Despite rising awareness, counselling and psychotherapy remain mysterious, especially for people outside the field. Popular narratives sometimes bathe these processes in an unflattering light. Some people perceive counselling as offering instant, gift-wrapped solutions to their issues. Clients and counsellors are perceived as diametrically opposite and one-dimensional beings - the client is passive, weak, and troubled; the counsellor is active, assured, and composed. In this article, I aim to address a few of these narratives to paint a more accurate picture of counselling, the roles of the client and counsellor, and their relationship.
I will use the terms counselling, psychotherapy, and therapy interchangeably. The differences between them are subtle, blurred, and often insufficiently defined [1, 2]. Also, this article is limited to one-to-one counselling. It is not to be extended to couples, family, or group counselling, even though some elements may be transferable.
Counselling and psychotherapy have several definitions, but I would love to borrow John McLeod's as it describes the process from a client's perspective. Counselling is a process where a person facing a personal or psychological issue invites another to form a particular kind of professional relationship that can be helpful [3]. This relationship provides the person with conditions like undivided attention, unconditional acceptance, and confidentiality which might be hard to find in their everyday lives. These conditions can facilitate the client's change processes. As John states, 'Counselling is a cultural invention and a social institution' [3]. It might not be helpful to assume that the client and counsellor are immune to the influences of culture and society.
It is often helpful to identify what isn’t counselling to separate it from scenarios that include some aspects of or claims to be counselling. Persons providing only advice, suggestions, or solutions are not providing counselling. These elements rarely take precedence within the counselling space. Counsellors may provide advice or guidance, but this is not frequent, unsolicited, or out-of-context. Further, counselling is not advice from parents, an insight-filled conversation with friends, or guidance from persons with power or experience (school principals, teachers, managers). These can be helpful, but the conflict of roles, blurred relationship boundaries, and power imbalance impede one's ability to provide a confidential space free from judgement, preconceived notions, and personal agendas. Their existing relationship can also become confusing and difficult to navigate. It might be more appropriate to consider such scenarios as providing some conditions of counselling, but not as counselling itself.
In one-to-one counselling, only two persons are directly involved - the client and the counsellor. These persons need to hold particular values and characteristics essential for the process. The counsellor must strive to be curious, empathetic, and have an attitude of non-judgement and unconditional acceptance for their clients. They must remain respectful and preserve their client's confidentiality and dignity. Being genuine, open, and honest (usually called being congruent) is necessary. The client should be a willing participant and hold enough motivation to engage in the process. Learning to take responsibility and exert effort to actualise their potential is also a necessary characteristic for the client.
Counselling is seldom straightforward and rarely offers readymade solutions. The client and counsellor undertake a complicated journey through the messy realms of experiences, sensations, meanings, and cognitions. They tackle psychological, philosophical, relational, and social issues together. In this journey, the client and counsellor are both experts - the client is the expert on their life, experiences, resources, and abilities; the counsellor is the theoretical and professional expert. These two experts form a working alliance, defined as the ability of the counsellor and client to collaboratively engage with therapeutic tasks, agree on targets, and work towards change [4]. A non-collaborative counsellor who tries to fit a client into a rigid mould might make the latter feel unheard or invalidated. An ineffective counsellor might make the client feel lost, unsupported, or stuck. A passive client might be inert as the change process requires their participation. A disengaged client might experience the counselling space as a microcosm of their outside life, risking a fall into familiar and unhelpful patterns. The counselling process requires balance and collaboration, with an efficient working alliance at the helm.
“It’s the relationship that heals”
This working alliance is only one of the many components of the therapeutic relationship - the latter is defined as the feelings and attitudes shared and expressed by the counsellor and client [5]. “It’s the relationship that heals”, claimed the eminent existential psychiatrist Irvin Yalom [6], with research also evidencing the therapeutic relationship as one of the strongest predictors of success ([7]; also see [5] for a detailed review). However, clients and counsellors do not always share similar perspectives on their relationship [8 -11], and often it is more important to know the former’s perspective. The client’s perception of the relationship, the therapist’s empathy, and their collaboration correlate higher with the outcome than the therapist’s or an observer’s ratings [12–15]. When choosing what was helpful in therapy, clients choose emotional and relational events while therapists choose cognitive and technical aspects [16]. Do therapists blindly know what is better for their clients, or should clients have a say and help inform therapy? Research evidence supports the latter. The counselling process benefits from listening to clients, valuing their perspectives, and building a working alliance through collaboration [20–24]. Also, studies have found client and extratherapeutic factors to be better predictors of change than therapist or treatment factors [7, 17–19].
Arthur Bohart’s [17] brilliant article has much to say about the role of clients in therapy. From an examination of the research base, he points out that most people get better by themselves without any formal therapeutic interventions. Arthur concludes that people have an innate capacity for self-healing and that it is unsurprising that clients can use different kinds of therapy for their benefit. He strongly advocates for clients to be considered active agents in the process of counselling and psychotherapy.
Considering the importance of client factors, participation, and perspectives, it might not be productive in practice to ask a general question like, 'What works in therapy?'. Instead, it might be beneficial to switch our focus on what works for a particular client and counsellor in that context. Even way back in 1967, Gordon Paul [25] framed an appropriate question:
What treatment, by whom, is most effective for this individual with
that specific problem, and under which set of circumstances?
This is a mouthful but necessary to tailor counselling for a client to maximise chances of success. Think about this for a minute. We all have vastly different lives and experiences. We have multiple thoughts and feelings about events, varying levels of support and resources, and fluctuating needs. How can a standard treatment suit us all? Counselling requires specificity, which is difficult to achieve without inviting the client to be an active participant. As we have seen above, client perspectives are better predictors of outcomes, so why would we not ask them to help direct their support? Pluralism in therapy does just this. First described by John McLeod and Mick Cooper, the pluralistic approach invites clients to become active participants in meta-therapeutic conversations and direct their support [26]. Counselling can be truly collaborative only when clients can actively participate, express their preferences, and direct the nature of their support.
'Clients are the
heroes of therapy'
In conclusion, counselling is a collaborative process between two people sharing a unique, professional relationship that can facilitate change. The client and counsellor need to be active participants and play their roles effectively to maximise their chances of success. Despite common misconceptions, the client is an active agent of change more critical to the process than the therapist or treatment factors. The counselling process is made more effective by considering client perspectives and preferences. As Arthur Bohart [17] stated, 'Clients are the heroes of therapy’. Counsellors and therapists are the unwavering sidekicks who enable the hero to be the best versions of themselves.
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