PTPC Counselling

“Relationship counselling usually refers to interventions that involve a couple attending multiple sessions with one counsellor, generally together but individual sessions for one or both partners may also be included.” (Hunter & Commerford, 2015, p. 12)

Generally speaking, the term ‘relationship’ can encompass a wide range of relationships, such as the relationship between romantic partners, the relationship between a parent and child, the relationship between relatives, and the relationship between friends. However, for the context of this article, the focus will be on romantic/intimate relationships. It is also important to note that reference to a ‘couple’ is inclusive of marital relationships, de facto relationships, and both heterosexual and same-sex relationships. As such, in our context, relationship counselling involves helping a couple in an intimate relationship to improve and enrich their lives together.

While relationship counselling involves many of the same counselling techniques as individual counselling, counselling a couple is very different to counselling an individual. The following extract aptly summarises some of the challenges of relationship counselling.

“Individual therapy is a smaller world—just you and the client. Your focus can be simple and direct. The process seems easier to control. There is one voice to listen to, one side to take…. Couple therapy can certainly have moments of intimacy like individual therapy but it’s often analogous to a two-ring circus, with each of the partners doing his or her own act for the therapist, or perhaps more accurately, like a courtroom, with each trying to persuade you that his reality, not the other guy’s, is right. And so they stack up facts, and as emotions rise, so does their stack, with both partners pulling up more examples (“What about that time last Christmas when you…”) or offstage collaborators (“My mother said the same thing just yesterday that you…”). Their hope, of course, is that you sift through all this information and angst and judge who is at fault, who is the innocent victim.” (Adapted from Taibbi, 2017, pp. 2-3)

Additionally, Payne (2010) outlines the following challenges of relationship counselling:

The need to manage three-way communications. One of the most fundamental differences between individual counselling and counselling a couple in session together is that there are three people in the counselling room – the counsellor and both members of the couple. Counsellors must adapt their approach to facilitate three-way communication. The counsellor must ensure that both members of the couple are engaged in the counselling conversation and they may even need to adapt their approach. For example, silent time that might be given for reflection in individual counselling is likely to be interrupted by one of the partners in relationship counselling. 

The immediacy of emotions and conflict. The feelings and attitudes expressed during relationship counselling sessions are usually immediately reacted to by the other partner. This can result in the escalation of conflict as the partners speak about previously withheld or misunderstood thoughts, feelings, or events. It takes a skilled counsellor to help clients by maintaining a safe and therapeutic relationship and offering helpful strategies for the couple to use. Additionally, effective relationship counsellors need to continually observe the interactions and reactions of each individual in order to facilitate effective counselling.

Remaining neutral. This means that the counsellor must remain a neutral party and not be perceived as ‘taking sides’ with one or the other partner. Relationship counsellors must rise to the challenge of ensuring both parties feel heard and supported. They must be tactful to ensure fairness, equity, and safety to allow all parties an opportunity to engage in the counselling process.

Managing split agendas. Relationship counsellors must work with the goals and agendas of the couple as a whole as well as the individuals within the couple. Sometimes the partners will have very different goals for counselling and the relationship counsellor will need to successfully balance each partner’s goals/agenda.

Managing ethical issues. Counselling couples can raise some challenging ethical dilemmas due to the nature of a counsellor’s legal and ethical responsibilities. A relationship counsellor has a responsibility to the couple – there is a duty of care to protect them from harm, both individually and as a unit. However, this may not be as easy as it seems. For example, one partner may try to collude with the counsellor to keep a secret, one partner may attend counselling but not participate equally, or one partner may continually speak for their partner rather than allowing them to express themselves. Each of these represent specific ethical dilemmas that relationship counsellors must navigate. 

When making the transition from working as an individual counsellor to working as a relationship counsellor, counsellors must be fully cognisant of these differences and the impact that such differences will have on their practice. Of course, it is also recommended that counsellors take the time to consider the complexities and challenges of relationship counselling and obtain specialist supervision as they embark on this career path. 

