Talking Therapy: Counselling vs CBT (Cognitive Behavioural Therapy)
What are ‘Talking Therapies’?
The term ‘talking therapies’ refers to a wide range of different psychology-based treatments for mental health issues, including disordered eating and body image.
Therapy may be used as an alternative to medication, or used alongside it. You may be referred to an in-person therapy session, or have therapy over the phone or online via video call. Some types of therapy are provided by the NHS via GP or self-referral but you can also access them privately, though this can be expensive. If you approach a mental health charity, often private therapy can be offered at a price based on a sliding scale related to your household income.
Different types of Talking Therapies
Some of the most common types of talking therapies you will come across include:
Cognitive Behavioural Therapy (CBT)
Dialectical Behavioural Therapy
Counselling
Psycho-dynamic counselling / psychotherapy
Below I’ll discuss each of these, along with the advantages and disadvantages
What is Cognitive behavioural Therapy (CBT)?
CBT refers to a practice in which with the help of a trained professional, you will explore your thoughts (cognitive processes) and how these impact your actions (behavioural response). During the sessions, your therapist will assist you in breaking down your problems into smaller, more manageable parts or stages, such as your thoughts, your feelings and then your actions.
A practice I use with my clients and students on my coaching courses is the ‘Worry Tree Exercise’. With this exercise, we take a particular problem and ask ourselves firstly, are we falling in to a ‘thought trap’ or ‘Cognitive Distortion’? Examples of thought traps include downplaying positives when it comes to how we view ourselves or catastrophic thinking (imagining the worst possible scenarios.
We then ask whether the issue is within our control, i.e. is there anything we can do to help the situation?) or out of our control. If an issue is something in our control, we move on to create a 3 step action plan for tackling it and note down a date in the future for when we returned to our ‘worry tree’ and reflect on our progress.
If an issue is out of our control, we work on accepting it for what it is right now, and set a date in the future to return to it and reflect on whether the situation has changed. Doing this, helps clients see that more often than not, things turn out better than we think they will, and reinforces the universal truth that everything in life is temporary and that they are strong enough to get through different times.
This is a good example of how CBT can be used to break problems down and look at them objectively, instead of getting trapped in a cycle of ruminating on the ‘what ifs’ and catastrophising a situation, leading to further feelings of anxiety.
CBT therapy is usually provided in the form of a short-term course of treatment, lasting around 8-12 weeks with 30-60 minute sessions once a week.
The advantages of CBT:
CBT has been show to be very effective for anxiety, depression, PTSD, OCD, anger and self-esteem.
It’s a short-term therapy and typically more accessible than longer term counselling (in terms of availability on the NHS and length of waiting lists).
CBT is highly structured and practical and because of this it can be provided in different formats, including small in-person or online groups, self-help books and apps. A CBT app I really like is Moodnotes for iOS as this takes you through the process of identifying your negative thinking, feelings and cognitive distortions.
The skills and practical strategies you learn in CBT can be used in everyday life and long after the course of treatment has finished. You may find that self-help books and online CBT courses are useful to refer back to after a course of intensive therapy to remind you of the the strategies and tools you will have learnt.
The disadvantages of CBT:
It is not a passive treatment, you need to commit yourself to the process to get the most from it. A therapist can help and advise you, but they need your co-operation. Your therapist cannot tell you what actions to take, they are there to help you understand your thoughts and feelings on an issue, look at them objectively and understand how your thought patterns influence your actions.
Attending regular CBT sessions and carrying out the extra work between sessions (such as worksheets and mood logs) between sessions can be time consuming.
It may not be suitable for people with more complex mental health needs or learning difficulties, as it requires structured sessions.
The structured nature can feel restrictive for some people, who may instead prefer the free flowing nature of counselling.
It can be emotionally challenging to confront your emotions and anxieties head-on.
It focuses on the person's capacity to change themselves (their thoughts, feelings and behaviours) but this doesn't address any wider problems in systems or families that often have a significant impact on someone's health and well-being. It’s important that we recognise the impact of environmental factors such as socialisation, housing, work and life events, as well as economic, cultural and religious influences, in shaping someone’s circumstances.
Some critics also argue that because CBT only addresses present-day problems and focuses on specific issues, it doesn't address the possible underlying causes of mental health conditions, such as an unhappy childhood. Other methods of therapy, such as Psycho-dynamic , address past traumas and experiences, and their role in shaping present-day thoughts and behaviours.
