Is counseling an art or science?

One of the hottest debates in the psychotherapy field today is whether counseling is an art or a science. If it’s an art, then we try to tap into a counselor’s innate affective and relational qualities. If it is a science, we emphasize skills in counselor training, seek to manualize treatment so others can utilize the same practices. To pose the question slightly differently, should we emphasize evidence-based practices or practice-based evidence? In the end, what matters is what works. Does the client get better?

So, is counseling an art or a science? The answer is YES. It’s both. Counselors need to have key affective qualities and helping skills, knowledge of and competencies in the 12 core functions, familiarity with legal and ethical issues, and grounding in various theoretical frameworks. Most importantly, they need to be able to establish a helpful therapeutic alliance with clients. Hubble, Duncan and Miller (The Heart and Soul of Change) summarize 40 years of outcome research and assert that the single most important aspect of counseling is the alliance. The quality of the therapeutic alliance accounts for 30 percent of the change in counseling. Does the client feel listened to, cared for, supported, a sense of bond with the counselor, warmth, respect, genuineness, not judged? A good working relationship is the heart of effective counseling. The non-specific factors that contribute to this alliance are:

1. having a time/safe place to talk
2. feeling understood
3. a meeting of the minds
4. a sense of encouragement, coaching, teaching

What does not work in counseling is attributing failure to the client, arguing with the client, passivity, hostility, negative confrontations, mechanical responses, and ignoring the client’s feelings. Fundamental to the therapeutic relationship is the client’s perception of that relationship. It is not how the counselor sees it, but how the client sees it. Is the counselor meeting the client at their stage of readiness? In what ways does the client gain hope of recovery from the counselor?

The question of counseling as art or science is well illustrated in this issue of Counselor Magazine. There is an article about treatment planning in the real world linked to evidence-based practices. One article discusses NIDA’s development of medications for treating addiction. New networks for treatment planning are presented. There also is an article on well-being, incorporating 12 steps and Native American models of care in healing rituals. This issue bridges the gap in the debate by emphasizing both sides of the equation. Our counseling practice needs to incorporate sound procedures that enhance (the science) and build rituals and the therapeutic alliance (the art).

Implications for counselors and supervisors
There are several implications for counselor training and supervision:
1. The key to effective supervision is the quality of the relationship between the counselor and the supervisor. Are the counselor’s issues being addressed in supervision? The most important question a supervisor can ask a counselor is “What do you want? And how can I help you get there?”
2. Supervision starts with the counselor’s stage of readiness of change. Even as clients come for counseling at different stages of readiness, so do counselors come into supervision. Some may not want supervision. They don’t think they need it. However, organizations have a legal and ethical responsibility to supervise. Agencies have an ethical responsibility to protect the welfare of the clients, to assure that appropriate care is provided.
3. Supervision builds on the strengths of the counselor. Solution-focused methods of supervision are effective in providing a strength-based methodology.
4. Since the therapeutic alliance is critical to outcome in counseling, the aim of supervision should focus on helping the counselor find what works best with a particular client. Competency should be defined by outcome, what works. If it does not work, the counselor needs to take a different tact. The aim of supervision is not just to ensure competency of counselors but outcome of clients.
5. The quality of the supervisory alliance is central to positive outcome in supervision. Just as the counselor/client need to build a therapeutic alliance, so should a supervisor/counselor. This entails teaching skillful therapeutic action, helping the counselor choose the therapy approach that best fits each client.
6. Counselors need to be able to quickly establish therapeutic alliances with clients, to encourage them to see their own gains, conveying positive expectations. They need to become familiar with the vast network of social support and community resources and build on positive extra therapeutic factors. Counselors need to be able to walk a client through the stages of change, promoting the client’s sense of personal control, focusing on the future.
7. Counselors need to assume the client is capable of finding his/her own solutions, and expect the client can get better. How often do we give up on a patient? We reflect this feeling when we say “they are not motivated, not ready yet, in denial, haven’t hit bottom yet.” We need to learn collaborative vs. combative treatment approaches, helping the client find his/her own solutions. We need to better monitor the therapeutic alliance and repair ruptured alliances perhaps; caused by poor prior treatment experiences of the client. We need to adapt the relationship to different clients, and learn more subtle interpersonal aspects of that therapeutic relationship.

Conclusion
This issue provides an excellent blending of art and science, and is a good model for counselors and supervisors to following in building the therapeutic alliance while incorporating sound therapeutic approaches.

This article is published in Counselor,The Magazine for Addiction Professionals, August 2006, v.7, n.4, pp.18-19.

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