Counselling and Psychotherapy Orientations in Australia : Responses from 24 Australian Psychotherapists

Counsellors and psychologists worldwide use different theoretical approaches at least sometimes in conjunction. The theoretical orientation of Australian practising psychologists and psychotherapists appears to be following an international trend that emphasises eclectic or integrative use of the orientations. The aim of the current study of 24 experienced counsellors and psychotherapists in Australia was to identify dominant theoretical orientations used in assisting clients and to compare these orientations with the trend towards integration of theories in practice. We were also interested in which of the major theories were most used in practice by these professionals and what strategies or skills they considered most important. Twenty-four counsellors and psychotherapists thus responded to a series of online survey questions about their personal approaches, resources and practices. Cognitive-Behavioural Therapy (CBT) was the most common of all therapies cited, but person-centred approaches were also popular. However, 21 of the 24 psychotherapists adopted an eclectic or integrative approach (using three or more approaches in their practice). This current finding is consistent with some earlier Australian research, though the eclectic trend may be strengthening. This study also provides insight into the key strategies that the 24 psychotherapists indicate as making a difference for clients, and outlines main reasons why they joined the profession.


Introduction
Individuals throughout the world seek psychotherapy for reasons including stress, anxiety and depression amongst other presenting factors (Cook, Biyanova, Elhai, & Schnurr, 2010;Hohenshil, Amundson, & Niles, 2015).Although it could be speculated that individuals seek out therapy for similar reasons and that psychotherapists and counsellors have similar aims, research has identified that some theoretical orientations are more commonly used in some countries than others, and that changes may occur over time (cf., Pearson & O'Brien, 2012).This paper reviews the emphases reported in a selection of papers, about national trends in counselling and psychotherapeutic theory use in European, North and South American, and Asian and Australasian countries over several decades and then presents findings on the theoretical orientations of a sample of 24 experienced counsellors and psychotherapists, and on their motives for entering the profession and the strategies they emphasized in their practices.Sibbald, Addington-Hall, Brenneman, and Obe (1996) in a sample of 60 counsellors from England and Wales, found that behavioural therapy was the most commonly used theoretical intervention, followed by Rogerian counselling and psychodynamic approaches.Moreover, a quarter of their sample of counsellors identified their style as "eclectic", suggesting a multiple orientation approach to practice.This was reflected rather more strongly at the time also in research in the UK by Hollanders and McLeod (1999) who indicated 87% of British counsellors adopted eclectic approaches rather than emphasising just one approach.Sibald et al. (1996) identified that patients or clients were most commonly referred for depression, stress/anxiety, relationship issues, and bereavement.

European Area Studies-Emphasizing the UK
Jacobsen, Nielsen, and Orlinsky (2012) using data from 158 Danish psychologists in 1995, identified that in the main in the 1990s the psychologists were using psychoanalytic-dynamic orientations rather more often than humanistic, systemic, cognitive and behavioural approaches.By the year 2010, however, Jacobsen et al. (2012) after carrying out their study using data from 350 psychotherapists in 2010, reported a shift towards cognitive approaches, with both cognitive theoretical approaches and analytical-psychodynamic approaches being commonly used in practice.
There is evidence that a psychodynamic orientation was also dominant in England/Wales as in Denmark in the 1990s (Sibbald et al., 1996) though the theoretical orientations may have shifted similar to Jacobsen's research.We have different specialities in psychotherapy and counselling, among which psychologists, counsellors, social workers, psychotherapists and health practitioners generally may be included.Some of the differences in results in the reported studies on orientation would have to do with specific training differences in the specialities.For example Sibbald et al. used data from "counsellors" and Jacobsen et al. used data from "psychologists"-therefore it is possible that differences in speciality may have contributed to the difference in theoretical orientations identified as used in practice.
A study of Turkish counsellor trainees (Demir & Gazioglu, 2012) found that eclectic approaches were favoured most, followed by cognitive and humanistic approaches.
In Sibbald's UK research, counsellors were listed as including community psychiatric nurses, "practice counsellor", clinical psychologists, psychiatrist, health visitor and practice nurses.Often research into counselling and psychotherapeutic practice recognises counsellors and psychotherapists in this more generic approach, rather than emphasising specialist fields (such as clinical and counselling psychologists).Other research singles out the speciality areas.This is the case also in other research into the dominant theoretical approaches used in other countries also-such as in North America, Argentina, New Zealand, Australia, and Malaysia.Our own study because of limited numbers of individuals from each of the different professional areas reports "generic" or counselling and psychotherapeutic professionals without specifying any one of the professions.First, however, some further reviews of studies carried out internationally.