What is Dialectical Behavioural Therapy (DBT)?
This is based on CBT, but has been adapted for intense feelings, like those seen in patients with borderline personality disorder. 'Dialectics' means trying to balance opposite positions, in DBT, this means striking a balance between acceptance and making changes. DBT is very much like CBT in that it focuses on your thoughts and behaviour, but different in that it encourages you to accept who you are, at the same time.
DBT was developed originally to help clients with Borderline Personality Disorder but is increasingly being used for mental health issues. In my social work practice, I became familiar with DBT in in the context of rehabilitation for drug use. These days , I draw on this approach when working with disordered eating behaviours, and find it works particularly well for emotional eating. and Binge Eating Disorder.
DBT therapy is focused on changing problematic behaviours (for example, drug use, self-harm, restrictive eating). It may be that changing your behaviour isn’t the main thing a you want to get out of treatment. For example, you may want to explore past trauma before addressing a coping mechanism.
What is Counselling, and how does it differ from CBT?
While CBT therapists and clients work together to change a client’s behaviour or thinking patterns, counselling is less directive.
The counsellor will listen to the client with empathy, without passing judgement or criticism. They will offer challenges to the client’s thought processes and in doing this, the client is able to safely explore their thoughts and feelings and as a result, gains a better understanding of themselves .
Clients are encouraged to find their own solutions to cope with the issues that face them. Counselling is not about giving advice, instead it is about providing a safe space for self-reflection.
Sometimes the term ‘counselling’ is used to refer to psychotherapy and vice versa. I’ll discuss what is meant by psychotherapy and how it differs from counselling shortly.
Counselling and psychotherapy tends to take place over the long-term rather than as a short-term course like CBT and DBT.
Advantages of Counselling
In-person counselling can feel more personal compared to over the phone. Counsellors are trained to observe subtle cues in your body language (such as facial expressions and the way you are sitting) to get a deeper understanding of what you are saying and how you are feelings.
All formats of individual counselling (in-person, online, telephone) can help develop your self-awareness and put you on a journey of self-exploration and reflection. As a result you will learn a lot about yourself and develop the skills of communication, setting healthy boundaries in relationships, and develop healthy coping skills.
Disadvantages of Counselling
An issue which is perhaps considered taboo and is rarely talked about, is that the chance of getting too personal and emotionally attached to the counsellor are high. It’s easy to see how this may occur, as the counsellor represents unconditional support and empathy, which may be qualities the clients lacks in their personal relationships.
Counselling is a longer term approach and you may find there are weeks where you’re not “getting anywhere”, or weeks where you experience a relapse. It is normal and part of the process, but can be unsettling for people who are used to the structured CBT approach where there is a start and end point of treatment and mental health symptoms are measured throughout the treatment using assessment tools.
It can be tempting for clients to disengage when they begin to feel well and don’t wish to talk about difficult issues, while the issues remain unresolved. This is less likely to be a problem for private clients, but it can be challenging for NHS clients who have to go through re-engagement procedures (after a certain period of time this may mean re-joining a waiting list or completing a self-referral again).
The outcome of the therapy very much depends on the individual counsellor’s knowledge of a problem and their ability to ask the right questions. Some counsellors may ask inappropriate questions owing to a limited knowledge of a issue. To give an example, a client may present with body image issues and speak of weight loss. A counsellor with limited experience in treating eating disorders may focus on how to encourage actions which support the client’s goal to lose weight, rather than unpicking the driving forces behind the desire to lose weight, such as a history eating disorders, disordered eating, a desire for love or acceptance which the client believes can only be gained with weight loss, using restrictive eating as a coping mechanism for stress or trauma.
What is Psycho-dynamic Counselling / Psychotherapy?
The terms ‘Psychotherapy’ and ‘Counselling’ are often used interchangeable these days, but the term ‘psychotherapy’ has its roots in Sigmund Freud’s Psychoanalysis and the development of Psycho-dynamic thought. This area of psychology was then added to by the theories of Swiss psychiatrist, Carl Jung, Austrian psychotherapist Alfred Adler and others.
Drawing on Psycho-dynamic theories, psychotherapy involves exploring traumatic memories from the past, particularly childhood. It focuses on personality and the unconscious mind, rather than behaviours and conscious thought patterns. This area of therapy suits individuals who are keen to explore their thoughts and feelings and develop a greater understanding of themselves.
