Counseling and psychotherapy in the United States

Table of Contents

Abstract

Preface

Introduction
Standard in Germany

Counseling in the U.S
Principal Definition
Education Pathways
Historical Development
Primary Theories
Cognitive-behavioral counseling
Humanistic theories of counseling
Existential counseling
Adlerian counseling theory and practice
Systems theory
National Association
Service Delivery

Psychotherapy in the U.S
Principal Definition
Education Pathways
Historical Development
Primary Theories
Psychodynamic psychotherapy
Cognitive-behavioral psychotherapy
Humanistic-experiential psychotherapy
Psychotherapy integration (eclecticism)
National Associations
Service Delivery

Counseling and Psychotherapy in the U.S
Differences and similarities between counseling and psychotherapy
Principal definitions
Education pathways
Historical developments
Primary Theories
National Associations
Service Delivery

Conclusion

Comparison to Germany

Ideas for Future Studies

References

Abstract

This paper discusses differences and similarities among counseling and psychotherapy in the United States. The author describes both professions, their historical roots, definitions, theories, their associations, and services delivery. The description enables the author to draw comparisons with the German-speaking system. It has been found that principally no reasonable distinction between the professions in the United States can be stated. Scholars, practitioners, and consumers are using the terms interchangeably. Further findings indicate a great number of professional stakeholders (associations, their subdivisions and specializations, professions like psychology, social work, or education), what carries advantages and disadvantages for the mental health profession. Based on the findings the author suggests further questions on how different mental health systems might benefit from each other.

Preface

As I finished my final thesis -Psychosocial Counseling – New Concepts and Developments- for the German social work degree, I thought to myself: “Wow! Now, I have four weeks to go to be able to explore the American mental health system, including counseling and psychotherapy.” This system is part of the Anglo-American areas of social work, psychology, and other professions that has impact on and is influenced by the counseling as well as the psychotherapy professions. Since my clear goal is to keep on working theoretically (through a Ph.D. program and a professorship), studying in America will give me the great opportunity to compare the German speaking system, with the system that we often consider to be further developed.

My overall goal is that, one day, I will be able to not just compare those two (or even more) systems with each other, but also be able to reach a standpoint where I can develop answers to some theoretical/practical issues in the mental health services. Those answers would be based on (1) a comparison between different well-established and theoretically-based systems, (2) knowledge of successes and failures within both systems, and (3) a culturally-sensitive, best-practice oriented awareness.

This paper will give me the chance to broaden my horizon and gain in-depth knowledge about counseling and psychotherapy in the United States of America.

I would like to thank the following persons for their time and support: Prof. Dr. Richard Lewine, Department of Psychology, University of Louisville; Dr. Dana Christensen, Kent School Department of Social Work, University of Louisville; Dr. Terri White, Counseling Center, University of Louisville; and Prof. Dr. Daniel Wulff, Kent School Department of Social Work, University of Louisville.

Introduction

This paper will allow the author to examine possible differences between counseling and psychotherapy in the United States, how these services are delivered, and the primary theoretical orientations used in each. From this analysis, comparisons can be drawn with the author’s understanding of counseling and psychotherapy in German/European contexts.

To allow the reader to comprehend where the author is coming from, that is, how counseling and psychotherapy work in Germany, the paper starts with a brief description of the standard in Germany.

This paper is divided into three parts: Counseling in the U.S., Psychotherapy in the U.S., and Differences/similarities between counseling and psychotherapy. In the first section on counseling and the second on psychotherapy, topics covered will include (1) the principal definition, (2) educational pathways, (3) historical development, (4) primary theories, (5) national association, and (5) service delivery. As part of the third section, a conclusion will be drawn, including a summary of the findings, a comparison between counseling and psychotherapy in the United States of America and Germany, and suggestions for future studies.

Even though those parts are assigned to present the gathered information about both professions, the author decided to voice his opinion through out the entire paper rather than holding his comments for the conclusion. The comments will be easy to identify, since they go beyond the scope of stating simple descriptive facts.

Standard in Germany

Germany’s psychotherapy field has a long history of different theoretical schools (such as Freudian, Behavioral, etc.), which have different educational programs, such as Cognitive Psychotherapist, Depth Psychological Psychotherapist, or Behavioral (Children and Adolescents) Psychotherapist. Those degree programs are offered through institutions, mainly outside of universities. They are open to students with a degree in psychology or medicine. Graduates of social work programs are only eligible to become psychotherapists for children and adolescents. Depending on the program, this education lasts three to five years, costs around 17,000 US dollars, allows the graduate to work independently, and to get paid by insurance companies.