North and South American Studies
Research has also assessed the theoretical orientations of psychotherapists in America.Cook et al. (2010) using data collected in an online study from 2000 psychotherapists in North America, identified that Cognitive Behavioural Therapy (CBT) was the most commonly endorsed theoretical orientation, followed by family systems, mindfulness, psychodynamic and Rogerian/client-centred humanistic approaches.In addition, the majority of psychotherapists endorsed an eclectic approach.Moreover, they identified that mood and anxiety disorders were the most common presenting issues, followed by social problems.Other issues identified included homelessness, substance use and behavioural problems.
However, in South America Muller (2008), using a sample of 525 Argentinian psychologists, found that psychoanalysis was the most commonly used theoretical orientation followed by eclectic approaches.In addition, when an eclectic approach was used, psychologists again used psychoanalysis as a main or influencing theory, followed by cognitive theory.Moreover, it was identified in the 2008 study (Muller) that there had been a shift towards an eclectic approach.From these studies, there is again an indication of a difference in theoretical orientations across countries.However, there is also some indication that psychologists from both regions in North and South America also use eclectic approaches in practice.

Asian and Australasian Studies
There are few studies of the practices of Asian counsellors and psychotherapists; one recent study, however, being that of Mohamad and Rahman (2011).Mohamad and Rahman studied 241 Malaysian counselling practitioners finding the person-centred approaches were most dominant, followed by "rational emotive behavioural therapy" and an eclectic approach.Other studies have included those by Bae, Joo, and Orlinski (2003) on South Korean psychotherapists and more generally, in chapters on counselling around the world including Africa, Asia and Australasia, in a volume by Hohenshil, Amundson, and Niles (2015).
In New Zealand and Australia there have been rather more studies reported than in Asian countries.In a study conducted by Kazantzis and Deane (1998) using a sample of 221 New Zealand psychologists CBT was the primary orientation but multiple theoretical approaches were used in practice, including behavioural, systemic, narrative and interpersonal orientations.In particular Kazantzis and Deane (1998) identified that 31% of those reviewed adopted an eclectic approach compared with figures for other countries indicating 27% of North American and 32.6% of Australian psychologists (where they endorsed two or more approaches as their dominant approach).This indicates in the late 1990s that Australian and New Zealand psychologists were adopting orientations somewhat similar to the orientations internationally beyond their borders-that is, some emphasis on eclectic approaches.
In a study of 132 Australian psychologists, Poznanski and McLennan (1998) identified that CBT was the primary theoretical orientation adopted, followed by psychodynamic, experiential, family systemic, and eclectic approaches.Although eclectic was the least endorsed primary orientation, 113 of the psychologists endorsed at least one secondary approach to practice.Pelling (2007) using a sample of 102 Australian counselling psychologists found that eclectic approaches were the most common, followed by CBT.CBT was the main influence when an eclectic approach was used.
From the literature referred to, there is some indication that Australian psychologists use an eclectic approach with CBT as their primary theoretical orientation.However, Schofield (2008) in a study of 316 Australian psychotherapists and counsellors found that psychodynamic was the most common theoretical orientation followed by eclectic/integrative approaches and numerous others such as humanistic-existential, experimental, narrative, solution focused, CBT, systemic, somatic and hypnotherapy (Schofield, 2008).Although not entirely consistent with the other Australian studies identified that emphasised the eclectic and CBT areas, this again indicates some emphasis on eclectic approaches.The differences in results of course, could reflect differences in the samples used, the kind of question asked, and in how "eclectic" is defined.
Although there is some indication of the common theoretical orientations used in practice worldwide, there is less information about the strategies and the techniques used by counsellors.The current study aimed to identify the leading theoretical orientations used to assist clients among the 24 counsellors and psychotherapists.We report the preferred orientations, degree of eclecticism shown, presenting issues of their clients, key strategies used, and the perceived personal motives for joining the profession.

