Psychotherapy, Counseling, Psychological Support, Counselling, Psychological Intervention... — So What Are the Differences

1 - Many Countries, Many People, and Many Ways of Saying the Same Thing

There are many ways to talk about the practice of psychology. To try to explain my point of view in a concise way, I'll start by defining what psychology is and from there address the different terms.

A unanimous definition of Psychology, quoting the APA (American Psychological Association), is that psychology is "the study of the mind and behavior." In this way, the practice of psychology — psychological intervention — is the use of knowledge about the functioning of the mind and behavior across a variety of contexts for a variety of purposes.

When we use psychological knowledge to intervene in the area of health and well-being, we call it, more specifically, Psychotherapy, Therapy, Psychological Counseling, Psychological Support, or simply Counselling.

About psychotherapy, the Portuguese Order of Psychologists (OPP) states:
"…part of the professional competency profile of Psychologists and the acts they can perform as Psychologists (…) includes psychological consultation/support/counseling, psychotherapy or any psychological therapy for behavior modification, as well as psychological and psychoeducational interventions."

2 - But Why So Many Names?

Over time, psychologists have viewed mental health in different ways. There are perspectives where methods are based on measures of "healthy" personality characteristics, what constitutes a deviation from that norm, and psychological intervention aims to correct those deviations. And this is understandable — after all, these are characteristics that may be causing suffering. In fact, the origin of the word therapy means to cure or treat, so just like with an organic disease, the goal of treatment is to restore normal functioning. It truly makes sense to use the term psychotherapy (therapy based on the study of the psyche) to treat and restore the normal functioning of the mind.

From another perspective, one that other psychologists follow, people are not viewed within a framework of normal and abnormal. The psychologist doesn't claim to know, nor pretends to know, what is normal or abnormal, or what the correct way to live is. Instead, the psychologist's actions communicate genuine interest and curiosity, helping the client explore their experience and build the life they truly want to live. The psychological intervention these psychologists use is also psychotherapy, just like those from the previous perspective, but as we'll see next, there are various models of psychotherapy and some fit better within certain perspectives than others. Because of these different ways of viewing people's problems and difficulties, psychologists may want to distance themselves from terms that carry connotations of illness or "norms," such as clinical psychology or psychotherapy, and instead use terms like psychological counseling and/or support, or Counselling.

From yet another point of view, the term Counselling means something different depending on the country you're in. In the United States, Counselling is a profession in its own right and the person's training is not in psychology, although their practice is also psychological intervention using one of the psychotherapy modalities. In the United Kingdom, there is no such separate profession from psychologist — there is Counselling Psychology, which appears as an alternative to Clinical Psychology when choosing a postgraduate path for psychology students (see a clinical program, see a counselling program, another source). After reviewing several university programs and the differences between both fields of study, my conclusion is that the biggest differences are that Counselling places less focus on psychopathology and psychological assessment and, in turn, places greater focus on a psychotherapy approach called Client-Centered Therapy, compared to Clinical Psychology programs.

In fact, the term Counselling is also used to refer to that very specific psychotherapy approach — Client-Centered Therapy developed by Carl R. Rogers, who in the introduction to his book "Counselling and Psychotherapy" highlights that both terms essentially refer to the same thing. There is merely a tendency to call psychological intervention that is less frequent and shorter in duration Counselling, and to call intervention that requires more time and greater frequency psychotherapy. But technically, there are no actual differences.

Nowadays, especially in countries like Portugal where the Counsellor profession doesn't exist, the term Counselling is used by psychologists to differentiate the use of Client-Centered Therapy developed by Rogers, or to signal that they identify with and work according to the values (or attitudes) identified by Rogers: authenticity, unconditional positive regard, and empathy. A space built on these values promotes the client's natural tendency toward well-being.

In Portugal, the term Counselling is translated as "aconselhamento psicológico" (psychological counseling), which in a way carries a connotation of brevity, and for this reason, the terms counseling and psychological support are sometimes used together (or individually) as an alternative to the term psychotherapy.

3 - Psychotherapy: One Word with Different Meanings

We concluded in the previous section that the terms Psychotherapy, Therapy, Counseling, Psychological Support, and Counselling essentially mean the same thing — that is, they refer to psychological intervention carried out in the context of health and well-being. The only difference is that the terms Counselling, Counseling, and Psychological Support may be used to refer specifically to the use of Person-Centered Therapy, or as a way of highlighting the values of authenticity, unconditional positive regard, and empathy that these psychologists embody, and also to distance themselves from the connotations the term psychotherapy has acquired. By the way, this last option is my case.

That said, from here on I'll use only the term Psychotherapy to refer to psychological interventions used in promoting people's health and well-being.

Psychotherapies are born from theory and research on the functioning of the human mind and behavior. Different theories with different practical implications gave rise to different psychotherapies. In a way, it's possible to reach Rome by more than one road; in another way, some psychotherapies are specific to certain psychological problems or disorders and should only be used within those parameters.

