1. Reaching more people than ever before
Fifty-four per cent of people say that they, a family member, friend or work colleague have consulted a counsellor or psychotherapist, according to BACP’s 2014 'Attitudes to Counselling and Psychotherapy' survey. Forty-one per cent say they would seek help from a counsellor for depression, anxiety or workplace stress. ‘When I started off as a mental health social worker, therapy was seen as a sideline rather than core treatment, but then a significant shift happened, where talking to people and the value of the work we do in terms of people’s mental health was acknowledged,’ says BACP Chair Dr Andrew Reeves. ‘Lots of people have worked really hard for a long time to push the value and importance of psychological therapies in their broadest form.’
Counselling was the most-used psychological intervention for people experiencing depression (7.7%), according to NHS Digital’s 2014 data, followed by psychotherapy (7.2%) and CBT (5.6%). ‘More people know what counselling is today; it’s become part of our common parlance,’ says Lynne Gabriel, Professor of Counselling and Mental Health at York St John University. ‘It’s seen as a more accessible and less medicalised intervention.’
The expansion of school counselling in particular is one achievement we should be proud of, believes Professor Mick Cooper, at the University of Roehampton. According to the recent Department for Education Supporting Mental Health in Schools and Colleges’ survey, counselling is, along with educational psychology, the most common support provided in schools (61%). ‘The reach and impact of counselling in schools that has developed over the last 40 years is providing children with a space to talk through their issues and to feel supported. The research suggests that young people and schools really like counselling, and it works,’ he says.
2. Stepping into the mainstream
Public figures, including politicians and sportspeople, are now willing to speak openly about their mental health, and how they have benefited from counselling. Perhaps the most notable instance in the past year was Prince Harry (above), who talked about how counselling helped him come to terms with the death of his mother. He joined his brother and sister-in-law, the Duke and Duchess of Cambridge, to launch a new charity, Heads Together, specifically to support mental health, partnered with Mind and counselling charity Place2Be, among others.
‘The young Royals coming out in favour of counselling, Government ministers and top sports people talking about their depression, these things are a reflection on the tolerance of our society,’ says Sue Wheeler, Emeritus Professor of Counselling at the University of Leicester. ‘Counselling becoming acceptable has played a part and helped these things happen. Even people in The Archers go for counselling! It’s portrayed by the media as an everyday event now, rather than just what “weird” people do.’
While some media portrayals of counsellors are inaccurate to the point of damaging (see, for example, Netflix’s drama Gypsy, in which a therapist stalks her clients’ friends and family), the willingness of programme makers and media networks to devote airtime to talking therapies (such as Susie Orbach’s In Therapy on Radio 4) can be seen as a reflection of our growing significance in society.
The offer of counselling, whether funded by charities or Government, is increasingly expected by the public after major trauma, as seen in the aftermath of the Manchester Arena bombing and the Grenfell Tower fire. ‘I happen to be having counselling myself. It’s really important; it’s something that people need to talk about and work through to try to stop them having problems in the future,’ said Dany Cotton, Commissioner of the London Fire Brigade, interviewed on LBC radio on 21 August, after the Grenfell Tower fire.
Mental health in the public eye
‘For too long there has been a taboo about talking about some important issues. If you were anxious, it’s because you were weak. If you couldn’t cope with whatever life threw at you, it’s because you were failing. Successful, strong people don’t suffer like that, do they? But of course – we all do. It’s just that few of us speak about it. There may be a time and a place for the stiff upper lip, but not at the expense of your health.’ (Prince William, Heads Together press conference, 18 April 2017)
3. Government recognition
In 2007, the Government pledged £173 million over three years to the development of the Improving Access to Psychological Therapies (IAPT) programme, and a further £400 million over four years in 2010.
‘For all its limitations, IAPT is one of the things psychological therapies can be most proud of,’ says Mick Cooper. ‘I would love to see it more inclusive of counselling and relational therapies, but all the work to make psychological therapies more available has been amazing – the sheer reach of it. It’s the Government acknowledging and putting money into talking therapies, and it’s affected hundreds of thousands of lives.’
In addition to CBT, counselling for depression (CfD), behavioural couples therapy, dynamic interpersonal therapy and interpersonal psychotherapy are all now recommended by NICE as effective treatments for depression. ‘It may not seem like progress, but we are now arguing over whether CBT or CfD is most effective for depression, whereas 10 years ago we were trying to convince people that therapy works at all,’ says Andrew Reeves.
‘Counselling as a key mental health intervention is a no-brainer, because it is relatively cost-effective,’ says Lynne Gabriel. ‘There has been increasing recognition of the need for action to safeguard mental health across the lifespan, and that counselling and psychotherapy have a lot to offer to mental wellbeing.’