Psychotherapists are gathered under the umbrella organization named the German Association for Behavioral Therapy (dgvt). Recently, German-speaking scholars have created a similar society for the counseling profession, named the German Association for Counseling (DGfB).

In order to become a licensed counselor you have the option of enrolling in literally hundreds of counseling programs throughout the nation. Only several are accredited though, such as the programs leading to become a System-Theoretical Counselor, a Family-Orientated Counselor, or Intercultural Counselor.

Usually, those counseling programs do not have educational requirements for interested students, but considerable pre-knowledge in psychology, sociology, and interpersonal communication. Also, they are only useful for students, who are already working in a placement where they do counseling. Usually, such a program lasts about 1,5 to 3 years, and costs a total of 1,500 to 3,500 US dollars.

Thus, one of the differences between counseling and psychotherapy in Germany is the educational process necessary to a “counselor” or a “psychotherapist”. Furthermore, the development of two different umbrella organizations clarifies that there are indeed two different professions. Even though the backgrounds of both professions are based in psychology, they each have developed different theories. Briefly, psychotherapy rather depends on the theoretical schools, as they are known in America (principally Freudian, Cognitive, and Behavioral). Counseling more or less started as the so-called “little therapy” but, by now, has developed and is currently working on its own theories. The majority of counseling theories/approaches is focused on the client in his/her bio-psycho-social conditions and views the client as a person with abilities and resources, which need to be activated. On the other side, psychotherapy is viewed as a profession that is focused on the individual, and views patients/clients in a manner that is deficit-oriented.

The following case examples will offer the reader a practical picture of how a typical counseling and a typical psychotherapy case looks like. Let’s imagine a twenty-one years old female, who feels extremely sad and unmotivated in almost all areas of her live. Recently, she has developed thoughts of attempting suicide. She decides to seek professional help when she realizes that the only reason for not buying razor blades with which she would had killed herself, was the fact that she felt too anxious going out in public.

The female would find a typical mental health counselor in one of the counseling centers, either run by municipal or churchly provider. Due to the immediate risk of her situation, she might be able to see a counselor on the same day of her request, or she will be asked to see a psychiatric physician until an appointment is available (usually in three to six weeks). The counselor would have to determine the client’s suicidal thoughts, and decide whether she needs to be hospitalized. If not, the counselor would start his/her work by focusing on possible help in the client’s environment. Who are you living with? Who would notice if you feel like killing yourself? And other similar questions would be asked. Family members, friends, or other might be included in those sessions. At a later point the counselor will start to work on ways that would help the client to get out of her sadness. Typical questions would be such as: What have you done in the past when you got sad? What would your friend tell you, what you should to do get out of the sadness? The counselor will also ask for possible reasons and determine ways to overcome the situation.

If the female would seek for help from a psychotherapist, she would be able to do so in two common ways. First, she calls the psychotherapist in his/her private practice and asks for an appointment. Likely, she would be told that she has to wait up to six months for a free spot. The psychotherapist might suggestion the second way, which would lead the client to a psychiatric facility or its ambulant unit. There, she would be assessed based on the ICD 10^[1] and either placed in an ambulant or inpatient program. Once a psychotherapist is available, the professional would start with the so-called probatorisch (German) sessions, in which he/she diagnoses the client. The insurance company of the client pays for those sessions. The psychotherapist would need to make an application to the insurance company to get paid for any additional sessions. Based on the psychotherapist’s education and the diagnosis he/she would most likely start to focus on the reason for the client’s depression and anxiety. He/she would ask whether other family members are suffering or did suffer from depression and anxiety, and whether the client has had those symptoms before. If the psychotherapist were also an educated physician he/she would consider possible medications as additional treatment. A so-called psychological psychotherapist (a psychotherapist with a degree in psychology) would ask the client to see a psychiatrist in order to receive medical treatment, since he/she is not eligible to prescribe drugs. The session would include only the client and her psychotherapist, who would try to understand the cause for the client’s disorder. Every theoretical school of psychotherapy would ask different questions. Psychoanalysts might ask for conflicts in the childhood of the client. A psychotherapist grounded in cognitive-behavioral therapy might ask for automatic thought or core beliefs, and helps the client to apply different techniques to overcome her anxiety.

