Category: Articles

Introduction to Counselling and Clinical Psychology differences

Perhaps the most common point of confusion for people who want to start therapy is the difference between Counselling and Clinical Psychology. It’s not only clients who are unsure, healthcare professionals and even therapists themselves often struggle to explain the difference. People use the terms as if they were interchangeable and often people use the term ‘Counsellor’ to refer to any sort of talking therapist.

Counselling and Clinical Psychology are actually two different approaches to therapy, although there is some overlap. They draw on different theories and traditions. They are also two different professions with their own training routes, qualifications, job titles and regulatory bodies.

This article aims to clarify the differences between the two from the perspective of a Clinical Psychologist*.

The different backgrounds of Counselling and Clinical Psychology

Modern Counselling began to take shape in the 1940’s in America and was heavily influenced by the work of Carl Rodgers (Moynihan, 1993). Rodgers believed that an accepting, supportive relationship between a Counsellor and a client could help the client to gain insight or understanding of their situation. This insight could then help them to make the changes necessary to reach their potential. The Counsellor’s job is to assist the client in making their own decisions and solving their own problems. This is based on the belief that the client knows what is best for them; the wisdom is in them and the Counsellor’s job is to help bring it out. They do this by asking questions, listening and offering emotional support.

Modern Clinical Psychology began in the 1890’s, also in America (Reisman, 1991). Originally it was based in laboratories and focused on developing a scientific understanding of how the mind works. It was not until the 1940’s when therapy became a major part of the profession. This scientific foundation remains a big part of Clinical Psychology today. Psychological therapy is based on scientific research and aims to change the way clients think, feel and behave. My job is to show clients where things are going wrong and what they can do differently to make changes and become more satisfied with their lives.

How do Counsellors and Clinical Psychologists work?

A Counselling session and a Psychology session can look very similar on the surface. Two people sit across from each other in a room and talk. There are some differences however. In a Counselling session, the client often sets the agenda and decides what is going to be discussed. In a Psychology session I will bring topics that I feel are important to help the client achieve their goals. This difference is a result of the idea mentioned before: in Counselling the client is seen as more of the expert, in psychology, the psychologist is. Due to the scientific background of Clinical Psychology, we are more likely to use questionnaires, structured assessment tools and worksheets.

Another consequence of this difference in perspective is that I often assign home tasks for the client to do between sessions. In order to make changes to patterns of thinking and behaviour, one hour a week is not enough. People have to practice coping skills or different ways of responding to stress between sessions too. In my opinion this development of new habits is the main way that people make lasting changes.

In Counselling, changes are thought to come from the development of insight and understanding. They can also come from processing difficult experiences through talking about them out loud and from having the emotional support of another person.

How do you become a Counsellor or a Clinical Psychologist?

There are lots of different training programmes and qualifications aimed to help Counsellors develop their skills and demonstrate their competency (BACP, n.d.). ‘Counsellor’ is not a protected title however and you do not need any formal training or experience to call yourself one. Counselling has a rich tradition and is a highly skilled profession; there are many experienced and effective Counsellors. It is standard for professional Counsellors to be registered with a regulatory body such as the BACP. Achieving this registration requires a lot of hard work.

There is only one way to become a Clinical Psychologist and that is through the doctoral training programme (National Careers Service, n.d.). This 3 year post-graduate training programme combines academic study and clinical placements and entitles people to use the ‘Doctor of Clinical Psychology’ title. An undergraduate degree in Psychology is necessary to be accepted on to the programme which means that the average new Clinical Psychologist will have been studying and practicing for approximately 8-10 years. In this way, Clinical Psychology training is more similar to medical training than Counselling.

How do you choose between a Counsellor and a Clinical Psychologist?

Both Counselling and Clinical Psychology have the potential to help people to improve their lives. So how do you choose? My advice is this:

If someone does not have a specific problem but is interested in maximising their potential, if they want to process difficult experiences such as grief, loss or other major life events, if they want to understand their experiences and talk about them in detail, then I think Counselling is a good choice.

If someone has a recurring or urgent problem such as trauma or severe anxiety, if they want to develop new coping skills and learn different ways to respond to stress, then I think Clinical Psychology is a good choice.

An important factor is cost. Partly due to the difference in the training demands, the fees charged by each profession tend to vary significantly. Counsellors may charge around £50-60 per session whereas Clinical Psychologists may charge twice as much, £100-120 per session. Counselling engagements tend to involve more sessions however; I see clients for an average of 12 sessions whereas some people may see the same Counsellor for years.