4. Growing evidence base
Perhaps one of the most exciting advances in our profession over the past 40 years has been the growing evidence base proving that talking therapies improve mental wellbeing. ‘Evidence is important, because we need something other than our own fallible, direct experience of our clients, and a lot of the research methods involve not just taking our word for it, but asking our clients and getting evidence from people who are not so invested in proving that it works,’ says Professor Robert Elliott, at the University of Strathclyde. ‘It’s important to be able to create some sort of outside perspective, using standardised measures, that brings in another kind of knowledge. It’s not to discredit our experience, but we may be better at understanding our clients than gauging if they are getting better.’
Elliott’s meta-analysis1 of more than 180 studies of the person-centred approach found that person-centred therapies are associated with a significant post-therapy client change, and the improvement is maintained after a year. ‘We don’t know so much about the application of counselling techniques to clients with psychotic processes; we have often written off those client populations, but I think that is a mistake as there is evidence for effectiveness of sensitive, tuned-in counselling for clients with psychotic processes,’ he says. ‘Also, there is promising evidence for clients who are coping with chronic medical conditions, with self-damaging activities and anxiety – there’s some new forms of emotion-focused counselling that are turning out to be very effective with anxiety.’
Large-scale randomised controlled trials (RCTs) are expensive and demanding of time and resources, but counselling is rising to the challenge, with a substantial investment by BACP into the PRaCTICED trial led by Professor Michael Barkham at Sheffield University, with Sheffield IAPT, to compare the effectiveness and cost of CfD with CBT, the results of which are due next year. ‘We set up a research foundation at BACP, and we are moving forward on the research agenda, investing in this pivotal CfD trial, investing in research interests, the knowledge base, research capability, and the counselling professions’ knowledge base,’ says Lynne Gabriel. In 2016, the University of Roehampton was awarded £835,000 by the Economic and Social Research Council to conduct an RCT of school-based humanistic counselling, with additional support from its Department of Psychology and BACP.
‘The strength of research is a sign we are a profession that is deeply engaged with working with clients and committed to helping their problems,’ says Andy Hill, former BACP Head of Research. ‘Research also ensures employability – if we want to work in the NHS, social services and education, we need a solid research base.’
For Hill, the most exciting development in recent times has been the growth of practice-based evidence to complement evidence-based research, which can be less costly than an RCT. ‘It’s a bottom-up approach, taking the data from what is happening in practice and trying to understand what’s going on. We now have the software to compare the results of hundreds of thousands of clients – there is a vast amount of information to be gained from routine practice.’ He points to recent research carried out with Sheffield University that collated data from over 33,000 clients with depression.2 It found that counselling was as effective as CBT, but may be more efficient, getting results on average in seven sessions rather than nine, which has implications for the cost-effectiveness of delivering the services.
Hill says: ‘We know from data collection that different therapists have different levels of effectiveness so, rather than looking at what model works, and this turf war between CBT, psychodynamic and person-centred, we can look at what makes some therapists better or worse than others. That can influence how we train, and use supervision and CPD.’
5. Leading professional ethics
Counsellors are at the forefront of a paradigm shift in professional ethics, believes Tim Bond, who rewrote BACP’s Ethical Framework in 2016. One of the unique aspects of the Framework is its focus on counsellors as people, rather than simply how we should work. ‘We are at the forefront of challenging a concept that has crept in, by implication rather than deliberate decision, in a lot of professional ethics, that professionalism is a mask you put on when you’re in the role, and you put it aside in other aspects of your life,’ he says. ‘Because of the importance of the relationship in the work we do, we can’t afford that luxury. We need to integrate our professionalism with ourselves as human beings and how we relate to other people. It doesn’t mean we have to live like that in every relationship outside of the counselling relationship, but our combination of the personal and the professional is a major resource that we bring to the counselling relationship and other ways of working.’
We can also be proud of the emphasis we put on trust, at a time when incidents of professional malpractice and even abuse are proliferating within the health and social care fields, Bond says. ‘We pioneered trust as an ethical point of reference. It is a way of both honouring the relationship with the client and putting the client first, but it’s also about how we engage with the ethical challenges around us – what would my clients expect of me, what would they consider to be trustworthy? The ethical significance of trust is increasingly recognised in other professions, particularly medicine, and a growing literature on what trust means in a professional life,’ he says.
