooley
Does psychotherapy = counselling?
The much-debated question of the difference between counselling and psychotherapy has come under the spotlight recently. With the impending possibility of Statutory Registration the question has arisen, surprising many of us, as to whether they will be treated as a single profession or as two separate professions. Enquiring further, I came across a recently released document outlining a viewpoint that there is no difference between the practices of counselling and psychotherapy, no proficiency difference, and that both professions should be regulated with the same baseline qualifications for practice (Irish Association for Counselling and Psychotherapy, 2013). Further to this was an article in the Summer 2014 edition of Inside Out (Boyne, 2014a) pointing out some concerns for psychotherapy and the protections of standards should such a viewpoint prevail.
This has stirred some energy into the cauldron of vagueness that has indeed seemed to surround how counselling and psychotherapy are defined. Is there now a real possibility that counselling and psychotherapy might be blended into some kind of soupy mix? How do we (IAHIP) meet the challenge now posed by the viewpoint that regards psychotherapy and counselling as the same? There is, I believe, a clear need to distil the essence of each of the professions out from this apparent ‘gloop’ of interchangeability and blurred understanding. Dr. Bill Shannon, a former President of the Irish College of General Practitioners, in the Spring 2014 edition of Inside Out described how, the “psychotherapy profession must establish itself enough to be taken seriously…” and cease “… to be a kind of Cinderella profession” (Boyne, 2014b: 8).
Having completed a professional training in counselling and psychotherapy in the mid-1990s, I began in practice using the professional title of ‘counsellor’. I used this term as it seemed to be the most familiar professional term at the time and also because I sensed that psychotherapy, as a depth-orientated developmental process, required further exploration and integration to have due integrity in practice. My first supervisor was a Jungian psychotherapist and this ignited my interest in the deeper meaning inherent through the Jungian therapeutic lens. Through my own continuing therapeutic process and other experiential work, I deepened my insight into unconscious process and only then felt a competency to expand the definition of my work to include psychotherapy. I have since specialised in Jungian sandplay, becoming a registered member of the International Society for Sandplay Therapy. My language and perspective is largely framed by my Jungian specialisation which I hope is not overused here and translates across other psychotherapeutic approaches.
Difficulties in defining ‘psychotherapy’
Having used both terms in my professional practice, I have on many occasions sought exacting definitions for both counselling and psychotherapy. The proliferation of the dual professional identity of counsellor/psychotherapist, with practitioners emerging from a myriad of schools and approaches, has created confusion and difficulty in defining specific differences, beyond what has been a generalised understanding. This somewhat nebulous understanding describes psychotherapy as a longer-term and a more deeply engaging process, while counselling is described as a process that is generally shorter in duration and primarily issue-focused.
One of the difficulties in arriving at a clear definition of ‘psychotherapy’ is that the word itself has a very broad meaning and is therefore open to wide and varying interpretation. The basic origins of the word are ‘psyche’, meaning soul, mind or spirit, while ‘therapy’ translates as healing, cure or remedy. Therefore, in effect, any activity that remedies, cures or heals the soul, mind or spirit can perhaps describe itself as ‘psychotherapy’. This makes it very difficult for us as psychotherapists in an IAHIP context to protect our professional definition of the term ‘psychotherapy’ and so possibilities from broader interpretations can lead to confusion and blurring of the professional practice. While we (IAHIP) hold a clear definition of psychotherapy and fasten down our requirements and restrictions for professional practice, we cannot prohibit or negate other interpretations. This means, in effect, that those who hold the view that there is no difference between counselling and psychotherapy may be able to show some validity to this. Counselling may well provide such a healing or remedy experience and therefore lay claim to being psychotherapeutic. However, this is not the same as saying that counselling, a word derived from ‘counsel’ which is defined to mean advice, opinion or instruction (http://dictionary.reference.com /browse/counselling), is the same as psychotherapy, as professionally defined.