The evolution of relationship counselling

Relationship counselling, as we know it today, is very different to its very first form. Historically, relationship counselling first emerged in the 1930’s in the form of ‘marriage counselling’ that was mainly carried out by clergy and medical professionals (e.g., gynaecologists) who would provide advice on adjusting to the practical aspects of married life (Gurman, 2010). However, just like the field of individual counselling, the field of relationship counselling has evolved since its inception. Relationship counselling has been influenced by the evolution of individual counselling theories, the development of family therapy approaches, and the evolution of specific theories for relationship counselling. 

“Couple therapy has historically been a stepchild of sorts in the therapy field, in which individual and family therapy models have been adapted and applied to it. Traditionally couples relied upon their doctors or their ministers to help them with their relationships. The first professional marriage counseling centre wasn’t established until 1930, and for the next several decades couple work was incorporated into psychoanalytic models. In the late 1950s early family therapists began writing about marital therapy from a communications framework. Over the last 10 to 15 years therapists/researchers such as John Gottman (2007), the developer of the marriage laboratory, and Susan Johnson (2004), the co-developer of emotionally focused couple therapy, and Harville Hendrix (2007), the creator of imago therapy, have looked more closely at the unique dynamics of happy, as well as unhappy couples, applying what they’ve discovered to the shaping of the therapy process.” (Taibbi, 2017, pp. 4-5)

There are a wide range of theoretical approaches that can inform the work of relationship counsellors today. Many relationship counsellors practice from a particular theoretical/therapeutic approach, while other practitioners choose to adopt an eclectic or integrative approach given the complexity and diversity of issues presenting in relationship counselling (Gurman, 2010; Snyder & Balderrama-Durbin, 2012). 

“There are two distinct categories of couple therapies. The first includes those originating early in the history of the broader field of family therapy. Although core attributes of these methods have endured over several generations of systems-oriented therapists, they have been revised and refined considerably. Examples of such time-honored approaches are structural, brief strategic, object relations, and Bowen’s approaches. Couple therapies also include a second wave of more recent approaches developed within the last few decades that have become very influential in practice, training, and research – for example, cognitive-behavioral and integrative behavioral; narrative and solution-focused; emotionally focused and Gottman’s; and integrative approaches.”
(Adapted from Gurman, Lebow & Snyder, 2015, p. 2)

As mentioned in the extract above, some major theoretical approaches to relationship counselling stem from theories developed for the field of family therapy. These theories usually emphasise a systematic view of the relationship and propose that changes in the relationship dynamics are necessary for the positive development of the relationship. While many relationship counsellors today do still apply theories and techniques from the field of family therapy in their work with couples, strict use of these family therapy approaches is more often used in work with families, and it is more common for relationship counsellors to apply the general family therapy concepts or ‘second wave’ approaches when working with just couples in relationship counselling. 

When deciding upon an approach to use, it is generally best practice to consider the efficacy of each approach (i.e., how effective the approach is in improving couple relationships). Unfortunately, while there have been great strides taken in recent years in regard to efficacy research in individual counselling, there has not been as much research conducted on the efficacy of the various approaches to relationship counselling. The research that has been conducted does show that, overall, relationship counselling is generally effective.  However, there is limited evidence suggesting any single approach to be more effective than the others (Hunter & Commerford, 2015). In fact, there are number of limitations in research conducted on relationship counselling due to the following factors:

1. Many couples experiencing relationship distress do not seek professional assistance
2. The effects of relationship counselling tend to deteriorate over time
3. Relationship counselling is not effective for all couples
4. Couples having the most relationship difficulties tend to benefit least from relationship counselling
5. There are large number of widely applied approaches to relationship counselling that have not been rigorously evaluated for their effectiveness
6. There is not a lot of ‘transportation’ of research studies to the ‘real world’ of counselling
7. Research continues to largely involve married, middle-class, heterosexual white couples
8. The majority of research has been done by a small number of researchers who are highly invested in the models of relationship counselling they are testing
9. There is limited understanding of why or how different approaches to relationship counselling are effective (Hunter & Commerford, 2015)

Moreover, within the limited number of recent studies conducted on the efficacy of relationship counselling, the available research is mostly American or UK-based – there is a significant gap in research on Australian couples and families (Evans, Turner & Trotter, 2012). At this stage, evidence-based research in relationship counselling still has a long way to come. Therefore, regardless of which theoretical orientation you choose to take in your work as a relationship counsellor, it will be important to continually stay abreast of research in the field and seek out ongoing opportunities for professional development and education to help remain up to date with any best practice developments and ensure your continued effectiveness. 

