York and District Mind

Psychotherapy/counselling is talking with someone, trained in the art of listening, in order to gain relief, support or to try to change an aspect of one's life. But why the two terms, and how do they differ? Both psychotherapy and counselling are primarily about talking and listening. The terms cover a wide range of approaches, with the trained person having spent from a few months to several years getting their qualifications. However, because there is no statutory control anyone can call themselves a psychotherapist or counsellor without having any recognised training or qualifications. One way of differentiating between psychotherapy and counselling is to think of a continuum with counselling at one end, psychotherapy at the other, and an overlap between the two in the middle. Training for counsellors is usually shorter. They tend to work in a more problem-based way and for a shorter period of time than psychotherapists.

There is a saying that a problem shared is a problem halved. Most of us share our trials and tribulations with family or friends, so why seek out a stranger? It may be because we do not wish to burden those who usually support us, or because we feel we need more than they can offer in terms of time, understanding and trust. People seek out this type of help for a wide variety of reasons. It may be for the relief of symptoms such as anxiety, depression, stress or phobias. It might be as a result of a loss, such as a bereavement, the ending of or difficulties in a relationship, or job redundancy. We might be experiencing a crisis, be confused about ourselves, or want to develop a greater level of self-understanding. Talking and being listened to by someone who shows empathy and acceptance can help us gain relief from our emotional pain. In addition we may be offered programmes to help us work on particular behaviours, or the therapist may be more concerned that we develop greater insight into our feelings, thoughts and behaviours.

It depends on what you are looking for, where you live and what resources are available to you. If you are white, middle class, living in London and have money, you will have the most choice. Psychotherapy and counselling may be available from statutory agencies (the NHS, your GP), voluntary agencies and privately. Access to all therapy, including counselling is patchy. London, in particular, and the larger cities are the best resourced.

Free psychotherapy in the NHS is comparatively scarce, and there is a lot of competition for what does exist. White middle class people tend to have the advantage in accessing this service. It is mostly offered by psychiatrists or psychologists, who have taken further training in psychotherapy. However there are more and more other professionals, such as nurses, social workers and occupational therapists, taking further training in psychotherapy and counselling. In recent years an increasing number of GPs are employing counsellors.

Some voluntary agencies such as Relate (formerly Marriage Guidance) only offer counselling, whilst others, such as some local MIND groups, offer counselling as part of a range of services. They may ask for a fee or contribution towards their costs or it may be free. There are an increasing number of psychotherapists and counsellors who work privately. Their fees range from about £5.00 to £45.00 per session. To find out if there are any private therapists in your area you could contact the following: your GP, community health council, local MIND Group, Citizens Advice Bureau or any other information-giving agency such as the British Association for Counselling or the United Kingdom Council for Psychotherapy (for addresses and telephone numbers, see Helpful Organisations). Many people find their therapists through personal recommendation from a friend, colleague or a professional working in an associated field. Some employers offer access to counselling -Employee Assisted Programmes - and many colleges and universities have a student counsellor.

WHAT kind of THERAPY DO I NEED?

Assuming you have a choice, ask yourself how much of a commitment you want to make in terms of time, and money if you have to pay. If you have a specific problem then it is best to try to find someone who specialises in that area. Do you think you would favour a problem-solving approach, or would you prefer to explore aspects of your self or your life, possibly looking at childhood influences?

There are many different kinds of therapy, from psychoanalysis, involving five sessions per week over several years, to supportive counselling which may take only one or two sessions. The next section gives a list of books with information about the different theoretical approaches (see also the section on Useful Terms for explanations of words and phrases which are commonly used in talking treatments). It is possible to categorise the various theories into psychodynamic (including psychoanalysis), humanistic, and cognitive behavioural.

Psychodynamic approaches tend to be longer term, focus on the effect of the past on the present and seek change and greater self-understanding by exploring unconscious forces. Humanistic approaches believe that we all have an in-built capacity to grow and thereby reach our full potential. The focus is on helping the client to find their own answers. Behavioural approaches help to identify goals and part of the therapist's role is to design programmes to help reach those goals. The cognitive approach helps the client to identify their negative thoughts and how this affects the way they view their world. The focus of the therapy is on developing more positive thoughts.

Research shows that the success of therapy depends less on the theory used than on the quality of the relationship between the therapist and the client, the skills of the therapist and the motivation of the client.