Finally, one of the main activities of Clinical Psychologists is Psychological Assessment. This typically involves questionnaires and an assessment interview with the goal of determining something specific about the client’s psychological situation. For example, Clinical Psychologists may assess if someone is experiencing trauma as a result of an accident at work. This assessment could then be used in court or to access financial support etc. If you need a specialist assessment, then a Clinical Psychologist is usually the best choice.

If you still are not sure, then contact the therapist and talk these points through with them. Most therapists are happy to have a brief chat and answer any questions before you arrange an appointment.

Thanks for reading,

Andrew

Dr Andrew Morgan, Clinical Psychologist

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*A lot of what I am going to say here is my personal view and other people within either profession will have different opinions. There is a lot of overlap between individual Counsellors and Psychologists and everyone has their own personal style. There is more nuance to this topic than can be covered in such a short article. As such, this is intended to be a helpful guide for potential clients, not an exhaustive account.

References

1: Moynihan, C. (1993). A history of counselling. Journal of the Royal Society of Medicine, 86(7), 421-423.

2: Reisman, J. M. (1991). A history of clinical psychology. Taylor & Francis.

3: BACP. (n.d.). Training to become a counsellor or psychotherapist. https://www.bacp.co.uk/careers/careers-in-counselling/training/

4: National Careers Service. (n.d.) Explore careers: Clinical Psychologist. https://nationalcareers.service.gov.uk/job-profiles/clinical-psychologist/

Introduction to therapy for trauma

Trauma is one of the most common issues that I see in both my private practice and my NHS work. Often people who come for help with trauma don’t know what is happening to them or why they are having nightmares, flashbacks or feeling scared a lot of the time. I am writing this article so people experiencing trauma can better understand how therapy can help them to overcome this often frightening and overwhelming situation.

Trauma and anxiety

The first obstacle people face when getting help with trauma is realising that they are suffering with this specific issue and not a more general experience of anxiety. Without specific training or knowledge it is easy to confuse the two. Awareness about trauma is improving however, partly due to media attention focused on celebrities like Prince Harry. Healthcare professionals like GPs, nurses and psychologists are also becoming more knowledgeable about the issue and the need for specialist trauma therapy.

It is no surprise that people struggle to tell general anxiety and trauma apart as one of the main ‘symptoms’ of trauma is intense anxiety. Indeed, psychiatrists used to consider trauma to be a type of anxiety disorder¹. The distinction between anxiety without trauma and anxiety as a result of trauma is important however because they require different types of therapy.

For people experiencing trauma, anxiety can be thought of a consequence of living with traumatic memories. Traumatic memories aren’t just remembered, they are re-lived and can be incredibly vivid and upsetting. Even if people are able to learn effective ways of coping with moderate anxiety in their everyday lives (e.g. breathing exercises or refocusing techniques), their mind can still feel paralysed when a traumatic memory is activated by a trigger.

Anything which reminds that person of the traumatic event (or series of events), such as an advert or story line on TV, a smell, a thought or a noise can act as a trigger which ‘turns on’ the vivid traumatic memory. In these moments the helpfulness of breathing exercises or similar to manage anxiety can feel limited.

What is trauma?

This article is only going to briefly touch on what trauma means in terms of psychology, but if you would like to find out more ‘The Body Keeps the Score’ is a popular book which outlines the concept in more detail². For our purposes a basic definition of trauma is: a person is exposed to an event which causes an overwhelming amount of anxiety (it could be that they or someone they care about is in danger). After this event, the person re-experiences the trauma through nightmares, flashbacks and intrusive memories. In other words, they have times when they feel like the trauma is happening to them again and they may find it hard to remember that it is just a memory.

People often feel highly anxious and like they are constantly on the lookout for danger. They may find it hard to relax and can be easily startled or frightened by things like loud or unexpected noises. Because this experience of reliving trauma is so horrible, the person likely begins to avoid things which trigger off their memory (e.g. people, places, objects) and so their life begins to contract around them. People suffering from trauma can also come to feel very negatively about themselves and their place in the world. They can blame themselves, feel like a burden to others, or like they don’t fit in³.

How does trauma therapy help?

Trauma therapy aims to help people to process their traumatic memory so that they don’t feel like they are reliving it whenever they are reminded of the event. Their body does not react as strongly to triggers and so they feel less anxious. They can start to do more of the things they enjoy and feel more positively about themselves.

There are two main models of therapy which are proven to be effective in processing trauma: trauma focused CBT and EMDR (Eye Movement Desensitisation and Reprocessing). Both are effective⁴ but I have chosen to specialise in EMDR, partly because it requires clients to talk less about their trauma to achieve a positive result, and often this is something which people find very difficult to do.