Participants
Twenty-four psychotherapists participated in the study.Counsellors and psychotherapists were invited to par-ticipate (from the membership) of the Australian Counselling Association and the Mental Health Academy of the Australian Instituter of Professional Counsellors.The responding therapists were employed across a number of professions-these included: government and private sector counsellors, psychologists, social workers, psychiatric nurses and other health professionals.
In terms of experience, five psychotherapists (20.8%) indicated they had spent 0 -1 years practicing as a psychotherapist, five (20.8%) 2 -4 years, five (20.8%) have spent 4 -9 years, and six (25.0%) have more than 10 years' experience-with three revealing more than 20 years' experience in counselling.(Three psychotherapists did not provide a response).
The pattern of responses on gender, age, education and experience indicates our sample contained mature individuals with a considerable amount of life experience among them, solid educational levels (supplemented as will be seen by many professional development workshops and training experiences), and strong levels in the main of workplace experience in counselling following training.The gender mix is roughly what is reflected in national figures also for memberships of professional counselling bodies (for more detailed information on background to counselling and psychotherapy in Australia see: Schofield & Roedel, 2012).

Materials
The study of Australian counsellors and psychotherapists was supported by Bond University and the Australian Institute of Professional Counsellors and involved both personal responses (such as to theoretical orientations, key treatment strategies, education); and personal preference and attitudinal responses (such as on personality, experienced stress, and personal style).This paper reports on the personal responses in regard to theoretical orientation, presenting issues, strategies used, and reasons for being in the profession.The questions in the personal (written) responses asked the psychotherapists what theoretical orientation or orientations they used in practice (with space for one or more orientations to be listed, what kinds of presenting issues were most common for them (again with space for several issues to be written in), what the psychotherapists did in their practice to help their clients (what strategies did they emphasise).And what were the motives that had lead the therapists to join the profession.All these questions were open ended.The psychotherapists also completed a number of scales including on personality, stress, and burnout experienced but these are not referred to in the current paper.However, a further paper on the personality, stress and attitudinal style aspects of these 24 responders is proposed in due course.The RESULTS of our study on theoretical orientations and related aspects are now presented and discussed in turn.

Results and Discussion
Five tables are presented in what follows, showing 1) the top five theoretical orientations used, as indicated through response to a question asking which theoretical orientation(s) were used by the professionals in their practice; 2) the number of theoretical orientations used with their clients-as garnered from the open responses to the question about orientations used; 3) the presenting issues from clients as experienced by the professionals; 4) what the professional counsellors and psychotherapists did in their interactions with clients that made most difference as they saw it; 5) what were the main reasons given as to their motivations in joining the profession.
These tables are dealt with in order with a brief description of each, followed in each case by Discussion with comments relating to how the results of this study in turn reflect earlier reported trends or do not reflect them.In a later section (Summary, Limitations, and Observations) we consider scenarios for further study.

