Talking therapies are recommended for various presenting issues, from anxiety to chronic pain, addiction to complicated grief, and a myriad of other conditions (NHS England, no date). Mirroring the variety of client groups, is the array of therapeutic approaches available to them. Person-centred (PC) therapy, CBT, psychoanalytic therapy, and many, many more. Searching for a therapist on counselling-directory.org.uk gives users the option to choose from over 80 therapies, with the added possibility of filtering by 120 reasons for needing therapy (Counselling Directory, 2024). More and more people are seeking counselling, with those accessing treatment via the NHS alone increasing by 21.5% between 2020-21 and 2021-22 (NHS England, 2022). Now, more than ever before, individuals are much more open and able to attend therapy in order to address their mental health issues. However, perhaps we, as therapists working in specific modalities, should ask ourselves if we are always the best fit for every client whose enquiry lands in our inbox.
Necessary and Sufficient?
Carl Rogers stated that the core conditions of PC therapy are not only necessary but also sufficient. This stance is unsurprising coming from the father of PC therapy. The implication of this is that nothing else is required in order to bring about positive change (Rogers, 1957). However, his assertion is backed by evidence from numerous studies which have explored the efficacy of a person-centred approach (PCA) when working with diverse client groups. For example, PCA was found to be effective in the treatment of PTSD in adolescents, resulting in a lower drop-out rate than other approaches (Van de Water et al., 2018). Research also found that PC therapy decreased distress in parents of children with developmental delays and lowered the incidence of parent-child dysfunctional interaction (Fung and Chan, 2024). PCA has also been found to be helpful when working with clients suffering from grief (Vogel et al., 2021) and as effective as CBT when working with depression (Pybis, Saxon, Hill, and Barkham, 2017).These findings imply that PCA is suitable for any clients, with any presenting issues, but is this true? Not according to some critics of PC therapy who have argued that it is not as effective for all client groups as other modalities. They highlight its shortcomings when working with clients who have low levels of motivation or lack insight into their behaviour (Noel, 2018). There is also a general perception that the open-ended nature of person-centred counselling can result in it being cost-inefficient, however, I have been unable to find data that supports this view. As a PC therapist I would argue against these broad-brush criticisms. However, given the unique and individual nature of each client, I also think it would be foolish to ignore the assertion made by Smith et al. (2021) that some modalities might be more suitable for some clients.
Child’s Play
One such client group that might require a specific approach is that of children. Those of us who have worked with this client group might have encountered the various issues that can arise, from a lack of verbal communication skills, to the inability to accurately describe emotions or events (Bosgraaf et al., 2020; Scheeringa et al., 2007). Given these roadblocks, play therapy is ideally suited to working with preschool and school age children, particularly those struggling with social skills, developmental and behaviour problems, or children who have experienced abuse (Koukourikos et al., 2021). In addition to its suitability, play therapy is not restricted to a specific modality, having been successfully used by therapists of various backgrounds, from humanistic to behavioural (Van Lith, 2016). As we know, play therapy takes many forms. One such form is sand tray therapy, which has been found to reduce anxiety and depression in preschool children (Abdollahi Keivani and Abolmaali, 2018), as well as enhancing their self esteem (Lee et al., 2018). Positive results have also been seen in the use of art therapy, for example when working with children experiencing grief, enabling them to explore their emotions (Green et al., 2021). Art therapy has also been found to have a positive impact on children and adolescents suffering from trauma, as well as those with additional educational needs (Cohen-Yatziv and Regev, 2019).Whilst play therapy has shown to have positive results on this particular client group, its limitations should also be noted. You might have encountered the cost of additional equipment, or the struggle to find a suitable space where your young client can play (MindEd, 2018a). Interestingly, some research has also shown that the success of play therapy is dependent on the development of the therapeutic relationship and behaviour of the therapist. Indications are that flexibility and the ability to react to the client as an individual result in more positive outcomes (Bosgraaf et al., 2020). The importance of the role of the therapist, as opposed to modality, has been proposed for almost a century, with one of the earliest, and often overlooked, advocates being Rosenzweig (1936) in his essay ‘Some Implicit Common Factors in Diverse Methods of Psychotherapy’.
A Change of Thought
As we are all aware, more recently the counselling spotlight has shone on CBT, championed by the NHS as the answer to many, many presenting issues. NHS Talking Therapies (formerly known as Improving Access to Psychological Therapies - IAPT) offers CBT as the treatment for depression, PTSD and social anxiety disorder (NHS England, no date). Despite the prevalence of CBT within the NHS, its provision has come under fire. Interviewing several IAPT therapists, researcher Bruun (2023) found that some felt unable to provide appropriate care for clients due to the demands of outcome measures, with others reporting that the therapeutic relationship was lost due to constraints of the medical model. One therapist interviewed highlighted the discrepancy between her training and the IAPT work that she had undertaken. We should keep this discrepancy in mind when exploring the efficacy of the modality. The CBT received by some NHS clients appears to be quite a departure from what was originally intended by Beck.Beck’s original theory was not simply a technique to change a client’s thought process. It explored the impact of early learning experiences, which later become activated in response to critical events or social constructs (Beck, 1979; Beck et al., 2005; Sudhir, 2018). Whilst this process, and subsequently its impact, has been diminished by the financial and time constraints of the NHS, that is not to say the modality is ineffective. Research has shown CBT to be an effective way of working with many client groups. The approach is widely used for drug and alcohol addiction (Magill et al., 2020), with third wave CBTs such as Acceptance and Commitment Therapy (ACT), Dialectical Behaviour Therapy (DBT), Mindfulness-Based Cognitive Therapy (MBCT) and Schema Therapy (ST) shown to be a suitable treatment for those living with addiction (Balandeh et al., 2021; Zamboni et al., 2021). Beyond addiction, CBT has been shown to have positive outcomes when working with clients suffering from conditions such as schizophrenia (Vita et al., 2021), chronic pain (Driscoll et al., 2021; Glombiewski et al., 2010), insomnia (Muench et al., 2022; Van Straten et al., 2018) and many other conditions (Fordham et al., 2021). As well as being effective in the treatment of various presenting issues, it is also important that we do not overlook the practical benefits of CBT. Its structured, time-limited nature can be beneficial for clients who lack spare time and money. Whilst these benefits have been squeezed by the NHS to the point where there is a potential impact on the client, we should not see this as reflective of CBT as a whole. Once again, when the therapeutic relationship is established and clients are treated as individuals, as opposed to case numbers on an ever quickening conveyor belt, the strengths of the modality are evident.