The client in this case might see her counselor for six or more sessions, and his psychotherapist for about ten or more sessions, based on her process. A counselor might refer the client to a psychotherapist or psychiatrist if the client appears to have severe mental disorders, which hinders the client to mentally process the counseling sessions. This is so, because counseling programs usually do not educate their students in treating underlying conflicts deep in the client’s psyche, such as personality disorders.

Counseling in the U.S.

Principal Definition

The American Counseling Association (ACA) offers the following definition of counseling: “The application of mental health, psychological, or human development principles, through cognitive, affective, behavioral or systematic intervention strategies, that address wellness, personal growth, or career development, as well as pathology” (ACA, 2004).

Different efforts have been made to establish the term professional counselor. This term makes it possible to distinguish between educated, licensed counselors and others. ACA defines professional counselors as those who “work with individuals, families, groups and organizations. (…). Professional counselors help clients identify goals and potential solutions to problems which cause emotional turmoil; seek to improve communication and coping skills; strengthen self-esteem; and promote behavior change and optimal mental health” (ACA, 2007b, para. 1).

The definition describes professional counselors as those who work with clients who need “potential solutions to problems which cause emotional turmoil.” By stating it so, it distinguishes the professional counselors from others who might refer themselves as counselors (e.g. financial or legal counselors). It also excludes school counselors who advise students in questions about their careers. Those clients of school counselors do not have problems as the ACA definition describes it. One could say that they are at risk of developing those problems if they do not find ways to accomplish their personal or professional goals. This, however, would then be called preventive counseling and is probably not the focus of school counselors, nor are their educational curricula set up this way. Hence, school counseling fits within the definition of counseling, but not into the definition of a professional counselor. It appears to be challenging to develop a definition around such a term as profession counselor. Professional work is provided not only by those mental health practitioners, but also by school and other counselors. Thus, a definition that says who is a professional counselor and who is not, contains difficulties. The definition should be reconsidered in order to clearly describe who is a mental health counselor and who provides different services. Still, such attempts to define core terms are valuable, especially for the counseling profession, which struggles to communicate who exactly they are; internal as well as for the public.

Education Pathways

The official homepage of the ACA (2007b) states the following:

Professional counselors have a master's or doctoral degree in counseling or a related field which included an internship and coursework in human behavior and development, effective counseling strategies, ethical practice, and other core knowledge areas.

Over 80,000 professional counselors are licensed in 48 states as well as the District of Columbia. State licensure typically requires a master's or doctoral degree, two to three years of supervised clinical experience, and the passage of an examination. In states without licensure or certification laws, professional counselors are certified by the National Board for Certified Counselors (NBCC). Participation in continuing education is often required for the renewal of a license or certification. (para. 3)

In the state of Kentucky, two different credentials can be obtained: The Licensed Professional Clinical Counselor (LCPC) and the Licensed Professional Counselor (LPC). Both licenses pasted the accreditation process in 1996 and allow the graduate to diagnose and treat clients/patients.

Historical Development

“In general it is true to say that counseling has historical roots in practical guidance and problem-solving issues, and was often agency based rather than associated with private practice” (Feltham, 2006, p. 4).

Bradley and Cox (2001) state the following:

Counseling historically has been a part of education both as a discipline and within its institution. School and educators were the first to embrace guidance and counseling as a vital function for all people at all levels of education. Counselor preparation programs are located principally in colleges and schools of education as a result of this historical connection. Psychology, sociology, anthropology, and demography all have been important to counselor preparation, as noted in our earliest national standard. (p. 24)

The development of the counseling profession in the United States has been shaped by many social events as well as shaped by individual practitioners and scholars. First of all, “the foundation for the counseling profession is established within the Bill of Rights and fortified by the Constitution and system of government of the United States” (Hutson, 1968, p. 65). Feltham (2006) states that it is “usually agreed that early American vocational guidance projects and associations (for example Frank Parsons’ Vocation Bureau in Boston in 1908) laid the foundations of counseling, and guidance for the young generally was a strong element” (p. 4). What is remarkable about Parsons’ work was that he was one of the first who ever outlined procedures of working with clients in several steps (i.e., personal data, self-analysis, the client’s own choice and decision, counselor’s analysis, outlook on the vocational field, direction and advice, and finally general helpfulness in fitting into the chosen work) (cf. Baruth & Robinson, 1987).