For the purposes of this article I will use the term ‘psychotherapy’ to refer to the definition supported by the IAHIP as described on the Irish Council for Psychotherapy (ICP) website. Humanistic and Integrative psychotherapy:
…invites people to develop awareness as to what may be preventing them from accessing their own true nature in the inner and outer expressions of their life. It is aimed at the person as a whole: body, feelings, mind and psyche. It invites people through the therapeutic relationship to develop awareness and insight leading to an integration of the internal and external self. It explores each person’s own resources and capacity for self- determination and ability to improve their lives.
This definition clearly illustrates that psychotherapy is primarily a developmentally-focused process, which is intrinsically different from what I describe in this article as the issue-focused process of counselling.
I came across a recent description from a psychologist familiar with the practices of counselling and psychotherapy, saying how she had explained her understanding of the difference to a colleague. She used an analogy, familiar to many, of doing home renovations. Elaborating somewhat, she described that counselling would be like getting in the painters and decorators, while psychotherapy would be like getting in the builders. This is an analogy that offers a lot of scope for amplification and debate. For my purpose here it illustrates clearly that while both professions can be seen to have a role in the same space, they nonetheless have a significantly different focus, impact and outcome.
So how are counselling and psychotherapy actually different?
Counselling and psychotherapy are both relational processes. In addition they are closely aligned within the broader group of ‘helping’ professions. Indeed it is understandable that for those unfamiliar with the inherent differences, they can appear from their similar settings to be the same. The relationship between client and therapist is fundamental and central to both disciplines, however it is the focus of the work within that setting that is intrinsically different. In this article I am going to illustrate this through two primary aspects that define this difference. The first aspect relates to how each profession views psychological disturbance/issues and the second looks at key differences in relation to the place and use of boundaries in the practices.
Difference in addressing disturbances/issues
One of the defining aspects of psychotherapy is that it offers a place where people can safely focus on exploring their deeper developmental needs and difficulties. It is a process that takes place when a psychotherapist, with their specialised skilful awareness, works with a client in exploring disturbances (which may arise through presenting issues), drawing attention to aspects of conscious and unconscious experience. I use the word ‘disturbance’ here to refer to a kind of noticeable experience that can seep through the dynamics or symptoms of the client’s presenting concerns. Such disturbances often become ‘visible’ through the therapist’s relational experience with clients, including transference and counter-transference possibilities.
Counselling as a similar ‘relational’ therapy also has an impact on internal development, as indeed do other relationally-based helping initiatives and intimacies. It is the focus and understanding however, that defines the difference here. While both counselling and psychotherapy generally begin from a presenting issue or concern as described by the client, they part company soon after. The counselling process moves forward by focusing on the client’s presenting issues/concerns and working towards their resolution. The approach here is to explore with an emphasis towards resolving the disturbance. Counselling, therefore, can be said to focus primarily on helping the client to re-establish equilibrium and a return to an experience of well- being. Psychotherapy however works differently, slowing down to take detailed notice of the disturbance, heightening attention and interest there and moving to amplify and explore the possible unconscious dynamics within the experience. In psychotherapy such disturbances are explored as possible entry points into the client’s unconscious need, through which as yet unmet developmental aspects may be worked with. Such entry points present a type of portal or opportunity for deeper developmental exploration and growth and access to a greater sense of self, which is a primary and deeply-rooted human urge.
Resolving an issue in a focused way through counselling can be therapeutic, effective and a very satisfying experience. Psychotherapy, with its developmental focus, can support individuals to discover more about their own innate identity, gaining a more complete sense of self which can also be therapeutic, effective and a very enlightening experience. For psychotherapy, calling in the builders is a commitment to possible upheaval and distress as the ‘structure’ generally has to be taken apart, to allow the creation of the sought-after individualised design to take shape. For counselling, the surrounding structure is felt to work well but there is a difficulty with overt aspects and focusing on redressing them may be the most effective and appropriate approach. Psychotherapy and counselling can therefore be seen here to be very different practices within the same space.
