Taking that first step to book a counselling session can be a daunting experience and sometimes it can take a while to reach this point. We often feel that we should be able to manage what troubles us better, just stop that habit or addiction or already possess the willpower to change ourselves. There's often a considerable amount of inner judgemental and demeaning self-talk involved that at times can feel like it goes non-stop.
We are often using all that we know and learned to cope and change, but as a species driven toward endless education, betterment and survival, often what we need to admit that we do not actually know or have the answers to escape the bonds and more often than not we are reluctant, embarrassed and ashamed to admit we cannot cope. As was once famously said, doing more of the same and expecting different results can equal madness, yet that is how we are wired and generally makes a solid argument for why counselling and psychotherapy exist.
Historically we searched for solace in the religion of our society and its inherent guidance or wisdoms in times of personal or collective strife. In our globalised and fast-paced contemporary world, many of us have found limitations with these systems, often enough to make us abandon them, but where do we go? Some of us use logic, reason and science and others find ground and peace through secular and non-secular practices of a more spiritual orientation. For many now, the GP and the biomedical model is the first point of call, but the problem is that medical practitioners are time limited and often not deeply trained for interpersonal and empathic mental health support on the emotional or psychosocial level.
Counselling and psychotherapy offer a more suitable model for longer support and facilitation of change and growth.
If you are reading this page, you may be seeking a counsellor or you already did some counselling or do not feel that your existing attempts are working. Maybe also have mastered more entry level or empirical approaches to your mental health such as Cognitive Behavioural Therapy (CBT) and either the issue persists, feels deeper or is wanting for a different angle.
Choosing a counsellor is not easy, right? Get on Google, form a few quick judgements from people's photographs, read some things you like, or not and then take the risk of booking a session. It is clear that not every practitioner is right for every client and maybe it may take a few attempts of connecting, learning and asking yourself within if the connection feels right.
The therapeutic relationship and gold standard treatments
Practitioners like everyone else come from all walks of life and have had different challenges and experiences. One practitioner may be highly informed with lengthy qualifications but may never have undertaken their own therapy or had much training in university working with people. Another may have minimal qualifications but grown up in an environment that challenged them significantly enough to go on and work with supporting others to get through similar challenges.
Ultimately though, the managed care debate in the USA a while back saw psychotherapists who were afraid of being sidelined by a medical and for profit evidence-based model undertake extensive research into what works in therapy. They found that the therapeutic relationship was the most important contributing factor to successful outcomes in therapy, more so than qualifications or type of therapy used.
Guided by an understanding of human nature and our psychological development, this makes a lot of sense. Attachment theory amongst others has demonstrated that we are relational beings who form bonds, trust or distrust and a resulting sense of security with others.
On the other side, more studies have been undertaken on Evidence Based therapies such as CBT than one really wants to read. There's no question these therapies are effective, but limitations can include lack of follow-up at intervals after treatment to see if the effect holds.
There are many valid arguments for all approaches, however consider what you need. If you have never attended therapy, are experiencing anxiety or depression and don't know why or where to begin, my approach would be to work with CBT with you. If you have worked with several therapists, understand yourself fairly well and know your story inside and out, yet still experience the symptoms of the complex trauma of abuse stemming from childhood, more cutting edge and longer term approaches such as somatic (body-based) therapy may over the longer term give you the answers, skills and inner solutions you need to stay with often intense emotional experiences.
So how did we get here and who is right?
We live in a time of great complexity. We want evidence and certainty, we also want stability and various forms of security. Western psychology emerged from the work of Freud and it was often the wealthy who could undertake longer term psychoanalysis. The pressure emerged particularly in the USA for change for a variety of reasons, but the for-profit model of health care was not prepared to fund such lengthy pursuits and timely also was the need for simpler models that catalysed quicker and more cost effective change without the need to exhume the whole past.
These models could only prove their benefit if they showed results and the system required the evidence to provide the funding. Thus, modalities like CBT, Solution-Focused, ACT are heavily driven by an Evidence-Based structure and popular particularly with the bio-medical approach to treatment which sees a practitioner take an empirical or observational approach to the client and their problem with techniques designed to unlock it.
This created a big challenge to more humanistic approaches that take a more psychosocial orientation and work with emotions and feelings. Modalities that had developed over lengthy periods of time and were perceived to be effective now had to prove their worth. Psychodynamic psychotherapy remains challenged that the very nature and the longer term duration of its approach means that often it will not be funded by goverments or insurance companies.
