Comparative Models of Counselling
A report that reflects on Person Centred Therapy and considers how this model could be incorporated alongside the core model of Cognitive Behavioural Therapy in my current Counselling Practice. I reflected on Person-centred Therapy (PCT) as the comparative model because of the conflict that exists between this and Cognitive Behavioural Therapy (CBT). The conflict is historical, political and from personal experience.
In therapy twenty years ago I became frustrated with my counsellor’s person-centred approach. I challenged my counsellor to provide me with more support and help.
I therefore had preconceived ideas of PCT which may be similar to stereotypical thinking of these models. It was excessively warm, completely non-directive and only reflected back to the client, which I found frustrating. I understand now it was because my coping style was externalised and I had no control over external events, which suited a more direct counselling approach. So, how would this influence my practice as a counsellor? In theoretical terms and in observed practice I appreciated the benefits of PCT for its empathetic understanding and for clients who require a non-directive approach to gain emotional awareness.
Presenting issues that can be helped by PTS are bereavement, drug and alcohol issues, depression, panic and anxiety, eating difficulties, self-harm, childhood sexual abuse (Tolan and Wilkins, 2012). I have used the model affectively for bereavement and sexual abuse as an offer of a direction would have been inappropriate and incongruent at the time. My preconceptions of CBT were solution focused, challenging and that low intensity based interventions ignore the client’s past. I feel competent in using certain behavioural intervention in my practice and challenge maladaptive thinking patterns in sessions.
CBT is a medical model and although we have been taught the disadvantages to diagnoses, CBT is seen as the treatment of choice for many presenting problems due to the amount of empirical evidence available. These are anxiety disorders, panic, phobias, obsessive-compulsive disorder, PTSD, bulimia and depression as identified by NICE (NICE, 2008, Accessed online 27/06/201). This report reflects on the appropriate use of the models. Stereotypes have some element of truth, but at the same time, are not the truths. I wanted to understand the similarities and parallels while respecting the fact that, in practise, I use both models.
I didn’t want to do a bit of each badly, but use a model in full at the appropriate time and understand my reason for doing so (Casemore, and Tudway, 2012). Both PCT and CBT are deeply rooted in the same philosophical underpinning of humanism, existentialism, and both are phenomenology particularly to the nature of suffering. However, there are differences in the understanding and interpretation of the philosophy. Both approaches view a person as continually seeking growth and self-actualisation. There are incompatible beliefs between the models. (Casemore, and Tudway, 2012).
PCT observes that seeking growth and self-actualisation is a way of being and in itself therapeutic. Rogers’ professed that there were six necessary conditions for therapeutic growth that alone were sufficient to lead to a fully functioning person. The individual is the own expert who can determine their own journey of their reality and can heal themselves with the core, being the relationship itself. The structure of the self includes self-concept and introjected beliefs. PCT communicates acceptance of the client’s own experience and encourages then to identify alternate choices.
It is a continual journey of self-awareness and knowledge, with the drive always towards growth (Mearns & Thorne, 2012). CBT views growth and self-actualisation as a shared goal of therapy to be reached with a set of tools, to be implemented in therapy. CBT’s view comes from Ellis who defines a person as irrational and rational. In CBT terms ‘dysfunctional beliefs’ are similar to ‘introjected beliefs’ and led to distortion in the self-concept. The irrational cause’s distress and rational directs the individual to fully functioning. CBT primary belief is self distortion and the process of cognitive dissonance.
Interventions such as the ABCDE framework are used to challenge and dispute irrational thinking and are aimed at increasing client’s self-awareness and self-understanding. CBT sees the relationship as more collaborative and facilitates new learning. An individual’s construct of reality is dimensional and irrationality stops the client from changing. Therefore, a person’s drive is not always towards growth (Casemore, and Tudway, 2012). A similarity of both approaches is the understanding of self-worth and unconditional self-acceptance. The nature of suffering is seen the same. Humans are flawed, imperfect and we cause our own disturbance.
Both see the client as the expert in the relationship. Authenticity is of great importance to both PCT and CBT as is the therapeutic relationship. It is the emphasis on the process of change, to become oneself, where the differences in two models lie (Castonguay, & Hill, 2012). From a PCT perspective a client discovers some hidden aspect of them self that they weren’t aware of previously and moves towards a greater degree of acceptance of self by being prized by the therapist (unconditional positive regard), have a sense of realness (genuineness) and listen to them self (empathy).
A client moves towards seeing new meaning. These changes are characteristic of therapeutic movement. The client moves along a continuum from rigid structure to flow which can be seen in the seven stages of therapeutic change. Rogers’ term was ‘organismic experiencing’ which was interpersonal in the therapeutic relationship through unconditional positive regard and intrapersonal within the client accepting a new experience into their awareness (Castonguay, & Hill, 2012). In PCT, the process of change there are different corrective experiences for a client.
For me practising with a client group from a women’s refuge I use PCT and Rogers’ condition-of-worth. The incongruence between the self-concept and authentic self is evident due to the abuse. This creation of a false self is corrected with unconditional positive regard, empathy and genuineness. Process Theory is where, change in the experience of feelings and the recognition that the client is the creator of their own construct occurs. The therapeutic change has a developmental sequence.