'Counselling and Psychotherapy' Hefty Einzig (BAC and available from them on receipt of an sae)

'Talking to a Stranger: A Consumer's Guide to Therapy Lindsay Knight (Hodder & Stoughton, 1995)

'Room to Listen, Room to Talk' Tony Lake and Fran Acheson (Bedford Square Press, 1988)

'A Complete Guide to Therapy' Joe Kovel (Penguin, 1992)

'One to One: Experiences of Psychotherapy' Rosemary Dinnage (Penguin, 1992)

'Who Can I Talk To? The User's Guide to Therapy and Counselling' Judy Cooper and Jenny Lewis (Headway 1995) Available from MIND Publications.

Unless you see a therapist privately you may have no choice regarding who you see, but you are entitled to ask about their training, qualifications, experience and approach. If you see someone privately, the British Association for Counselling (BAC), in their 'Counselling and Psychotherapy Resources Directory', list the training and qualifications of their members. Only those who have had a minimum of 450 hours of counselling practice are eligible to apply to be BAC Accredited Members. The UKCP which represents over 70 psychotherapy organisations, provides access to information about accredited psychotherapists. Psychotherapy training usually takes a minimum of three years. Some of the member organisations of the UKCP do not allow their individual members to advertise, and concern is sometimes expressed about the training and qualifications of those who advertise in the classified columns of newspapers and magazines.

If you have a choice it can be helpful to see more than one therapist to assess which one you feel would be best for you.

The following is a list of questions you could ask at a first meeting:

• What training, qualifications and experience does the therapist have?

• What approach does the therapist take?

• What professional organisation(s) do they belong to, and could you have a copy of their code of ethics?

• Do they receive supervision for their work?

• Have they had therapy themselves?

• How long is a session, how often are they held, and for how long does the therapy normally last?

• If there are fees to pay, what are they, when are they payable, what happens in the event of cancellations and holidays? Is there a sliding scale of fees based on the individual's ability to pay?

• Is it a totally confidential service? Are there circumstances when confidentiality is broken? For example, would the therapist pass on to other professionals information about child sexual abuse or about clients putting their own lives or the lives of others in danger?

• Under what circumstances might they refer clients to somebody else?

• What are the arrangements in the event of an emergency?

You should ask yourself if you feel comfortable and safe with this person. Do you feel you could trust them with intimate details about yourself? It is important to try to trust your feelings in this matter, although this might be difficult if you are seeking help because you are in a crisis or feeling very negatively about yourself.

Psychotherapy and counselling remain primarily white middle class activities. For people from black or minority ethnic groups, linguistic minorities, gays or lesbians, or people with a disability, a question they might wish to ask is, 'Can I find, or is it important to find, someone who comes from a similar culture or who has similar experiences to myself?' If it is not possible to find such a person then the question might be, 'How much understanding does this person have of the issues I have to face? Will they be accepting or try to impose their values on me? 'ln some parts of the country there are networks or organisations which offer psychotherapy or counselling to particular groups of people. Also, individual therapists might state that they work with particular groups or through languages other than English (for addresses and telephone numbers, see Helpful Organisations).

Most people who have a mental health problem and who seek help from a GP or psychiatrist are likely to be given drugs such as tranquillisers or anti-depressants. Unfortunately they are much less likely to be offered counselling or therapy, partly because of the shortage of therapists. Also there is a prevailing belief that people with a diagnosis of psychosis such as schizophrenia or manic depression are not suitable for counselling or therapy. More important than the diagnosis is whether or not the person feels strong enough. Many people with mental health problems mainly want someone to talk to, a supportive approach which is not too threatening. Others may feel confident to try a programme which will help them deal with certain situations or to develop insight into their difficulties.

Therapies that explore the past may touch on painful and distressing material which can make us feel worse. So the questions here are, 'Can I cope with this?', 'How much support have I got from my family or friends?' There are a few organisations, such as the Arbours Association, which offer psychotherapy in a residential setting to people who are experiencing a fair degree of disintegration but who want to use therapy to try to rebuild their sense of self. One criterion a therapist might use in assessing whether or not they can work with an individual is, 'Can this person make a relationship with me, or are they too cut off at present? 'Some therapists are reluctant to work with people who are taking mood-altering prescribed drugs. But research into treatments for depression shows that a combination of drugs and therapy is more effective than either on its own. Also some therapists support their clients in coming off their drugs, should they so wish.