Theoretical Orientations
Table 1 shows the responses to a question asking which orientation(s) were used in practice by the professional counsellor/psychotherapist.The question was open, allowing for respondents to indicate just one or several orientations.Hence the percent responses in the table add to more than 100% as clearly the great majority of these respondents used more than one approach (see Section 3.2 on the eclectic approach).However, the most commonly endorsed approach was CBT.This finding is in line with some earlier Australian and New Zealand research indicating CBT as one among a number of dominant approaches, often the main approach (e.g., Kazantzis & Deane, 1998;Pelling, 2007;Schofield, 2008;Schofield & Roedel, 2012), though psychodynamic approaches were most dominant in some studies.
CBT has been identified as the most commonly endorsed psychotherapeutic approach in many countries across the world: it is the leading therapeutic approach or one of the leading approaches cited in the US (e.g., Cook et al., 2010), UK (e.g., Hollanders & McLeod, 1999), Denmark (e.g., Jacobsen et al., 2012), Turkey (Demir & Gazioglu, 2012), and Malaysia (Mohamad & Rahman, 2011)-but not in Argentina where again the psychodynamic approach predominated (Muller, 2008).Jacobsen et al. (2012) though indicating CBT was highly ranked (as indicated above), also indicated that the Danish psychologists equally or nearly equally emphasised analytic/psychoanalytic orientations.That is that there had been a move to a more cognitive behavioural approach over the decade or more since the earlier studies conducted in the 1990s.
An interesting finding not reported in Table 1 but related to it, was that although nearly all psychotherapists used CBT, only five indicated that it was their primary approach.In addition, five Psychotherapists also indicated they used person centred therapy as their primary approach.This suggests that although psychotherapists might commonly use CBT in practice, it is not always their main approach.Much depends on the clients and their needs; and this implies that multiple methods are being used in practice.
This observation leads into our next section dealing with eclecticism where there is a clear indication that Australian psychotherapists adopt multiple approaches or orientations in addressing the needs of clients.

Degree of Eclecticism Shown
As can be seen in Table 2, 21 of the 24 psychotherapists (87.5%) indicated that they used 3 or more Psychotherapeutic approaches in practice, indicating an eclectic approach.Only two psychotherapists indicated they used 2 or fewer approaches.One participant did not provide a response.This very strong preference for an eclectic orientation was also seen in earlier studies (Kazantzis & Deane, 1998;Pelling, 2007;Schofield, 2008) though our sample indicates a rather stronger emphasis.This is reflected also in the definition of "eclectic" given by Kazantzis and Deane (1998).Psychologists were identified to be using an eclectic approach if… "they did not endorse a single approach greater than or equal to 50% of the time, or if they endorsed two approaches for 50% of the time each" (Kazantzis & Deane, 1998: p. 11).The current study did not ask our respondents how often they practiced each therapeutic approach.Consequently, we are unable to establish whether psychotherapists in Australia focus on one main approach but it is clear there is an openness to using a variety of approaches.This openness is consistent with what appears to be a growing worldwide trend (see papers by Cook et al., 2012;Hohenshil et al., 2015;Pearson & O'Brien, 2012).Further research is needed to clarify this area.

Presenting Issues of Clients
In Table 3, anxiety was the most common presenting issue in clients of these 24 psychotherapists, closely followed by depression and relationship breakdown/issues.Grief and life problems/dissatisfaction were also identified.These presentation issues are directly consistent with findings presented over many studies around the world on issues that clients present.In specialist practices there will be some differences but the general trends are consistent (see for example: Cook et al., 2008;Hohenshil et al., 2015;Jacobsen et al., 2012).Sibbald et al. (1996) in a slightly different emphasis in a different decade identified stress/anxiety as the most common issue referred to counsellors; followed by relationships, depression, bereavement and sexual abuse.There is a strong similarity over countries and time in the presenting issues of the clients seeking help.

Key Strategies Employed to Assist Clients
Few papers have been identified by the current authors that have reported what the psychotherapists considered to be the strategies or processes used that made a difference in the outcomes of their therapy.In our study, as can be seen in Table 4, seven psychotherapists indicated listening to clients as most significant, with building rapport or building the psychotherapeutic relationship (6), using an empathetic approach and being non-judgmental (10) also highly important in making a positive difference for the client.Validating the client was also a significant strategy with a limited number (2) identifying this-however, observation suggests validation underpins much of the other strategies listed also.(The numbers add to more than 24 responses as some psychotherapists cited two or more elements that made an impact in their practices.There were more than 10 other responses also listed.Clearly a number of the responses include overlapping skills and strategies).
These key emphases are fairly consistent with other limited research (e.g., as reported by Cook et al., 2010).Cook et al. (2010) identified that aiming to convey warmth/respect was their main practice, followed by acceptance of the client, understanding, empathy and clear, direct expression.