Thus, no one is really right and this is a very brief summary of the very complex issues, but some questions may arise as you search for a new therapist that could include considering the following:
- If you are seeing someone under Medicare but you have used up your 10 sessions, but found it helpful and like the therapist, you may continue and self-fund. If you cannot afford the full fee, many Medicare practitioners charge more cause of the rebate and there are excellent and potentially more cost-effective therapists around.
- If you feel like you only believe in an evidence based approach, but don't really like the therapist and are not really getting better, could it be worth rethinking if your values and beliefs are forming a barrier to effective treatment?
- If you benefitted from CBT or other evidence-based treatments, yet feel you mastered these modalities and yet there is still an underlying issue and concern that you have not resolved, could it be worth considering you need to either ask you practitioner to work in other ways with you, or if they cannot then consider a change?
Therapists and their models
There are many reasons why therapists and healthcare professionals will stick to and enforce certain approaches. In Australia a core one is that the service providing the funding for care will not do so unless there is evidence given for its efficacy. Another is that they are trained in a certain approach and that is how they work and that is what they believe works for their clients.
Many practitioners hide behind the label of the professional in a similar way to others in the broader scheme of our market driven society. They meet the requirements of their registering body and professional association and ensure professional development training is undertaken to keep their skills up to date. This can often detract from the need for personal development and self-care.
Therefore, it is worth considering or even asking if your therapist has ever been a client or if they undertake personal development activties that help them grow as a person and support resistance and resiliance to vicarious traumatisation and burnout. It is also worth considering if the therapist is open and empathic toward you and can really relate to you as a person and you feel really listened to, engaged with and understood. Examples of where this is not happening could be that the therapist is directive and insists you follow the model of their therapy rather than take an interest in your feelings and experience of the process.
Therefore, on the other side of the empirical is the subjective. As therapists, we can never truly understand or be fully immersed in your subjective experience. We need to go on what you tell us and effectively respond and make changes to be more congruent or challenge client's blocks and defenses to determine if they are a help or hinderance. Many of the nuances of the relationship take more than just a uni degree and a modality of practice. They take the cultivation of empathy, compassion and other factors that are very difficult to measure.
In Western society we find it easy to use rationality and logic to explain cause and effect. Therapists who fight empirically with a stated direct, subjective experience of the client may not be achiving their desire to help the client change and at worst, can be dangerous.
Thus, consider whether you need an applied model of change and where you may need to question the authority or direction of that model and its practitioner if you fail to see positive evidence and benefits in your life. How the therapist responds to that challenge may well dictate whether they are the right practitioner for you.
Some factors beyond evidence-based models
Our society and its neoliberal tendancies have their drawbacks and can leave many of us who have emotions, feelings and who just do not get better by what they are being told to do wanting. A dark side of this era arguably is that in some way most of us are in business and agenda driven. Thus, the collateral of the wars we fight is that it provides jobs for therapists specialised in relieving post traumatic stress. That the social and interpersonal fallouts from national highly profitable industries such as alcohol and poker machines again create jobs for therapists.
Existentially we may experience pain, stress and mental health issues if this is happening to us, a family member or in our societies. Directly we may feel a loss of meaning cause of the hours we work or how much debt we have or that we cannot get out. We can use a variety of techniques to increase resiliance or performance and many of these are evidence-based approaches that fit the societies that created them.
Or otherwise we may be looking for an approach that helps us cope with the sense that things are not ok, we don't want to go back in to that horrible job or boss or we no longer share the values with our partner and we want to leave them. Such issues may be further exacerbated by issues from our past of all kinds that happened to us or impacted us in those around us.
In this, you may also consider that you are searching for something more, something or someone who brings meaning. Again, the loss of religion in your life or society does not equate to the loss of a spritual self. You can actually still have this and develop something personal and precious that is more you than the crazy society and all its impositions on us can touch. Again, psychotherapy with the right therapist can help you establish and stabilise deep inner meaning for you in a way that supports you and deep change in your inner relationship with yourself, others and the world.
Names and labels
Finally, if you are confused with all the titles out there in Australia, you are likely not alone. This is partly because many professionals can overlap in the skills and offering they bring to their clients. Let's take a look:
are medical doctors and can prescribe powerful psychiatric drugs. They also have legal authority over people and can make powerful decisions regarding the freedom of others based on their presenting medical health. Seeing them will get you a higer rebate, but they are often expensive, highly booked and considerably less findable outside of capital cities. Often they are flown at high public cost to see rural people where they don't choose to live. Many psychiatrists work therapeutically with evidence-based approaches though a few may have wider interests in psychology and psychotherapies.
