What are counselling modalities and why do they matter?
People rarely ever decide to start counselling when they’re thriving, most people I’ve seen start their first session sitting with a lot of trauma, grief, and other overwhelming emotions. Picking a counsellor in the middle of all of this is a difficult endeavour to say the least.
During my graduate training program in the late 2010s, I was taught that modalities didn’t matter for effective counselling as much as what researchers called rapport. I didn’t take this information too seriously at the time because the research I had been presented was done in the 1980s. As someone with science research training I couldn’t help but wonder if the knowledge had been properly updated since then.
A simple research literature lookup presented me with answers. As it turns out there wasn’t ever really an agreement on the definition of rapport and those disagreements never really stopped¹. This made sense to me, as the nature of psychotherapy and counselling makes it hard to do research on. I went on and did training in specific modalities I felt like anyway and I’m glad I did. Each new modality I learned presented me with new tools to help with different problems and situations and have been very useful to me since.
As for rapport, from my experience I can say my personal definition of rapport is a combination of the client’s positive reception to the counsellor’s empathy in combination with the client’s belief that something about the counsellor specifically makes the client feel understood and acknowledged. Marginalized people in particular often feel more comfortable sharing their experiences with someone with similar lived experiences. Others arrive looking for counsellors with training in specific modalities and even assurance that certain modalities won’t be used in counselling for specific experiences such as complex PTSD or obsessive compulsive disorder (OCD). This gives the client hope that the counselling process will be effective and efficient.
What is a counselling modality?
I’m sure most people have heard of a few counselling modalities by now, if only in passing, such as Cognitive Behavioural Therapy (CBT), Internal Family Systems (IFS), Emotionally-Focused Therapy (EFT), and many more.
Counselling modalities are essentially complete toolboxes that help counsellors understand the client’s problems and act as guides to provide solutions for the clients. Simply put each modality can be imagined as a troubleshooting manual made out of part diagnostic manual and part repair guide.
How are counselling modalities different from each other?
Modalities typically focuses on different aspects of the problem and will provide clients with different ways of change. In treatment this can look very different, even for the same client and the same problem.
A CBT counsellor helping a client with depressed mood will focus on the cognitive aspects of the client’s experience. Sessions will typically involve the counsellor helping the client track their thoughts relating to their depressive behaviour in order to understand the personal beliefs underneath. Change occurs as “maladaptive” depressive thoughts and behaviours are reframed into “adaptive” or less depressive thoughts and behaviours.
An EFT counsellor helping the same client will focus on the client’s interpersonal relationships of the past and present. The client will typically come to relate emotional experiences with interpersonal experiences in order to be more understanding and validating of their own feelings and experience relief as a byproduct of this process.
An IFS counsellor helping the same client will focus on internal experiences of conflict shape present time emotional reactions to external circumstance. The counsellor will likely guide client to reflect on past experiences and their role in shaping different parts of the client’s personality and problem solving strategies. Cultivating compassion, acceptance, and love for the self is also instrumental in the IFS healing process.
Not all modalities focus on emotional or cognitive experiences. Social Rhythm Therapy (SRT) is an effective treatment option for depression and other mood disorders in certain populations and does not emphasize discussion on internal experiences or past events. SRT instead focuses on providing structured daily routines tailor made for the client’s circadian rhythm and daily needs.
How do I know which modality is the best for me?
The answer depends on your needs as a client. In the current therapeutic landscape, most counsellors recognize the necessity of having many tools to help clients and don’t restrict themselves to any single modality. Choosing a counsellor comes down to your own specific type of need.
Clients needing help with processing traumatic experiences, whether single incident PTSD or chronic multiple incident CPTSD may want to consult counsellors trained in modalities specific for trauma. IFS, Sensorimotor Psychotherapy, and Eye Movement Desensitization and Reprocessing (EMDR) are typically recommended for CPTSD. Although lesser known, Brainspotting is another modality gathering more evidence for its efficacy². Cognitive Processing Therapy (CPT), and expressive therapies such as art therapy can be effective for single incident PTSD.
Clients needing help with managing Obsessive Compulsive Disorder (OCD) benefit from Exposure and Response Prevention (ERP), Habit Reversal Training, and Acceptance and Commitment Therapy (ACT). Counsellors who are experienced in helping OCD clients will know how to screen for conditions that look like OCD and apply interventions that help the client identify and disrupt the cycle of obsessive rumination and repetitive behaviour.
Modalities matter for neurodiverse clients especially. CBT is developed based on neuro-normative assumptions and does not account for differences in executive functioning ADHD and autistic clients experience. Cognitive differences and alexithymia can pose difficulties for in session exercises such as role-play skill building and Mindfulness Body Scanning.
Neurodiverse clients can find themselves struggle with the process of monitoring thoughts, identifying them, and follow through with the task of reframing. Worksheets and other forms of homework can pose the problem of being an additional cognitive load and can be counterproductive. Unexamined neuro-normativity often means ADHD and autistic clients’ struggle with the stigma associated with being neurodivergent remains unacknowledged. Attempts at reframing shameful past experiences of shame may not be aligned with the clients’ lived reality.
To recap
Counselling modalities are toolsets that help counsellors understand the client’s needs and plan corresponding treatment. Each modality sees problems differently and provides different treatment strategies as well.
Clients with different needs may benefit from different modalities, such as EMDR, IFS, and Sensorimotor Psychotherapy for trauma.
Neurodivergent clients may want to take care in their process of finding a counsellor as some modalities normalize neurotypical experiences.
References
Cuijpers P, Reijnders M, Huibers MJH. The role of common factors in psychotherapy outcomes. Annual Review of Clinical Psychology. 2018;15(1):207-231. doi:10.1146/annurev-clinpsy-050718-095424
D’Antoni F, Matiz A, Fabbro F, Crescentini C. Psychotherapeutic Techniques for Distressing Memories: A Comparative Study between EMDR, Brainspotting, and Body Scan Meditation. International Journal of Environmental Research and Public Health. 2022;19(3):1142. doi:10.3390/ijerph19031142