Therapy can bring about an immediate improvement for some as a result of sharing how they feel or what is happening to them. Sometimes the change is more gradual, and especially if the therapy is long-term it can be difficult to remember how one was a year or two ago. One way of recording your own progress is to keep a journal or diary on which you can look back. Exploring painful events and memories can make you feel worse before feeling better. It is important to discuss this possibility with your therapist and to consider strategies for coping with difficult feelings. Many people report that their problems do not go away, but they feel better able to cope.

When psychotherapy or counselling lasts over several months or years, strong feelings towards the therapist can develop. These feelings include admiration or even love on the one hand, or anger and hostility on the other. The technical term is 'transference'. Transference should be explored in therapy, and it is the role of the therapist to help identify the origins of these feelings, usually from the client's childhood, their impact on the client's life, and how they can be dealt with. This is different from the therapist encouraging actual dependence but not supporting the client to be autonomous, and in so doing disempowering them.

The number of times the therapist and client meet can be agreed at the beginning. Alternatively a review of progress and the continued value of the therapy might be conducted periodically. How the therapy ends can be extremely important and should always be carefully handled. The role of therapist is to help the client explore and understand what endings signify. The therapy may mirror other endings, losses and goodbyes in the client's life. Sometimes endings are less than ideal. This may be because the client decides to end abruptly, and consequently misses exploring their feelings about their particular relationship coming to an end. It may be the therapist who ends the relationship, possibly as the result of changing jobs. Whenever possible an ending should be planned. The longer the therapy, the longer is needed to work through the accompanying feelings.

Therapists can take advantage of or abuse their clients in a variety of ways. This can include emotional abuse by being unreliable or encouraging dependency, financial abuse through encouraging clients to stay in therapy when they are no longer benefiting, or seeing clients whose problems are beyond the scope of the therapist's experience. Perhaps worst of all is sexual abuse.

Under no condition should therapists have a sexual relationship with a client. Even if the client wants such a relationship, it may be because of transference feelings, and it is the responsibility of the therapist to maintain appropriate boundaries. Other types of abuse can include the betrayal of confidentiality, carrying out research or new techniques without the consent of the client, using the client's time to talk about their own problems and imposing their own personal values on the client.

Complaining about abuse depends upon the setting of the therapy. If it is within the NHS or any other agency there should be a written complaints procedure. In a private setting, the BAC have a written Complaints Procedure which applies to their members. All member organisations of the UKCP are required to have a UKCP approved Complaints Procedure.

Upholding a successful complaint should result in the therapist being barred from membership of their relevant organisation. However because there is no statutory registration of psychotherapists or counsellors, this may not stop the therapist from practising. Making a complaint can be a distressing experience for the client and it may be advisable to seek support, either from a friend, advocate or trusted professional, or from an organisation such as the Prevention of Professional Abuse Network (see Helpful Organisations).

ANALYTIC PSYCHOLOGY

A psychotherapeutic approach created by Carl Jung which emphasises the importance of the unconscious, dreams and fantasies and spiritual life.

COGNITIVE THERAPY

This approach emphasises that the way people think and see the world influences how they feel. People suffering from depression for example, are thought to have negative thoughts and the aim of this therapy would be to help the individual to recognise negative thought patterns and develop more positive attitudes.

PSYCHOANALYSIS

The psychotherapy created by Sigmund Freud, with emphasis on the unconscious, dreams and the transference relationship. In Britain few would now call themselves orthodox Freudian psychoanalysts, but would be influenced by the ideas of Melanie Klein and Object Relations.

REPRESSION

Pushing certain experiences out of the conscious mind, possibly because they are potentially too traumatic to face.

HUMANISTIC THERAPY

Humanistic therapies include gestalt, psychodrama and encounter groups. They place emphasis on knowing the real self and fulfilling individual potential.

OBJECT RELATIONS

A psychotherapeutic approach, derived from psychoanalysis which emphasises the importance of early relationships in the development of the individual.

OEDIPUS COMPLEX

Freud's explanation, based on the Greek myth, of a three to five year old's strong feelings of intimacy and rivalry towards its parents.

TRANSACTIONAL ANALYSIS

A psychotherapeutic approach based on ideas drawn from psychoanalysis, but more accessible partly through the use of ordinary language. Emphasis is placed on how games and scripts are used to avoid intimacy.

TRANSFERENCE

The transferring of feelings that are attached to one person to another eg. those held towards a parent onto the therapist. Through understanding the transference relationship, under-standing of the earlier relationship is gained.

UNCONSCIOUS

An active and dynamic force within us which is made up of hidden drives, desires, fears and repressed memories.