Difference in the place of boundary holding
The ‘firm but kind’ holding of boundaries and the meaning attributed to them is considered to be a pillarstone of psychotherapy and something that also differentiates it from counselling. Boundary holding and issues that may interrupt it are explored in the psychotherapeutic process and considered intrinsic to its efficacy. The counselling process, on the other hand, views boundaries from a practical and purposeful perspective, with their emphasis centered mainly on the overt safety of the work. Within counselling more space may be allowed for negotiating and setting boundaries around the conscious needs, external interruptions and the wishes of the client. In this setting it is the focus on the presenting issue that may set the requirements, pace and length of therapy. Counselling as a process draws from its detailed attention to the myriad aspects which are gleaned largely through conscious experience. As such, the need to address boundary issues does not necessarily require significant attention beyond the conscious aspects, which include the clear holding of ethical standards, confidentiality and provision of a safe space.
Returning to the building analogy above it could be said that psychotherapy views boundary creation as a ‘foundation footprint’ (the concrete platform upon which a structure is built) for the process. This largely disappears from sight as the building rises while it nonetheless remains in place, supporting the weight and protecting it from any underlying destructive forces. In the context of psychotherapy, boundaries also answer the conundrum of providing ‘open containment’. They support the work of open exploration of unconscious process, while containing this against the pulls of the ego (conscious), including the wish to remain within the familiar (and in this respect there are two vulnerable human beings in the room). If boundaries are too easily moved and changed, then the psychotherapeutic process is without reliable enough support for its work with unconscious process and unmet developmental need. Left unquestioned, flexible changes in boundaries will likely mean that unconscious possibility will be lost in this loosened holding. Requests from clients to take a break, finish, meet less frequently, arriving late to sessions, payment issues, cancelling/rescheduling, etc., are seen in the context of psychotherapy to hold possible underlying meaning and unconscious expression. The psychotherapist takes time to explore possibilities and attunes to possible transference/countertransference issues therein. While undoubtedly there are realities to these types of requests, it is also incumbent upon the psychotherapist in their understanding of suffering, and its place in the developmental process, not to unquestioningly collude. It is more deeply therapeutic, when appropriate, to look at how difficult, frightening and undermining it can be to look at one’s true experience, and the sacrifices that this can mean. The psychotherapist does this, holds support for the unconscious awakening and acknowledges the developmental opportunity for the client, but it is the client’s choice whether they wish to pursue this or not.
Exploring the deeper meanings that arise through boundaries and their ‘breaches’ has frequently been misunderstood. It has at times been seen as an aspect of psychotherapy that is ‘rule-based’ and ‘punitive’ and only relevant to pure analytical-style processes. It is likely, however, that a therapist’s understanding of boundaries and their place in the psychotherapeutic process will largely depend on their own experience of deep therapeutic containment. The familiar adage quoted by therapists that ‘you can only take a client as far as you have gone yourself’ could be added to with ‘…and you can only offer a client the containment that you have experienced yourself’. Boundary holding based on ‘rules’ is difficult and can be experienced as harsh and cold by clients. However, boundary holding based on a fundamental understanding of, and a respect for, unconscious process can be experienced as providing the essential ‘safe and reliable support’ for depth processing. Boundary holding in psychotherapy is not easy and often brings the therapist and client into some form of suffering, which is indeed usually a very difficult part of our work.
Psychotherapy: a specific discipline
In both of the aspects highlighted above, I have made a number of references to unconscious process as being a central focus for psychotherapy. ‘The unconscious’ is a much-used term and frequently referred to by psychotherapists. This contrasts somewhat with the reality of the very complex and difficult-to-comprehend entity that we call ‘the unconscious’. Our conscious experience struggles to grasp it and gains mere glimpses in focused moments. Our human urge seeks to know what exists there while we also fear its contents, a primary dilemma often expressed by clients in psychotherapy through various forms of hesitation and comments related to uncertainty around continuing.