Currently, a psychotherapy is classified as scientifically tested and supported when it meets one of the following two criteria:

• At least two quality between-group clinical trials demonstrating efficacy in one or both of the following ways:

  • Superiority — the treatment is statistically more effective when compared to placebo or another treatment;

  • Equivalence — the treatment is equivalent to another scientifically established treatment.

OR

• A large series of single-subject clinical trials demonstrating efficacy, where the study must be of quality and the intervention compared to another scientifically established treatment.

Additionally, for both criteria, the treatment must be manualized, participant characteristics must be well specified, and treatment effects must be demonstrated. These criteria were put forward by Chambless and Hollon in 1998, however, as psychological methodology has evolved in recent years, we are in the process of applying a more demanding and more informative set of criteria to developed psychotherapies.

I mention these criteria to highlight that a psychotherapy, in order to be used ethically and safely with a client, must meet a set of standards that prove its efficacy. However, there are various interventions with the supposed goal of promoting a person's health and well-being that not only fail to meet these criteria but may not even have a single real study proving their efficacy.

The Portuguese Order of Psychologists has issued a series of ethical and deontological opinions where they examined some of these interventions; the list can be consulted here.

4 - The Different Modalities of Psychotherapy

The different psychotherapies can be grouped into the following 3 modalities:

Psychodynamic Psychotherapies: This modality focuses on changing behaviors, emotions, and thoughts by working to uncover their unconscious meaning. They originated with Sigmund Freud but have since been extensively modified and evolved.

• Examples include Short-Term Psychodynamic Therapy and Transference-Focused Therapy.

Cognitive-Behavioral Psychotherapies: The Behavioral part focuses on the learning of behaviors, with key figures being Ivan Pavlov, John Watson, Edward Thorndike, and B.F. Skinner. The Cognitive part of this modality emphasizes the role of thought in the experience of dysfunctional emotions and behaviors. Key figures include Albert Bandura, Albert Ellis, Aaron Beck, and also David Barlow in the development of different applications of this modality.

• Examples include Cognitive-Behavioral Psychotherapy (2nd generation model), the Unified Protocol for the Transdiagnostic Treatment of Emotional Disorders, Acceptance and Commitment Therapy, Mindfulness-Based Cognitive Therapy, and Dialectical Behavior Therapy.

Humanistic Psychotherapies: This modality emphasizes people's capacity to make the best choices for themselves and to develop their full potential. Genuineness, respect, and acceptance of the other are also important aspects. Key figures include Abraham Maslow, Carl Rogers, and Fritz Perls.

• Examples include Emotion-Focused Therapy, Interpersonal Psychotherapy, and Person-Centered Therapy.

The list is not exhaustive and also reflects my training, which focused mainly on the humanistic and cognitive-behavioral modalities. Furthermore, some of these psychotherapies are only for specific issues, while others are broader and have proven efficacy across a variety of problems. Psychologists may also take a more integrative approach, drawing on knowledge from different modalities and adapting the intervention in whatever way will be most effective for the person in front of them.

5 - Who Can Provide Psychotherapy

It makes sense to think that whoever provides psychotherapy is the psychotherapist, and indeed, that's true. In different countries there are different professions that also study psychology and mental health. Since this varies from country to country, when someone addresses an international audience (such as authors of technical books on a psychotherapeutic approach) and wants to refer to the professional who does psychotherapy, they simply say Psychotherapist or Therapist. As we've seen, in the US a Counsellor is a psychotherapist, but social workers and psychiatric nurses can also be psychotherapists. Nonetheless, they have specific training and a body that regulates the practice of psychotherapy.

In Portugal, the only professionals who are legally recognized to use psychological interventions in promoting a person's health and well-being (that is, psychotherapy) are psychologists and psychiatrists registered with their respective professional orders.

The OPP issued a statement on the practice of psychotherapy that can be consulted here.

Psychologists receive their foundational psychotherapy training at university and may also, over time, pursue further training to obtain recognition as a Specialist Psychologist in Psychotherapy from the OPP. Similarly, psychiatrists also need foundational psychotherapy training to provide psychotherapy, though they already have the necessary background knowledge that qualifies them to access such training.

Most advanced psychotherapy training programs are closed to professionals who are not psychologists or psychiatrists. However, as I mentioned earlier, there are scientifically unvalidated "psychotherapy modalities" and institutions that provide training in these therapies to anyone, whether or not they know anything about mental health.

And since "psychotherapist" is not actually the name of a profession in Portugal, nothing prevents someone from calling themselves one and using whatever methods they choose, scientific or not.

Psychiatrists and psychologists, on the other hand, already having an understanding of what constitutes a valid intervention and having the duty to stay scientifically up to date, always use psychotherapeutic approaches with proven efficacy in resolving the problems and life difficulties a person presents.

To conclude, the purpose of this text is to inform, in order to help those who need it navigate this set of terms that psychologists unfortunately created. It is also to raise awareness, because much of what exists out there, despite possibly being done with good intentions, can end up being harmful. And finally, it is to highlight that if you ever need mental health services — regardless of what it's for (anxiety, depression, grief, difficult decisions, life transitions — anything that is creating difficulty matters) — in Portugal, please seek them from a psychologist or a psychiatrist.