There is a change in the client’s manner of experiencing feelings and recognition of being the creator of their own constructs, accepting responsibility and in relating to others openly and freely. This is compatible with the condition of worth. A person moves with acceptance to a fully functioning person. The person’s overall ‘way of being’ is changed. Relating to a congruent therapist, the client learns to be open and congruent themselves (Castonguay, & Hill, 2012). Unblocking or Focusing is where the self-correcting, self-healing process of the organism is blocked.
The person can’t refer inwardly, focus on feelings or articulate meaning. They have a rigid self-concept. Empathic listening within the therapeutic relationship opens the issue to re-examination and unblocks the person self-healing process. There is an interaction between the feeling and the attention the client brings to create a new meaning. This is Gendlin’s felt sense, an unexpected feeling of flow. The client becomes an active self-healer who has been felt heard and understood (Castonguay, & Hill, 2012).
In practice building ‘Meaning Bridges’ – new understanding which identifying introjects imposed by others who imposed external systems of value has been paramount because of the external pressure that have be imposed through a close relationship. Internal opposing voices can be accepted, examined and resolved through compromise and collaborative solution. Until now, I saw this as CBT but can now see this as PCT with Rogers’s necessary and sufficient conditions of therapeutic change all that is needed for the process of change and this change occurs without engaging in cognitive process, but in the moment (Castonguay, & Hill, 2012).
I am able to draw personal parallels from watching Rogers’ session with Gloria. Gloria wanted an answer from Rogers. In the session she found it for herself, even though she actively interpreted that he had helped her to the decision; even though he hadn’t. She makes the decision of honesty for herself. Although non-directive, Rogers’s session had a focused, this was of self-healing and self-direction. Refuting the belief that the person-centred way is only to reflect back to the client. The warmth from the counsellor is also part of the process of condition of worth.
This helps me challenge my preconceived ideas and understand what is happening in practice. In practise, I am aware from a CBT perspective the therapeutic approach can teach clients new skills. The therapist is regarded as more of a coach. The client benefits from new skills and perspectives which facilitate the learning and have a sense of efficacy. I have used CBT to look at specific problem behaviours and conceptualise them as having cognitive, affective, behavioural and physiological elements each of which can have a legitimate target for intervention and can be check for validity (Castonguay, & Hill, 2012).
The process of change occurs in practice as old ways are challenged through exposure exercise, behavioural experiments and cognitive restructuring techniques. Change occurs in the therapeutic setting or outside in a person everyday life. It may require repetition to produce a lasting effect and reduce maladapted patterns. This is where CBT and PCT are similar as this requires a strong therapeutic alliance, but CBT literature takes this as a given and may be a reason it is criticised. Clients are taught emotional regulation and basic functioning skills, such as problem-solving skills, breathing relaxation and active coping.
Specific interventions are then used to motivate and foster the therapeutic relationship, such as cost benefit analysis, daily thought records, and in vivo exposure. Aligning client’s goals with interventions in a formulation develops the therapeutic alliance and collaborates with the client, with hypothesis-testing strategies used to undergo the process of change [Casemore, and Tudway, 2012). CBT is focused on corrective experiences and facilitates through interventions rather than challenging a client.
It respects the importance of the therapeutic relationship and uses Rogers’ core conditions but does not see the conditions as sufficient. In-depth schema focused CBT takes the therapy to a deeper level and deals with past issues, than the low intensity offered by the NHS. Again my preconceptions are challenged for the benefit of my practice. I can see how the two models are not rivals, as Roger Casemore and Jeremy Tudway suggest in their book Person-centred Therapy and CBT, and that sibling as a metaphor works well (Casemore, and Tudway, 2012).
For me, the therapeutic relationship and the advanced empathy required in PCT are important in my practise along with the core conditions in order to create change. Rogers’ believes interventions as wrong, from a philosophical point of view, as the client always having to lead the therapy. This is because Rogers sees a person as having limitless potential. For me, CBT in offering intervention and gentle coaching helps a client on their journey to self-healing and a seed can be planted and therapeutic change can happen outside the counselling session.
I support the views not all humans have the same drive and there is an unconscious element to being rational or irrational. It is a more real idea and not as optimistic as Rogers. It is observation of this therapeutic change and this idea that supports the use of CBT in my practise (Casemore, and Tudway, 2012). The BACP ethical framework has been written with Rogers’ core conditions in mind. Therefore, PCT offers the client and the therapist the need to fulfil the principles of self-care, of being trustworthy and providing autonomy.
As to the personal moral qualities the PCT requires the therapist to have advanced empathy. CBT has been criticised for focusing too much on the intervention and not being of beneficence. In CBT extra competence in the implementation of the intervention is required, so the criticism of the technique becoming the therapy cannot be applied . In writing this report and in my practise, I feel the difference are enough not to combine the models, but that each model can go into the same toolkit and used separately in the same session with a client.
With the collaborative element in mind and further reading I am interested in the approach by Mick Cooper and John McLeod. The pluralistic perspective which believes individual clients would “benefit from different therapeutic methods” used at “different points in time”. Therapist would “work collaboratively” with clients. “Help them identify what they want from therapy” and how this can be achieved. It leaves the question of the process of therapy integration in practice open for debate. (Cooper, and McLeod, 2010, Assessed Online26/06/13).