Feltham (2006) also refers two other prominent names: Carl Rogers and Rollo May. The latter, who was strongly influence by Adler “wrote what many considered as the first counseling text in the 1920s” (p. 4). Carl Roger is mentioned because he “is probably the closest to being the ‘founder’ of (non-directive) counseling in the 1940s” (p. 4)^[2].

Also, many other social events influenced the counseling profession in America. Those include different social policies like programs of the “VA (e.g., its Counseling Services), NDEA [National Defense and Education Act, 1958] counselor training institutes, and President Johnson’s Great Society programs” (Bradley & Cox, 2001, p. 39). Another example is the Community Mental Health Centers Act, from 1963, when “over 2000 mental health centers were established following this legislation” (Baruth & Robinson, 1987, p. 13).

In its early stage, counseling “was offered from a parental/expert orientation; counselors were authorities who had the skill and knowledge to determine what was most helpful for their clients” (Locke, Myers, & Herr, 2001, p. 35). The authors add the following:

During the 1930s and 1940s, counseling often was linked to testing. It was hoped that psychometric assessment would provide a scientific base for understanding individuals’ capabilities, interests, strengths, and limitations. (…) This model began to erode during the 1940s with individuals’ greater desire for freedom and personal autonomy. (p. 35)

This desire for or spirit of freedom and personal autonomy, and the post- (WWII) programs offered by the VA changed counseling enormously. Locke, Myers, and Herr (2001) mention that directive counseling did not fit anymore with that new spirit, and psychoanalyses, the psychotherapy of the time, “was simply too long and expensive for wide application” (p. 35). Freud’s approach became either rejected and thoroughly transformed by a few influential thinkers, such as Albert Ellis, Victor Frankl, William Glasser, and Carl Rogers. One of the most remarkable, was Rogers and his client-centered approach (1951). According to Locke, Myers, and Herr (2001), the greatest shift for the counseling profession at that time, was the combination of Rogers’ influence and the above-mentioned Community Mental Health Center Act making counseling available to the masses.

“During the latter part of the 20th century, many ‘strength-based’ theories of counseling gained prominence. (…) Examples of such strength-oriented types of counseling include solution-focused and narrative therapies” (Lock, Myers, & Herr, 2001, p. 36)^[3],^[4],^[5]. Prominent names connected to those approaches were DeJong and Berg and Harlene Anderson and Harold Goolishian.

Finally, another shift in counseling theory and practice took place towards the end of the previous century. As an outgrowth of systems theory, family counseling, which includes all members of one family, became more and more a standard approach in counseling offices. “This movement toward the use of systems theory to explain family functioning was a radical departure form the traditional linear model for behavior” (Locke, Myers, & Herr, 2001, p. 37)^[6].

When comparing counseling international professions with the American one it becomes clear that one has to consider national events. That is, theoretical changes in counseling might be shared by professionals across borders, but important social events as described, gives a development a national touch.

[...]

^[1] ICD 10 is the tenth version of the International Classification of Diseases. Quite similar to the DSM IV, it allows the professional to assess the clients, based on his/her symptoms, and provides special codes for each diagnoses.

^[2] The non-directive approach is used in Rogers’ development of the persons- or client-centered therapy, in which the patient is encouraged to express his or her emotions. The counselor will not suggest how the person might be able to change, but by listening and mirroring what the patient reveals, he/she helps him/her to explore and understand his/her own feelings. The patient is then able to decide by him/herself what kind of changes he/she would like to make and can achieve personal growth.

^[3] Strength-based approaches are focusing on capabilities and resources of clients, rather than on their deficits. They are based on the belief that every client possesses his/her solutions in themselves, and just need to have some support to reveal and approach them.

^[4] Solution-focused therapy or related approaches are viewed as a reaction to the disease-, dysfunction-, and deficit-orientated school of psychotherapy. It focuses on possible solutions and how the clients will be able to achieve change. Therefore its techniques are future oriented, rather than trying to determine what went wrong in the client’s history.

^[5] “Narrative therapy finds ways of developing insight into the stories of the client’s life. A therapist using narrative therapy is interested in the history of their client. (…) Narrative therapy is sometimes identified as having the client ‘re-authoring’ or ‘re-storying’ their experiences. These descriptions emphasize that the stories of people’s lives are pivotal to an understanding of the individual” (Morgan, 2000, para. 6).

^[6] For a description of the systematic approach, please read Systems theory in the following chapter.