Editor’s Note: This is an excerpt from the unit Provide Relationship Counselling in AIPC’s Graduate Diploma of Relationship Counselling.

References:

1. Evans, P., Turner, S. and Trotter, C. (2012). The Effectiveness of Family and Relationship Therapy: A Review of the Literature. Melbourne: PACFA. Retrieved from https://www.health.gov.au/internet/main/publishing.nsf/Content/phi-natural-therapies-submissions-containerpage/$file/PACFA%20Family%20Therapy%20lit%20Review.pdf
2. Gurman, A. S., Lebow, J. L., & Snyder, D. K. (2015). Clinical handbook of couple therapy (5th ed.). New York, NY: The Guildford Press.
3. Hunter, C., & Commerford, J. (2015). Relationship education and counselling: Recent research findings, CFCA Paper no. 33, pp. 1-24. Retrieved from https://aifs.gov.au/cfca/publications/relationship-education-and-counselling
4. Payne, M. (2010). Couple counselling: A practical guide. London: Sage Publications.
5. Snyder, D. K. & Balderrama-Durbin, C. (2012). Integrative approaches to couple therapy: Implications for clinical practice and research. Retrieved from https://pdfs.semanticscholar.org/1744/fd7ca1e6e2d66f141196a313495e51fea358.pdf
6. Taibbi, R. (2017). Doing couple therapy: Craft and creativity in work with intimate partner (2nd ed.). New York, NY: The Guilford Press.

AIPC

Understanding Mental Health

Mental health can be defined as a wellbeing state whereby individuals realise their own potential. They could also cope with the common stresses of life and able to work in a fruitful and productive manner while contributing to their community in positive manner (World Health Organization [WHO], n.d., as cited in Queensland Health, 2017). It is often viewed as a positive concept related to social and emotional wellbeing of individuals and their communities. However, mental health exists on a continuum and is not fixed; it could range from an individual functioning healthily to another individual experiencing severe symptoms of mental health conditions. These mental health conditions are also known as mental health disorders or mental illnesses.

Mental Health in Australia

It was estimated that almost half (46%) of the people in Australia aged 16-85 experienced a mental disorder during their lifetime (AIHW, 2020). With the high prevalence of individuals experiencing mental health conditions in the country, Australia has a wide range of mental-health related support services are available in the country for individuals to access. The aim is that with the appropriate supports and interventions, individuals are able to manage and improve their symptoms/mental health conditions, and to maintain mental health. Ultimately, the goal is for individuals to achieve recovery in their own terms (Department of Health, 2021). Keeping in mind that restrictive practices were commonly used in the past, Australia is committed to minimise and if possible, eliminate the use of seclusion and restraint among individuals who are receiving mental health-related support (AIHW, 2020)

Types of Mental Illness

Individuals can experience mental illness when their thinking, emotional state, and/or social abilities are being affected. Typically, this manifests as a disturbance to their work, daily functioning, and/or interpersonal relationships; these disturbances can take place suddenly or gradually in the long run. While different types of mental illness have their own specific set of symptoms, there are still some general signs of mental illness that you should be familiar with. Individuals displaying the below signs may be experiencing mental health conditions, and appropriate support should be provided such that they can receive the relevant treatments to achieve recovery. Listed below are some signs of mental illness that you should be familiar with:

• unusual or illogical thoughts
• unreasonable anger or irritability
• poor concentration and memory, not being able to follow a conversation
• hearing voices that no one else can hear
• increased or decreased sleep
• increased or low appetite
• lack of motivation
• withdrawing from people
• drug use
• feelings that life is not worth living or more serious suicidal thoughts
• becoming obsessed with a topic, like death or religion
• not looking after personal hygiene or other responsibilities
• not performing as well at school or work

The signs above are helpful in assisting you to identify whether your clients and/or those around you may be experiencing mental illness. However, you should always remember that these signs are not definitive that they are experiencing mental illness, and you should never provide a clinical diagnosis of your clients’ situation unless you are qualified and trained to do so (e.g., psychiatrist, clinical psychologist).

