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Counselling and psychotherapy

Counselling and psychotherapy have been used as a panacea for all psychological problems, and there is a justification for doing so. Coming into contact with caring and genuine human beings who have received special training and have worked through their own inner stresses and mental conflict can be helpful. Unfortunately there are so many who need psychotherapy and very few who can deliver the goods or are honest enough to admit to their clients that they can not help. This creates a situation where the demand outstrips the supply. As a result many who can benefit from psychotherapy go without it.This problem can be solved only when psychotherapeutic principles move beyond the confines of professional settings and into mainstream life.

Formal versus informal forms of psychotherapy

Advice from a wise person, or careful listening from a friend, can bring about the same sort of results as formal psychotherapy but there are differences between the two. In this section two of us, who are experienced psychotherapists, will offer you some guidelines to help you decide whether formal psychotherapy is the right thing for you, or whether you would prefer to tackle your problems on your own using some of the stress management techniques described in other parts of this website, or whether you would prefer the informal psychotherapy that is involved in friendship or counselling relationships with peers.

Research done in recent years on debriefing (narrating traumatic experiences to a professional colleague after going through a stressful and traumatic experience) supports the observation that formal psychotherapy can be both helpful and harmful. It seems that debriefing helps those who are able to process the negative experiences at their own pace and in a secure setting, but makes things worse for those who can not manage the anxiety involved in relating the painful experience. If you belong to the second category you need to discuss issues of safety and timing with your therapist, so that together you can modify the therapeutic relationship and setting.

Clients are well advised to take full responsibility for making use of the space in therapy by being active and bringing issues for discussion. What is in the unconscious will gradually come to the surface of the mind and get worked on. Sometimes clients discover new elements in their thinking for the first time when they are narrating their problems to the therapist. It's very much like thinking about your problems before going to bed so that your unconscious dreaming mind can act on them whilst you are still asleep. For many people this is a naturally occurring healing process, but for others their dreams will take the form of disturbing nightmares.Those of us who can dream happily probably do not need professional or formal psychotherapy.Those of us who are suffering from nightmares and flashbacks might do better to call in some additional help in the form of psychotherapy.

What Heals in Psychotherapy?

Several years ago I asked my teacher this question and his prompt reply was - a relationship. I wasn't fully satisfied with this answer as I wanted to know what was in a therapeutic relationship that was not there in other relationships i.e. with our spouse, relatives, friends or teachers. I asked for further clarification and his answer was - through the therapeutic relationship you are brought closer to something called "reality". So it was about understanding "reality" in a more complete fashion which is normally beyond us. It has something to do with getting honest and open feedback in a secure setting where feedback is a two-way process that is welcomed by the therapist as well as by the patient. Our friends and family can offer feedback which will put us in touch with this "reality"; but their opinions are likely to be biased and may not have the same impact. Our friends are probably too kind to us and want to portray our weaknesses in a positive light. Our parents may have the need to maintain that they were good parents and the difficulties we feel we faced as children are somehow imaginary. This is an understandable thing given that for most of us quite a bit of our self-esteem is bound up with the idea of ourselves as caring loving parents.

Therapy is an opportunity to get a less biased opinion on one's life situations. In essence all psychotherapy can do is tell you what it's like for someone to be in a relationship with you and you should feel free to evaluate this feedback. Psychotherapists like parents will have their own prejudices and these may include wanting to portray themselves as therapists in a good light. However, a well-trained psychotherapist should be aware of these prejudices and should be able to talk to you about difficult aspects of the helping relationship including ways in which you may feel distressed by the psychotherapy at times. Be wary of therapists who are not open to your comments about doubts or difficulties you are having early on with the psychotherapy process! However a well conducted psychotherapy will give you the opportunity to look at past unresolved issues in a more objective way, informed by modern understanding of child development.

Another way of describing this involves talking about early attachments to our parents or first caretakers. About two thirds of us make secure bonds with our parents.These are relationships where we feel our parents love and understand us. For this to happen our parents need to have been in a position where they can give most of their attention to looking after us as children. For about a third of us this situation did not occur and we never felt securely bonded to our parents.This insecure attachment gives rise to problems later on in life. Many people without secure attachments feel they cannot trust other people in relationships. As a result of this, they also feel they cannot trust themselves and they suffer from low self-esteem, anxiety and depression. Children who are securely attached to their parents feel confident about leaving them behind and going out into the world to explore new environments and new relationships. Children who are insecurely attached tend either to cling to their parents in an anxious way or pretend that relationships don't matter at all and become dependent upon things such as food or objects. Such people often go on in adult life to become addicted to drugs, alcohol or repetitive behaviors such as cutting or overdosing when they are in emotional distress. They find it hard to turn to other people as a source of comfort, as quite naturally they have learnt to distrust people. It is possible in psychotherapy to enter into a relationship with the therapist where some of these difficulties can be relived. By talking about the relationship you have with your therapist openly, you can explore the specific ways in which you feel misunderstood and the specific problems you have in trusting other people. Insights into these difficulties can be very helpful, and can help you go on to work out different patterns with people you are close to in your current life. A good, if rather lengthy, account of how early attachments operate and continue to influence people in later life is given by John Bowlby in his three volumes entitled Separation, Loss and Attachment.