‘The mind is like an iceberg, it floats with one-seventh of its bulk above water’ (Freud, 2005)
As with psychoanalytic therapy, from which it was derived, psychodynamic therapy attributes current behaviours to unconscious perceptions developed within childhood - the parts of the iceberg that are unseen. In PCA, Rogers’ concept of self also places importance on the events of childhood, attributing the creation of the self construct to the introjected values and conditions of worth received by individuals during their formative years (Rogers, 1959). However, Roger also states that us PC therapists should follow the agenda of the client, treating them as the expert in the room. We are encouraged to suppress any urges to overtly direct the client to think about their patterns of behaviour in relation to the events of their childhood. In contrast, along with allowing the client to free-associate, the psychodynamic therapists amongst us take a more active role in focusing the client on their patterns of behaviour, intervening when necessary and directing the client towards their internal world (Katzman and Coughlin 2013). Research has shown that psychodynamic therapy’s focus on the unconscious is effective when working with various client groups such as those suffering from eating disorders, substance abuse, depression and anxiety (Gonon and Keller, 2020; Leichsenring and Steinert, 2019). The modality was also found to be effective in reducing suicide attempts, psychosocial functioning and hospital admissions (Briggs et al., 2019). Whilst these results are positive, psychodynamic therapy has been criticised for being non-cost-effective due to the number of sessions usually required (Jimenez et al., 2021). It has also come under fire for both a lack of research interest (de Iceta Ibáñez de Gauna et al., 2015) and a lack of scientific basis (Fonagy, 2015). In addition to this, the nature of psychodynamic therapy involves working with an individual’s very unique situations and circumstances, and as such it is difficult to determine through randomised controlled trials exactly how it works (Gonon and Keller, 2020). Despite this, Fonagy (2015) found that the success of psychodynamic therapy, as with other modalities, was dependent on two main factors: the availability of trained, competent therapists and the therapeutic relationship.
Jack of all Trades?
As I have circled back once again to the importance of the therapeutic relationship and the therapist’s ability to respond to both the client’s presenting issue and them as a unique individual, this might imply that an integrated approach to client work could be best. Many of us already work in this manner, nurturing the relationship whilst utilising a toolkit of interventions. Personally I feel that this approach places the client’s needs front and centre, meeting them whilst maintaining a safe working environment. This is in contrast with the close relation of integration - pluralism. This modality is championed by Mick Cooper, and positioned as a new, collaborative framework. This practice involves a single therapist offering multiple modalities from which a client can choose (Cooper and Dryden, 2015; Cooper and McLeod, 2011). However, we are all aware of the criticism this approach has faced. Pluralist practitioners have been labelled as jacks of all trades and the practice itself referred to as something old in new packaging (Ong, Murphy and Joseph, 2020). Despite pluralism apparently offering exactly what the client needs, or thinks they need, this is not necessarily a good thing. Given the lack of regulation in the industry, it can be difficult to establish whether or not a therapist is sufficiently trained in one modality, let alone numerous approaches. Unless proficiency in the multiple modalities can be guaranteed, I wonder if working in this way could prove unsafe and unethical.
Made to Measure
As can be seen, when it comes to therapy, it is not a case of one size fits all. Acknowledging that there is benefit in various modalities, and given the pressures of time, finance and the client’s well being, perhaps it would be productive for us to focus on why particular client groups respond more positively to some modalities than others. This work has begun, utilising technology to predict the efficacy of modality on particular client groups, leading to greater personalisation of treatment (Delgadillo and Gonzalez Salas Duhne, 2020; Lutz et al., 2022; Schwartz et al., 2021). Similar to previous research (Bosgraaf et al., 2020; Fonagy, 2015; Rosenzweig, 1936) this work also acknowledges the impact of the therapist themself and the therapeutic relationship they help to create, noting the difficulty involved in including these factors in an automated algorithm (Delgadillo et al., 2020). Whilst work has begun on exploring ways in which the personalisation of therapy can be determined, this is not yet widely available. Until accurate, personalised treatment prescriptions are available to all, I would argue that ultimately there is a benefit to underpinning any client work with a person centred approach. The core conditions are necessary to establish a successful therapeutic relationship (Rogers, 1957), which has been shown time and time again to be associated with positive outcomes (Barkham et al., 2021; King et al., 2000; Ward et al., 2000; Geller and Porges, 2014; Rogers, 1959; Ryland et al., 2021). Whilst the conditions alone might not be sufficient for each client, they provide a safe, secure environment in which the therapeutic process can begin. It is from here that an integrated approach can be used, drawing upon specific tools and techniques in order to meet our client’s specific, individual needs.
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