6. Theoretical and clinical innovation
The counselling profession is founded on a symbiosis of theory and practice, and we are drawn to innovation, as demonstrated by the development of new models and therapeutic approaches – from an estimated 36 in 1959 to more than 400 today.3
Our practice is informed by significant developments in the core modalities of humanistic/existential, cognitive/behavioural, psychodynamic, and integrative/eclectic approaches. In the humanistic world, the relational basis of Carl Rogers’ person-centred therapy has been integrated with other approaches, such as Gestalt, in the case of emotion-focused therapy, which encourages clients to focus on their immediate felt senses. In the psychodynamic field, we have seen the development of short-term therapies, such as interpersonal psychotherapy, an attachment-based, brief intervention that explores the link between interpersonal relationships and mood, and mentalisation-based treatment (MBT), a manualised approach for working with people with a diagnosis of borderline personality disorder. The ‘third wave’ of cognitive behavioural approaches has extended beyond the purely behavioural, with Linehan’s dialectical behaviour therapy, Hayes’ acceptance and commitment therapy, Gilbert’s compassion-focused therapy and Segal’s mindfulness-based cognitive therapy. The integrated/eclectic school has produced considerable innovation, including pluralism, and eye movement desensitising and reprocessing for treating trauma and PTSD.
Creativity and insight
‘The creativity and the insight of new models are incredibly positive attempts to build on our deepest possible insights,’ says Mick Cooper. ‘They are the work of people who want to make sense of things beyond what they have been taught or know, constructing new models and new understandings.’
‘We are trying to find that balance between science, particularly evidence-based practice, and recognising that there is a degree of art and craft involved in every counselling relationship. We are seeking new knowledge and expertise while honouring the human context in which we are working,’ says Tim Bond, Emeritus Professor at the University of Bristol.
7. Holding ourselves to account
In the past 40 years, the counselling profession has taken huge strides in bringing academic rigour to study and training, to challenge the perception that therapy involves little more than a good heart and a willingness to listen. As part of this, we have worked hard to self-regulate, through accreditation and, more recently, the BACP Register, established in 2012. We had an accreditation scheme and complaints procedure as early as 1983, a Professional Conduct Committee was set up in 1999, and the first Ethical Framework for Good Practice was published in 2001. In the 2016 BACP membership survey, 73% of members said what they most valued was BACP setting, promoting and maintaining standards for the profession. ‘BACP is working hard to professionalise counselling,’ says Sue Wheeler, ‘and it’s the only way we can survive and be taken seriously.’
8. Supporting equality and diversity
Part of our training as counsellors involves the exploration of our unconscious biases, prejudices and values that influence our interaction with the world around us.
The BACP Ethical Framework requires us to accept that ‘we are all vulnerable to prejudice’. We strive to be ‘culturally competent’ when working with clients from different countries and cultures, or who have had a different life experience in terms of disability, gender or sexuality.
Gender and sexual minorities experience higher levels of mental health distress, depression, self-harm and substance abuse than heterosexuals. A clear stand was taken by all the main counselling, therapy and mental health organisations in 2015, including UKCP, BACP, Pink Therapy, the British Psychological Society (BPS) and the Association of Christian Counsellors, when they signed the Memorandum of Understanding calling for a ban on reparative therapy in the UK. Training should ‘prepare therapists to have sufficient levels of cultural competence so they can work effectively with LGBT clients’, the signatories declared. We have come a long way since gay people were not allowed into psychoanalytic training, on grounds that homosexuality was pathological.
In our increasingly multicultural society, an understanding of the impact of race, culture and ethnic differences has never been more crucial. That understanding can come through counselling training and have a wider impact. ‘The changes made on an individual level can ripple out into society as a whole,’ says Eugene Ellis, director of BAATN, the Black, African and Asian Therapy Network. ‘A counselling course is a unique kind of training in that you can’t come out of it without having dug into your identity.’
That said, black and Asian people are still a minority on most courses, and BAATN is an example of how the counselling profession develops to meet its own identified needs. It was set up to promote wider availability of counselling services for black, Asian and minority ethnic (BAME) clients. ‘But we soon realised that started with establishing a community of practitioners to hold the work,’ says Ellis. ‘We provide gatherings where BAME students can be supported by experienced therapists in a group, and one-to-one mentoring, so they can become aware that there is a big community of black and Asian counsellors.’
Change has been slow, but it’s happening, believes Myira Khan, accredited counsellor, associate tutor at the University of Leicester and a BACP governor. ‘When I trained, I was the only BAME person among my peers, the training staff and on my placement. Now, eight years on, I see more BAME trainees, trainers and service providers. The more visible we are in the profession, both in person and on websites, social media and in articles, the more we help to break down the barriers and taboos for BAME clients around accessing mental health services. Our profession is starting to reflect the diversity of the society that we live in.’