- Clinical psychologists
can be either based in practice or research. Many can be highly experienced in psychotherapies or they can take a more research and professional orientation to practice and work less directly in this way with clients. They can be more expensive.
have generally undertaken less study than their Clinical counterparts. The psychology programs in Australia include a lot of analytical and statistical work along with the science of the profession, but actually the direct learning and training around working as a counsellor face to face with people is limited to very few subjects across the degree. A few psychologists will undertake further studies in these areas, but many perform a lot of evidence based approaches if they work directly with clients and often you will have been referred to one of these under Medicare by a GP. Where a health professional hides behind their theories, the empathic counselling relationship may be slow to develop.
- Social Workers
study a broad variety of areas often related to community practice or certain demographics of population such as aged care, drugs and alcohol or child protection. There is more counselling training in Australian degrees but again with evidence-based approaches. Social workers in private practice are fewer though some are accredited for Medicare rebates and use the title AHMSW. A social worker could be more a case manager of many clients in a service agency and thus less focused on providing broader counselling outside a specific problem.
are generally well trained in working with people and often use more advanced therapies. They are often one of the above and may use this title to indicate they work with people, generally in private practice. Psychotherapy per se is not usually funded long-term by agencies or government and is often self-funded. The professional label is a grey area that usually is not the only title this person will have, or if they do then they are likely a more experienced version of a standard counsellor.
is a very broad term and it is helpful to look at the person's experience as really, anyone can call themselves a counsellor and the training can be at times minimal. That's not to say that someone may be a counsellor in a particular area such as addiction or homelessness and be very adept at what they do because they have direct experience personally or in their families and friends of the issue in which they practice. It can however be helpful to look at a counsellor's professional accreditations such as level of association membership, practice areas and other qualifications such as psychology or social work as they may refer to themselves as a counsellor but have a deeper qualification.
- Life coach, mentor, corporate/organisational psychology
and other similar terms present a specific flavour regarding a specialisation such as the work place, sporting world or providing support to students at an educational institution and so on. They may have another qualification, often a first psychology degree but may be more practically oriented to their chosen field and less adept at supporting mental health concerns or crisis management and more corporately driven.
- Nurses and Occupational Therapists
also get much exposure to mental health issues and if they have chosen, can have aligned their careers to this field and have Medicare accreditation to provide mental health services. Many will often train in counselling or other psy professions to support their careers and can be very experienced in specific areas or later become counsellors or psychotherapists.
So should I choose someone only on Medicare?
We would argue no, but there are many opinions. Professionals on Medicare are required to perform evidence-based therapies with you. Their level of qualifications and time taken to attain them may see them charge higher prices but they may not have direct detailed training as a counsellor. The sessions may be shorter (50min) as time is needed to write notes and reports and with a limit of 10 sessions a year, this may not be enough to establish a strong relationship for change unless you continue out of your own pocket.
Further, the sessions are certainly not free or bul billed and the refund may see you paying a similar amount as if you were to see an excellent counsellor or psychotherapist who generally charge less and have made working with others their craft. Thus, a 50min session for $250 with a psychologist doing CBT with $125 or so refund leaves you paying $125. Many excellent and more deeply trained and experienced psychotherapists charge $100-130 for a full hour and can work freely with you to directly meet what you need now rather than imposing a certain approach as required by the scheme.
You may also ask whether the therapist has direct experience in what you need help with. For example working with someone who understands a mental health or psychological issue through their direct experience combined with education and time on the job could be far better value for you than going to see someone who learned a bit on that topic from a text book but you will get a bit back on Medicare. Never underestimate the value of direct experience when looking for a provider and just cause you get a rebate does not mean you are getting specific and direct care best tailored for you cultivated through years of experience in their own lives and with certain presentations.
Further, all professionals are required by their associations to do a number of professional development (PD) hours a year. You might also ask your therapist whether they have been to counselling and sat in the client's chair and know what it feels like to be a client as opposed to learning about it only at school.
So you can see it is not an easy task to find the right therapist for you. Sometimes you need to allow 4-6 sessions before you can make a true decision as when you react negatively to someone, you could just be coming from conditioning or a defensive part of your ego that does not want to change. In that, the therapist may remind you of your mother and you hate your mother, but you might also be able to harness the energy of reactivity to better understand why and move past some of that, hard as that may be.
Ultimately, there is not a hard and fast rule or guide for this topic, but we hope this page has given you a lot of food for thought.