During doctoral training for Clinical Psychology, we are taught multiple models of therapy. Trauma therapy is special in that it requires additional training after the standard doctorate. This is because it has its own specific nuances and skills which can take a long time to learn and master.

For EMDR there are multiple phases that a therapist and client must go through. To begin with they discuss the traumatic memories, what triggers them off and how they are getting in the way of the client living the life they want to live. Then the therapist and client prepare for processing of memories by practicing exercises which help to calm and relax the client so that they have a way of bringing themselves back to the present and feeling safe after thinking about the traumatic memory. The ‘preparation phase’ normally takes 2-3 sessions and is essential for the work to be carried out safely and effectively.

The preparation phase is followed by the ‘processing phase’ of therapy which is usually the longest part of therapy, taking anywhere from 2 to 12+ sessions depending on how many and how challenging the memories are. During the processing phase of therapy, clients follow the hand movement of the therapist, or alternate tapping left and right on their own bodies (a YouTube search will show you videos of how this looks in practice, as well as more detailed explanations of the different phases of EMDR). This is called ‘bilateral stimulation’ and is done whilst the client thinks about the traumatic memory.

Finally, after the traumatic memories are processes, the therapist and client will think together about the future and do some work to help the client to maintain their progress, and expand their life out to include more of the things they enjoy and care about.

Typically at the start of therapy the client feels highly anxious when thinking about the memory and can experience a temporary increase in anxiety and other effects of trauma. However, when therapy works well, this anxiety reduces dramatically over time. As the memory is processed over the weeks, clients can experience fewer nightmares, less intense responses to triggers and feel more relaxed in their everyday lives.

Why does trauma therapy work?

Although we don’t often like to admit it, in all honesty, scientists don’t really know why trauma therapy works so well. The positive results of trauma therapy are clear, but the psychological and biological mechanisms at work are still hotly debated⁵. As usual with psychological science, we tell a simplified story about how the brain works which makes sense to us: when we are using bilateral stimulation we are allowing the mind to explore new connections between the trauma and other, happier memories.

When done in a safe, supportive environment like the therapy room, this allows our minds to process the traumatic memory in a way which knits it together with the rest of our life story. Instead of feeling helpless or hopeless when we remember the challenging memory, our minds draw on other experiences where we overcame problems to give us a more positive and helpful story which makes us feel like we can cope with the past.

After trauma therapy, we are left with a sad or painful memory, but one which does not jump out and terrify us when we see a related advert on TV, or leave us drenched in sweat upon waking from another nightmare. Given how complex the brain is, I believe we might never really know why trauma therapy works as well as it does. I also believe that as long as we continue to be honest about this and conscientious in terms of the research which proves that it does work, then we can continue to help people in a productive and safe manner.

In my opinion trauma therapy is one of the most challenging therapies for clients and anyone who wholeheartedly engages with it deserves the utmost respect. The fact that I see so many clients who are willing to give it their all, despite how demanding it can be, just shows how difficult living with trauma is and why having specialist therapies like this is so important.

Thanks for reading,

Andrew

Dr Andrew Morgan, Clinical Psychologist

References

1: Pai, A., Suris, A. M., & North, C. S. (2017). Posttraumatic Stress Disorder in the DSM-5: Controversy, Change, and Conceptual Considerations. Behavioral sciences (Basel, Switzerland), 7(1), 7.

2: Van der Kolk, B. (2014). The body keeps the score: Mind, brain and body in the transformation of trauma. Penguin UK.

3: American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596

4: de Jongh, A., Amann, B. L., Hofmann, A., Farrell, D., & Lee, C. W. (2019). The status of EMDR therapy in the treatment of posttraumatic stress disorder 30 years after its introduction. Journal of EMDR Practice and Research, 13(4), 261-269.

5: Landin-Romero, R., Moreno-Alcazar, A., Pagani, M., & Amann, B. L. (2018). How does eye movement desensitization and reprocessing therapy work? A systematic review on suggested mechanisms of action. Frontiers in Psychology, 9, 1395.

Introduction to your first psychology appointment

When I meet someone at their first psychology appointment I almost always ask them the same two questions: a) how are you feeling about today’s appointment? and b) what are you hoping to get out of today’s appointment?

The most common answers are: a) I’m a bit nervous, and b) I’m not sure.

Most people don’t know what to expect from a first psychology appointment and this can understandably add to their anxiety. I am writing this article about what happens at your first psychology appointment so people have some idea of what it might be like. I hope this can help to make the process a bit less nerve-wracking.