Depression

Depression is one of the most common mental illnesses in Australia, whereby around one million people in Australia experience depression every year, or around 1 in 16 Australians. Depression can influence how an individual think, act, and feel, whereby they may feel hopeless, guilty, worthless, and unmotivated to carry out their daily activities. According to Mind (2017), individuals who are experiencing mild depression may still lead their life as usual, but everything may become harder or less worthwhile for them to perform. On the other end, those who experience severe depression may have suicidal thoughts and behaviours, which can be life-threatening.  Depression can also be described as an individual experiencing extreme distress whereby they are in a persistent depressed mood for at least two weeks.

We all can experience symptoms of depression from time to time and that does not mean that we are depressed. It is important to understand there is a difference between the symptoms of clinical depression and an individual feeling unhappy or sad. But of course, if you think that your client or anyone around you may be experiencing depression, in line with your duty of care, you should always direct them to the appropriate support for further care (Betterhealth Channel, 2018).

There are several types of depression that are all characterised by intense low mood, though with some important differences. These include major depression; melancholia; dysthymia; psychotic depression; antenatal and postnatal depression; and seasonal affective disorder.

Just as other mental illnesses, there is no single specific cause that leads to an individual experiencing depression. Every individual who experiences depression has their own personal circumstances that contribute to their mental health condition. Despite not knowing the exact cause of depression, it is still extremely helpful to understand the different factors that play a part in an individual developing depression (Healthdirect, 2020b).

The type of treatment administered for individuals with depression is dependent on a few factors such as the type of depression, severity of symptoms and whether it is a first or recurring depressive episode. With that said, depression is commonly treated with antidepressant medications to assist individuals to manage their symptoms by regulating their mood. However, it may require some time for the antidepressant to work fully, and it may also require the individual and their doctor to work together to find the right type of antidepressant and dosage. This is often complimented with other treatment approaches such as lifestyle changes, psychological treatments (e.g., CBT and mindfulness), community support programs (e.g., training and education, mutual support groups) and physical therapies (e.g., electroconvulsive therapy; SANE Australia, 2021).

Anxiety and Anxiety Disorders

It is a fairly common experience for individuals to experience anxiety when faced with threat, danger, or stress, e.g., facing a job loss, major accident or sudden death of a loved one. These life events typically induce feelings like being upset, uncomfortable, and tense (e.g., pounding heart and rapid breathing) but they usually go away after a short period of time. However, for individuals who have anxiety disorders, their anxious feelings are often excessive and irrational, which could interfere with their daily lives as these feelings are persistent. Hence, similar to depression, not everyone who experiences anxiety have anxiety disorder.

About 25% of Australians have an anxiety disorder that requires treatment and support, while another 25% of Australians experience less severe anxieties such as fear of snakes or spiders.

While most of the anxiety symptoms are common between the different anxiety disorders, there are still some stark differences between each of them. A few of the most common anxiety disorders include generalised anxiety disorder; social phobias; panic disorders; agoraphobia; obsessive compulsive disorder; and trauma and stress-related disorders (Betterhealth Channel, 2020).

There are no known exact causes of anxiety disorders, and it is usually due to a mix of different factors. When determining which treatment or intervention for an individual with anxiety disorders, there are many considerations to take into account. For example, what type of anxiety disorder and its severity; individuals with milder form of anxiety disorders may alleviate their symptoms by implementing lifestyle changes while those who have more severe forms of anxiety disorders may require medicine. Typical treatments for anxiety disorders are as below include cognitive behaviour therapy; exposure therapy;  anxiety management and relaxation techniques; and medication (Betterhealth Channel, 2020).

• Anxiety management and relaxation techniques: for example, deep muscle relaxation, meditation, breathing exercises and counselling.
• Medication: this may include antidepressants and benzodiazepines

Bipolar Disorders

Bipolar disorder is a severe mental health condition that was known as manic depression. This is because individuals who have bipolar disorders experience extreme moods; low (depressed) and high/excited (manic). Individuals who experience these mood and energy changes can also experience changes in their behaviour, which changes their daily functioning. While it is a common experience that our mood shifts to respond to the different life events, individuals who have bipolar disorders tend to have their moods fluctuate more than usual. According to Healthdirect (2020a), about 1 in 50 Australians (1.6%) are affected by bipolar disorder each year; more women are affected than men.