The following mechanisms can explain how psychotherapy works

So far we have talked about gaining insight into insecure attachments, which may offer insights about current dysfunctional patterns of relationships. However people may be suffering because of difficulties with relationships they have with themselves and this often comes out in the form of symptoms like anxiety, depression or compulsive patterns of behaviour. In addition, it is important to realise that insight alone will not be curative and you will need to try out new ways of relating to yourself and other people and new ways of tackling problems in the real world. The following points explain the mechanisms that underlie the psychotherapeutic change process:

Getting connected with the inner distress

It is a normal tendency to avoid discomfort and seek pleasure. Unfortunately both these attitudes can affect our ability to deal with stress adversely.There are inner natural healing mechanisms that operate all the time.These mechanisms get accelerated when we come in contact with stress, very much like the release of pain relieving chemicals (endorphins) when we experience bodily pain. A similar mechanism operates for the mind as well. Becoming aware of the inner distress activates certain homeostatic mechanisms that undo stress. The secret here is to allow yourself to experience distress without reacting to it using your familiar patterns such as avoidance, activity or being dependent on substances or unhealthy relationships.

Reprocessing of old emotionally charged experiences

Psychotherapy offers an opportunity to revisit some of the unresolved issues from the past and understand them differently. Clients learn to reactivate these past experiences and relive them. Whilst reliving they try to understand these experiences differently thereby neutralising their emotional charge. As a result clients are potentially freed from the restricting influences of these past experiences, because they have the opportunity to choose new ways of reacting to them.

Moving closer to reality

Psychotherapy enables us to look through our own defensive mechanisms (ways of distorting reality so that it becomes more acceptable to us). Defence mechanisms play an important role in coping with our daily stresses but they need to be worked on if they result in psychological symptoms or impair our psychological functioning.

Changing attitudes and behaviours

Insight alone is not going to be sufficient if you're looking for solutions to real life problems, although it may produce improvements in your symptoms and how you feel about yourself. To improve your situation in the world you will need to have the courage to face up to aspects of your behaviour which need to change. Cognitive behavioural therapy is particularly good at helping you examine new strategies for coping with problems such as loneliness, phobias, addictions, anxieties, depressive thoughts, obsessions and compulsions. For some people this means acquiring skills which they never had before and there is evidence that modelling behaviours using skilled role models such as friends or therapists may be the best way to acquire the skills. For others it is more a question of letting go of old patterns, so that they can put into place skills which already exist but are not being utilised. If you feel you have to acquire completely new skills you may be well advised to choose a psychotherapy that offers access to some behavioural modelling and remember that it may take you a bit longer to acquire new skills.Interpersonal skills such as learning how to listen to others and empathise with them are perhaps some of the most advanced human skills and take the longest to acquire.

Letting go of unrealistic goals and desires

Stress results when there is a big gap between our perception of where we are and where we should be.This gap can become bigger either because of a very low perception of self or very high inner standards of achievements.Psychotherapy can offer opportunity to individuals to evaluate their abilities and readjust life goals to a more realistic level.
The evidence from psychotherapy outcome research suggests that all of the commonly practised brands of psychotherapy are equally effective. This means, that rather surprisingly, it may not matter too much which type of therapy you are offered. We include a list of the commonly practised therapies below.The important thing is for you to under go an experience that includes developing a trusting relationship, tackling the feared problems and trying out new ways of coping with it.It is probably wise to ensure that your therapist has adequate training and supervision and practices under are cognised code of ethics which includes a complaints procedure should things go wrong.

The essential ingredients of therapy

• A safe, warm, trusting relationship with a therapist whom you feel understands you.

• Undoing avoidance: this means tackling emotionally painful experiences which you remain preoccupied with and which are currently causing you distress.This requires courage and determination. It is not necessary to bring up every unhappy topic in your past life.Things you have successfully forgotten or come to terms with can be left alone.

• Understanding things differently: understanding what lies behind your symptoms.Insight may not be essential but it is often helpful.

• Trying out new ways of coping. Until you try out new forms of behaviour you cannot predict whether they make you feel better or worse.It takes courage to change and you will probably need to evaluate with your therapist whether the change is going in the right direction for you.Ultimately you are the best person to decide this for yourself.

Different types of psychotherapies currently on offer in the NHS

• Cognitive behavioural therapy: e.g. Beck's cognitive therapy for depression or rational emotive behavioural therapy (REBT)

• Psychoanalysis/psychodynamic: e.g. Freudian or Jungian psychoanalysis.

• Interpersonal therapy: e.g. Klerman and Weissmans interpersonal therapy for depression.

• Supportive psychotherapy e.g. counselling using a humanistic approach, also called Rogerian or client centred counselling

• Integrative therapy e.g. Cognitive Analytic Therapy (CAT).

• Existential therapy e.g. Yalom's group therapy, logotherapy, daseinsanalysis

• Other therapies which have research-based evidence of effectiveness include Gestalt therapy, art therapy, music therapy, psychodrama, neurolinguistic programming, (NLP), systemic and family therapy, couples therapy, and pure behaviour therapy.
Most forms of psychotherapy can be carried out either in individual or group settings.People may be seen weekly fortnightly monthly or even less.Most of the improvement from psychotherapy takes place in the first few sessions and if you have not benefited from psychotherapy after about 20 sessions or one years duration in therapy you are probably aren't likely to do so.This word of caution may help you avoid the trap of becoming a stuck in a long-term form of therapy which is expensive and which is not producing change.
The authors of this section are Dr. Mark Pearson, consultant psychiatrist in psychotherapy, and Dr Kishore Chandiramani, consultant psychiatrist. We have both practised formal psychotherapy within the NHS in Britain for over 10 years.