It is important to say that one of the key principles of psychology is that everyone is different and therefore any psychologist needs to customise the appointment to fit the individual¹. Having said this, there are some typical parts to a first psychology appointment which I will be describing here.

Goals

Finding out the client’s goals is arguably my most important task when I meet someone for the first time. If we know what they are trying to achieve or what they would like to be different then we can think together about how psychology can help them to make this a reality. It is common for people to be unsure about their goals when they first come to see me and we work together to understand what is important to them and what a positive change might look like. We don’t need to set goals in the first session but starting the thinking process is often helpful.

As a therapist I have my own goals as well. In the first appointment I want to get to know the client. If I understand something about their personality then I can adjust my approach to suit them as an individual. If I understand their strengths and resources (e.g. their interests, achievements, important people in their lives), then we can draw on these things to help them to achieve their goals. If I understand what they find helpful in terms of their psychological wellbeing, then I can include those things in our plan.

What is a psychology assessment?

The technical name for this first psychology appointment is an ‘assessment’. Sometimes assessments include questionnaires although personally I would usually rather spend the time having a conversation with the client to understand their perspective. As I said before though, everyone’s needs are different and sometimes a questionnaire can be very helpful for understanding the situation. 

Assessments are different than the other main type of psychology appointment which is called ‘therapy’. The big difference is that therapy is about making changes in how people think, feel or behave. An assessment is about gathering information. Psychologists will always start with an assessment and usually the second appointment is when therapy begins. After all, how can you help someone make changes if you don’t know anything about them?

Sometimes a person only ever has an assessment and doesn’t continue on to therapy. There are several reasons why this might happen. The client might decide psychology is not for them, they might feel like the particular psychologist is not a good fit for them, or they might just want to get the psychologist’s opinion about a specific issue (perhaps some other professional like a medical doctor or a solicitor wants an opinion from the psychologist).

Common topics

There are some common topics which are covered during an assessment. We will talk about the issues the client is facing. I will ask about when the issues first started and how they have changed over time. I will ask about what kind of things make the issues better or worse. We will talk about the client’s concerns about the future and what life might be like if they were able to overcome the issues.

As mentioned, we will talk about the important people, activities, personality traits and resources which the client has to draw on. This is a crucial part of what is called a positive approach to psychology². It is common for psychology appointments to talk a lot about ‘problems’ (after all, not many people come to speak with me if everything is going perfectly!), but the solutions and the positive aspects of life are just as important. It is these things which help clients to achieve their goals. Therapy, like life in general, is difficult, and we need to use everything we can to support ourselves.

I don’t ask a lot about childhood experiences, unlike some other therapists. In my experience the present and the future are more important than the past when it comes to making changes in our lives. Unlike in TV programmes or films, it is rare for some past experience to be the key to unlocking someone’s psychological wellbeing in a ‘eureka!’ moment. Far more commonly, good psychology is about helping people identify what they want to be different in the future and supporting them to overcome any obstacles they face in the present. During the assessment I will ask a few brief questions about the client’s early years and then we will deal with any significant childhood issues as they come up in therapy. 

Finally I will also ask about things like sleep, physical health, medication et cetera as these sorts of practical issues can have a massive impact on someone’s wellbeing and ability to make changes.

The conclusion of your first psychology appointment

After around 45 minutes of conversation we reach the conclusion of the assessment. I put all the information we have gathered into a psychological story (the technical term is a ‘formulation’) which helps to explain why a person is experiencing the given issues and what might be helpful. A formulation is specific to that individual based on their situation and draws on psychological theory, research and experience³.

Perhaps most importantly, the client and I agree on a plan of action. Often this involves psychological therapy which would typically begin at their second appointment. Sometimes the plan is about something they can do on their own (e.g. reading some self-help material) or with a specialist organisation (e.g. a support group for people with similar experiences).

Sometimes at the end of assessments clients are certain that they want to continue on to therapy. Sometimes they would like some time to go away and think about it. Assessments involve talking about lots of important things and can be emotionally draining. It is natural for people to take time to process what has been discussed and to think about the psychological formulation and the plan.

Whatever people decide, I try my best to make the experience as comfortable and helpful as possible and I hope this article can help in achieving that goal.

Thanks for reading,

Andrew

Dr Andrew Morgan, Clinical Psychologist

References

1: Rogers, C. R. (1951). Client-centered therapy; its current practice, implications, and theory. Houghton Mifflin.

2: Gable, S. L., & Haidt, J. (2005). What (and why) is positive psychology?. Review of general psychology, 9(2), 103-110.

3: Johnstone, L., & Dallos, R. (2013). Introduction to formulation. In Formulation in psychology and psychotherapy (pp. 21-37). Routledge.