Individuals will experience extreme moods at different times for a period of time: manic (or hypomanic) episodes and depressive episodes. Different individuals experience the moods for different periods of time, whereby an episode can last for weeks for some, and it can last for months for others. Individuals will develop different symptoms depending on whether they are experiencing a manic or depressive phase (Healthdirect 2020a). Some individuals with bipolar disorder may also experience psychotic symptoms. These symptoms include hearing voices or delusions that are usually in the context of their current mood state/episode. For example, if the individual is in a depressive episode, they may believe they have severe physical health problems or they are in poverty. Individuals experiencing a manic episode might think they have special powers or special mission (Queensland Health, 2017).

While there are different types of bipolar disorders, the two most common types of bipolar disorders are listed below (Healthdirect, 2020a):

• Bipolar I Disorder: Individuals who have extreme, long-lasting highs (mania) and depressive episodes are diagnosed with it. Individuals who experience psychosis may also be diagnosed with this.
• Bipolar II Disorder: Individuals who experience highs that are less extreme (hypomania) and depressive episodes are diagnosed with it; a hypomania episode may last for only a few hours or days.

Individuals with bipolar disorders typically requires long-term medication to help manage their symptoms. Other than medications, they may also receive psychological therapy and alter their lifestyle. Individuals with bipolar disorders are typically prescribed with medications to alleviate their mood swing symptoms, e.g., mood stabilisers and/or antipsychotics (if there are psychotic symptoms present). Some individuals may receive electroconvulsive therapy (ECT) for individuals who do not respond to treatments for their mood episodes (Healthdirect, 2020a).

Schizophrenia

About 1 in 100 Australians are affected by schizophrenia, which is characterised by disruptions to thinking and emotions. Individuals with schizophrenia typically experience reality in an altered way, which are usually manifested in psychotic symptoms. According to Betterhealth Channel (2014), 20% to 30% of individuals with schizophrenia experience only a few brief psychotic episodes (i.e., psychosis) while it is chronic for others. During a psychotic episode, individuals can lose touch with reality and have reduced motivation, flattened emotional expression, and may find it challenging to process information. You should also keep in mind that individuals with schizophrenia are at a higher risk of suicidal behaviours.

Schizophrenia has a wide range of symptoms and it can vary across everyone and they are typically categorised into psychotic symptoms and non-psychotic symptoms. These symptoms can have negative consequences in the individual’s life, especially in relation to their daily functioning. As a result, individuals may be socially isolated and alienated by those around them. This is because individuals who experience the symptoms are often unable to participate in normal conversations or social events. Some of them may also lack enough motivation to carry out simple daily activities such as bathing or cooking. Some individuals with schizophrenia may also lack insight into their behaviours’ appropriateness and how that could appear to others (Betterhealth Channel, 2014).

Some individuals can recover from schizophrenia completely while some others may experience episodes, whereby they experience their symptoms come and go. Typically, individuals with schizophrenia receive a few different types of treatments to help manage their symptoms and achieve the best outcomes in their life. Medications such as antipsychotics are the main form of treatment for schizophrenia to help reduce and manage psychotic symptoms. Individuals would also receive psychological interventions to assist them to have a better understanding of their symptoms and learn how to manage and cope with them. Interventions usually include CBT and family therapy. Individuals with more severe symptoms (or out of control) could be admitted into hospital for further medical care to manage these symptoms (Healthdirect, 2020d).

Personality Disorders

Individuals who have personality disorders experience long-term thinking patterns, and behaviours and emotions that are extreme, inflexible, and dysfunctional. Consequently, individuals may find it challenging and distressing to perform daily activities. It can also be challenging for them to change or alter their behaviours and/or adapt to different situations; some individuals find it difficult to form positive relationships with others and/or maintain work.

It is important to recognise that personality disorders are distinct from personality traits. The latter can be explained through theories such as different personality types. For example, some individuals are more conscientiousness, whereby they are more careful and are able to exercise high self-discipline to achieve their goals. On the other hand, individuals with personality disorders often experience severe symptoms that could cause distress to their life and often find it challenging to control their own behaviour (Healthdirect, 2020c).