Once unconscious contents emerge into consciousness they must be met and managed somehow. Such emerging contents do not decipher between right and wrong, good and bad, or indeed between therapist and client. Support in this process requires very skilled and delicate holding and a response that will have minimal intrusion from the therapist’s own inner anxiety, fear and defensive responses. These contents need to be supportively and safely processed in the context of the client’s world, then later by the therapist in supervision, and separately, as appropriate, by the therapist in their own therapeutic process. Psychotherapy is very difficult in practice. It is difficult to hold the containment in its idealised essence, as the therapist is also a vulnerable, struggling human being and mistakes and failures in practice are inevitable. It is the willingness and available support to acknowledge and address these that is crucial for the well-being of the client, therapist and the practice of psychotherapy. Any lessening of requirements would weaken the necessary process supports and result in a dilution and a possible defeat for our definition of ‘psychotherapy’. Practising psychotherapists are encouraged to continue with their own exploration of unconscious material and developmental issues. It is only in this way that we can truly experience in ourselves the ego-suffering that must be worked through in order to come into true connection with a core sense of self. This is at the heart of our definition of the psychotherapeutic process. It is the nurturing of this heart that is behind the request for 250 hours minimum of personal psychotherapy as a requirement to become a member of the IAHIP (Bye Law 11, clause 3.3). While it must be noted that quantity of hours is no guarantee of quality of therapeutic experience, it is a strong indicator of what is needed. Indeed, practitioners have argued, and understandably so, that personal therapeutic process should be put at the top of our CPD requirements (O’Halloran, 2010). In contrast with this, it is possible for people to get professional recognition to practice psychotherapy with a minimum of 50 hours’ personal process work. Given what is required in the actual practice of psychotherapy as I describe it, this would be very unlikely to provide the therapist with the level of support and depth of understanding to hold and contain the dynamics of this psychotherapeutic process.
I recently came across a newspaper article about someone who described herself as a ‘psychotherapist’ and indeed had attended a well- known training institute included on the IAHIP’s list, also achieving a Master’s level qualification. The article was focused on the work of a voluntary organisation offering counselling. Despite describing herself as a ‘psychotherapist’, the individual referred to her work as counselling and spoke in the language of counselling, primarily focusing on conscious experience and solving issues to create a resolution. While the work sounded effective and helpful with positive outcomes, it was not psychotherapy in an IAHIP context. It could be asked here, how seriously do we take our definition of psychotherapy? Has it been allowed to become some sort of counselling/psychotherapy blend?
The Peter Weir film, The Truman Show, (1998) depicts how a man, unaware of a world beyond the one he knew, contentedly assumed the limited one he was in was the complete world. The film illustrates how difficult it can be to get beyond the known and assumed reality and scripted answers. Those who view the disciplines of counselling and psychotherapy as distinctly different may soon find themselves in a ‘Galileo-like’ experience should the prevailing view regard them as the same. Is psychotherapy to be subject then to a type of ‘Roman Inquisition’, perhaps born of a naivety that does not as yet grasp the intricate depths of the inner world? Perhaps some people see no need for the depth work I describe, however for those who do, negating it is not acceptable. The distress and upheaval caused by the appearance of a reality that challenges existing structures, desires and perceptions is ironically familiar to those of us who have engaged in deep therapeutic process. As psychotherapists we respect and know that it is no easy task to accept such realities and the consequences of the changes that they may bring about. However, and at risk of overstating but with the intention of absolute clarity, we as psychotherapists do need to assert that the practice of psychotherapy must not by dilution or blurring slip from its essence to become “an overwhelming failure or frustration…or even a vague sense of an unlived life” (borrowing from ICP’s description of challenges in the move towards wholeness, 2014b).
Maeve Dooley B.A (Psych), Dip. Counselling and Psychotherapy, Dip. Supervision, MIAHIP, ICP, BISS, ISST, SIAHIP is a practising Psychotherapist, Jungian Sandplay therapist and Supervisor based in Drogheda, Co. Louth. Email: email@example.com. Web: www.focuspsychotherapy.ie
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