9. Parity of esteem
The Government’s 2011 mental health strategy ‘No Health Without Mental Health’, and the Health and Social Care Act 2012 put mental health on a par with physical health, on paper. But, despite investment by the Government of £1.3 billion in mental health services over the next three years, we are still a long way from parity of esteem between physical and mental health. This is a disparity that counselling has been at the forefront of challenging, most notably through BACP’s Psychological Therapies and Parity of Esteem report and campaign, launched in 2014, and its stated commitment to social justice.
‘Along with the other caring professions, we have become very concerned about the relationship between mental wellbeing, health and social justice,’ says Tim Bond. ‘So we, along with social workers, psychologists and others, have exposed the impact of poor human relationships, abuse, neglect and poverty on wellbeing and played our part in finding remedies for these difficulties. Counselling is one of many professions that asks what is good for people and their relationships with each other. The insights from counselling and closely-related roles have helped to transform health care, education and other major services to be more humane and empowering. There is much more to do but hospitals and schools are generally more humane in how they support healing and learning than 20 years ago. Counselling, and especially counselling skills, have played their part.’
Another example is We Need To Talk, a coalition of mental health charities and professional associations, including BACP, which is campaigning for a full range of evidence-based psychological therapies to be available to all who need them.
There has also been a sea change in how we view mental health, says Andrew Reeves. ‘We are culturally moving away from the dominance of the medical model, and acknowledging that mental health is shaped by an interplay of interpersonal and intrapersonal factors, but also societal and systemic factors, and there seems to be greater acknowledgment of that. When I started in social work, the position was that we are all only biological beings and that our mental health is basically down to biochemical factors and, as such, the treatment was medication, or ECT, or inpatient care, or occupational therapy. But the shift to consider a mind–body continuum has created a context in which psychological therapies could develop. If we had persisted with the notion that as a species we are only biologically driven, it’s hard to see how therapy could have flourished.’
10. Contributing to social change
‘I believe that counsellors are perfectly placed to be “change agents” – at a micro level we can’t not be change agents but we can also effect change at a macro level,’ says Lynne Gabriel. ‘What counsellors do in the therapy room influences, even if there is no intention. We need to recognise the part that we play in social change and challenging dominant paradigms. At the very least, counselling helps facilitate people to make changes in their lives, and achieve positive momentum. We have a profession that is constituted in the main by people who have a strong set of values, and a good ethos, who want to make themselves available to support others to make positive changes in their life, or adjust or adapt to changes in their life.’
Counsellors are at the forefront of a move away from the ‘no such thing as society’ notion that was prevalent in the 1970s and 1980s, and the pursuit of individual gain at the expense of everything else, believes Andrew Reeves: ‘As a society, we are tiring of embedded selfishness and we are drawn increasingly to others connecting with others.’ Whether it’s by volunteering our time and skills to provide counselling to disadvantaged groups, or joining campaign groups such as Psychotherapists and Counsellors for Social Responsibility, we are working to make a difference. ‘There is a growing willingness in our profession to look at social justice issues,’ says Mick Cooper, who set up CREST, the Centre for Research in Social and Psychological Transformation, at the University of Roehampton, to research the relationship between psychological therapies and social justice. ‘As therapists, we are experts at effective communication – how people can talk to each other and really listen – and that is so important for the political sphere. If politicians could listen to each other in the way we listen to our clients, and have dialogues instead of arguments, then we would be in a much better place.’
Most counsellors aren’t just content to ‘mop up society’s mess’, agrees Sue Wheeler. ‘A good counselling course is a very rich, life-changing experience, and has a knock-on effect. Counsellors grow so much and their view of the world changes, and they spread their insight and understanding with the people they come into contact with.’
What makes you proud to be a counsellor? What achievements do you think we should celebrate? Email firstname.lastname@example.org
Sally Brown is a counsellor and coach in private practice (therapythatworks.co.uk), a freelance journalist, and Executive Specialist for Communication for BACP Coaching.
What the doctor ordered
Free article: More and more people are taking prescribed antidepressant medication. But are the drugs helping or hindering? Sally Brown reports on the overlooked problem of prescribed-drug dependency. Therapy Today, September 2017
Not so, NICE!
Free article: NICE may again be questioning the effectiveness of counselling. Catherine Jackson reports. Therapy Today, July 2017
How we live now
Free article: Sally Brown highlights some of the main ways in which the digital revolution is influencing all our lives, and what clients bring to counselling. Therapy Today, June 2017
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2. Pybis J, Saxon D, Hill A, Barkham M. The comparative effectiveness and efficiency of cognitive behaviour therapy and generic counselling in the treatment of depression: evidence from the 2nd UK national audit of psychological therapies. BMC Psychiatry 2017; 17: 215.
3. Norcross JC, Grencavage LM. Eclecticism and integration in counselling and psychotherapy: major themes and obstacles. British Journal of Guidance & Counselling 1989; 17(3): 227–247.