There are a wide range of personality disorders and hence different ways to classify these disorders. In general, they exist on a spectrum along with the normal personality traits, which means that some individuals may possess some features of a personality disorder without necessarily having the entire disorder, i.e., not experiencing every symptom of the disorder; some individuals could also exhibit symptoms of more than one personality disorder. With that said, personality disorders are loosely classified into three main groups, or clusters.

• Cluster A: Individuals are described as having odd or eccentric thoughts and/or behaviours.
• Cluster B: Individuals are described has having unstable emotions and dramatic impulsive behaviours.
• Cluster C: Individuals are described as having anxious and fearful thoughts and behaviours.

The main form of treatment for personality disorders is psychotherapy, which can effectively help individuals to manage their symptoms. Psychotherapies can also assist them with working on their lifestyle such as establishing satisfying and stable interpersonal relationships and making positive behaviour changes. These therapies include CBT, dialectical behaviour therapy (DBT), psychodynamic psychotherapy, and psychoeducation.

Editor’s Note: This is an excerpt from the unit Provide Recovery Orientated Mental Health Services in AIPC’s Diploma of Mental Health.  

References

1. AIHW. (2020, July 23). Australia’s health 2020. https://www.aihw.gov.au/reports-data/australias-health
2. Betterhealth Channel. (2014, May 31). Schizophrenia. https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/schizophrenia#current-treatments-for-schizophrenia
3. Betterhealth Channel. (2018, July 24). Depression Explained. https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/depression
4. Betterhealth Channel (2020, May 18). Anxiety disorders. https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/anxiety-disorders
5. Department of Health. (2021, March 17). About mental health. https://www.health.gov.au/health-topics/mental-health-and-suicide-prevention/about-mental-health
6. Healthdirect. (2020a, September). Bipolar disorder. https://www.healthdirect.gov.au/bipolar-disorde
7. Healthdirect. (2020b, December). Depression. https://www.healthdirect.gov.au/depression
8. Healthdirect. (2020c, December). Personality disorders: An overview. https://www.healthdirect.gov.au/personality-disorders
9. Healthdirect. (2020d, December). Schizophrenia. https://www.healthdirect.gov.au/schizophrenia
10. Mind. (2017). Understanding mental health problems. https://www.mind.org.uk/media-a/2942/mental-health-problems-introduction-2017.pdf
11. Queensland Health. (2017, June 6). Signs of mental illness. https://www.qld.gov.au/health/mental-health/signs
12. SANE Australia. (2021, April 20). Depression. https://www.sane.org/information-stories/facts-and-guides/depression

AIPC

12 Common Counselling Approaches

Although there are many more, here are twelve (12) of the most common approaches:

Counselling Type	Key Points
Psychodynamic	Focused on how past experiences affect current problems Concerned with unconscious drives and conflicting aspects of personality Traditionally, the therapist takes the expert role
Interpersonal Counseling	Diagnosis focused Concerned with interpersonal relationships Therapist functions as a client’s ally
Client-Centered Therapy	Humanistic approach Focused on realizing human potential Supports client discovery Counselor is empathetic, nonjudgmental, and nondirective
Existential Therapy	Focused on what it means to be alive Non-symptom focused Clients guided in discovering unfulfilled needs and realizing potential
Cognitive-Behavioral Therapy	Focused on how both thoughts and behaviors affect outcomes Evidence-based, effective, and highly versatile
Mindfulness-Based Counseling	Focused on feelings and thoughts in the moment, without judgment Includes CBT with a Buddhist-based mindfulness component Highly versatile
Rational Emotive Therapy	Focused on how faulty thinking relates to distress Therapist is active and directive
Reality Therapy	Focused on the present day Non-symptom focused Promotes individual responsibility and taking control of one’s life Counselor is positive and nonjudgmental
Constructionist Therapy	Focused on how cultural influences and interpretations shape meanings Strong interest in language Client driven, counselor acts as collaborator
Systemic Therapy	Focused on how systems (e.g., school, work, family) affect underlying issues Therapist collaborates with people across and within systems
Narrative Therapy	Focused on the stories we tell ourselves about who we are Counselor works collaboratively to create alternate stories
Creative Therapy	Focused on the use of artistic expression as a cathartic release of positive feelings Highly versatile — music and various art mediums may be used

H.S. Lonczak, Ph.D.