Cited Motives for Becoming Counsellors/Psychotherapists
As can be seen in Table 5, "to help people" was the most common reason stated for joining the profession; "interest" was cited most often by others-perhaps including the "challenge" aspect and related to the variety of human issues faced in therapeutic work."To make a difference" also reflects the "to help people" element identified.A small proportion in this sample (8%) indicated personal growth and learning more about themselves as significant elements in their choice of the profession.Perhaps these five reasons could be collapsed into three: two strong elements-helping others (including making a difference) and seeking intellectual stimulationinterest and challenge; and one other element to a smaller extent, that of personal growth.These responses about motives would appear to augur well for the counselling and psychotherapy profession as the major thrusts of the programs delivered to trainee professionals emphasise these elements-as they do also the strategies and skills identified in Table 4.
Interestingly motives for joining the profession have not been given a great deal of attention in the literature and some recent research has also indicated that the initial motives seem not to affect the quality of counselling and psychotherapy subsequently delivered to clients (Richardson, Sheean, & Bambling, 2009)-indeed in Richardson et al.'s study of 37 professional psychotherapists the psychotherapists cautioned aspirants to consider carefully the demands of the career before they embarked on the training required.

Summary, Limitations, and Observations
The aim of the current study was to identify the leading therapeutic orientations used by psychotherapists in Australia, at least in our small sample of experienced and mature counsellors and psychotherapists, and also to identify presenting issues of clients, strategies the counsellors and psychotherapists used to be effective; and the motives cited for joining the profession.The findings have demonstrated that a strong eclectic approach is used in practice; that a variety of specific approaches are used (notably CBT, plus person-centred approaches, and then others); that presenting issues are consistent with previous research (emphasising anxiety and related areas); that strategies used that contributed to positive outcomes including listening and being non-judgmental (again consistent with much research); and that motives for joining the profession included as hoped a desire to help others and make a difference in what are often challenging circumstances.
Limitations include that there were only 24 respondents to our detailed survey: there is sufficient to give clear information on trends but insufficient to allow for a wider variety of views.For example, counselling and psychotherapy now cover many fields and there are many different specialist areas such as in the expressive arts or in use of "multiple intelligences" (Pearson & O'Brien, 2012), which did not enter the "top 5" cited areas in the tables presented-and yet these areas may be significant in effective counselling.
In addition as a further limitation we did not request information directly on what should be included in training programs: in particular how counsellors and psychotherapists should be prepared or become fit to take on the professional role-for example, whether personal therapy should be undergone by all trainee therapists (cf., Malikiosi-Loizos, 2013)-and related to this, what arrangements for peer consulting and peer help our responding psychotherapists had in place.And not all clients come from our cultural background: we asked no questions on the cultural aspects of the professional practice but cultural diversity is an important area of study and practice for many psychotherapists (cf., Berger, Zane, & Hwang, 2014).There is clearly room for more research.
Nevertheless our research has given a snapshot of the theoretical orientations and practices and motives of 24 mature and experienced counsellors and psychotherapists in Australia.It appears that a move towards eclectic orientation in practice is gathering momentum and our training programs may need to prepare students to handle the combination processes involved more so than has been the case.It seems however that much training and exposure in training (in preparation through initial studies but also in professional development after joining the profession) have been heading in the right direction-in building the strategies and attitudes that help make a difference for our clients.

Table 1 .
Top five theoretical orientations used by 24 australian psychotherapists.

Table 2 .
Number of therapeutic approaches used in practice.

Table 3 .
Top five reasons people presented for psychotherapy/counselling.

Table 4 .
Top five key strategies used to make positive differenceswith clients.

Table 5 .
Top five reasons australian psychotherapists gave for joining profession.