Finding the right professional
When seeking any form of treatment or diagnosis, it’s best to begin with your GP. Your GP can make referrals on your behalf, advise you on who can help with your specific needs and provide you with details need for self-referral. You GP may also run additional tests to rule out any health conditions which may contribute to your symptoms.
You may also wish to search registers of professionals, particularly if you’re seeking private therapy. These registers make it easy to compare numerous factors, such as geographically area, expertise and cost. The links to these registers can be found at the end of this post.
If you wish to have private therapy (the advantage of which is not having to wait on NHS waiting lists) but at the same time struggle to pay for your therapy, it’s worthwhile check with mental health charities as these can signpost you to services who offer treatments on a sliding price scale based on your household income and sometimes may also be able to provide free support themselves. Relevant charities can be found at the end of this post.
What type of professional should I look for?
There are many different types of mental health professionals, with many different letters after their names, which can be confusing to know who to turn to.
Here’s a handy guide to the different professionals you may come across, along with what they specialise in, their qualifications and any registration requirements, where appropriate.
Counsellor / Psychotherapist (therapist)
The aim of both psychotherapists and counsellors is to create an environment in which you feel safe discussing your feelings. Counselling can take place on an individual basis, in groups, or in families and couples. Counselling sessions can take place face-to-face, via Skype, by email or over the phone. Counsellors encourage you to find your own solutions, rather than telling you what to do.
What you need to know about counsellors & therapists:
The term ‘counsellor’ or ‘psychotherapist’ is not legally protected title in the UK.
You are advised to check a counsellor/therapist’s qualifications and experience.
Counsellors and therapists are trained in psychotherapy, usually to degree or post graduate level.
Some therapists take on additional training to specialise issues, such as eating disorders, low self-esteem, trauma, phobias, abuse, anxiety and depression, family issues, marriage, addictions.
Psychologist
Psychologists are often either entirely research-focused or 'applied' (meaning they treat clients).
Counselling psychologists tend to deal with the same types of issues as counsellors. These include bereavement, trauma and relationship issues. They also take on more serious, long-term issues such as domestic violence and sexual abuse.
What you need to know about psychologists:
Many psychologists choose to specialise in a type of therapy (for example CBT or neuropsychology).
To have the title ‘psychologist’, the individual needs to have a degree in psychology.
A counselling psychologist will need to have a doctorate in counselling psychology, as well as a general degree in psychology.
There are many titles within the psychology industry that are restricted by law in the UK. These include clinical psychologist, counselling psychologist, educational psychologist, forensic psychologist, health psychologist, occupational psychologist, practitioner psychologist, registered psychologist, sport and exercise psychologist.
This means that anyone with these titles must be listed with the Health and Care Professions Council (HCPC) by law. (http://www.hpc-uk.org/check/ )
Being listed with the HCPC ensures that they have had the relevant training and adhere to a strict code of conduct.
Psychiatrist
A psychiatrist is someone who has had medical training and has decided to specialise in psychiatry. The term psychiatry refers to the study of mental disorders. This includes their diagnosis, management and prevention. Psychiatrists often work on a broad range of cases alongside an area of expertise and research.
What you need to know about psychiatrists:
As psychiatrists have medical training, they can do things other mental health professionals can't. For example, a psychiatrist can carry out medical tests (i.e. blood tests and CAT scans). They can also prescribe medication should it be required.
For an individual to call themselves a ‘psychiatrist’, they must train for five years as a doctor. A further two years of 'foundation' jobs is needed before specialising in psychiatry. To become a fully trained psychiatrist it typically takes another four years of dedicated study. There is also an option to specialise further still.
You can check the details of a psychiatrist, including their area of speciality, by looking on the medical register, a directory of all practising doctors in the UK. (http://www.gmc-uk.org/doctors/medical_register.asp )
If they have the letters MRCPsych (Member of the Royal College of Psychiatrists) or FRCPsych (Fellow of the Royal College of Psychiatrists) after their name, they're a current member of the Royal College of Psychiatrists (RCPsych).
Useful links for searching for a professional in your area
Relevant UK Mental Health Charities
Samaritans:https://www.samaritans.org/
Anxiety UK:https://www.anxietyuk.org.uk/
Beat Eating Disorders: https://www.beateatingdisorders.org.uk/
If you are seeking talking therapies in the UK and have any further questions about them which have not already been covered in the post, feel free to drop your questions in the comments below.
