23 Mar 2015
There are several therapeutic frameworks which can be used within different realms to help an individual with psychological problems they may be experiencing; cognitive-behavioural therapy, person-centred therapy or psychodynamic therapy, to name a few. Each therapy is distinct from each other in terms of methods of intervention and ideas and assumptions about the nature and sources of psychopathology. Each therapy is also, of course, considered by those who practice it, as widely applicable to the problems presented for psychotherapeutic treatment (Gabbard, Beck & Holmes 2005; Feltham & Horton, 2006). Within mainstream psychology, person centred therapy is often criticised because it lacks a solid theoretical and empirical foundation but in counselling and psychotherapy it remains influential.
Definition and Theory
The person-centred approach was established by Carl Rogers in the 1940s and 1950s. It offers a dynamic, process-focussed explanation of the development and functioning of personality, vulnerability to psychopathology, and of therapeutic growth toward psychological well being (Rogers, 1959). According to person-centred theory each individual is born with actualising tendency. This is what is described by Rogers (1951) as the built in motivation in every life form to develop to their full potential, within their own individual unique life circumstances and potentialities (Gillon, 2007). Although this is a controversial concept (Ryan, 1995; Levitt, 2008), and hence a main criticism of person-centred theory as a whole, it is a fundamental concept within the therapy; the therapy is rooted in the client's ability for awareness and self-directed change in their attitudes and behaviour (Bradley, 1999).
Roger's theory of the person is made up of two concepts, the first being the organismic self. This is the true and real person that we are. Roger suggests that this is innate and consistent throughout our lives; we do not learn this concept of ourselves we just 'are'. He postulates that it is within the organismic self where the actualising tendency exists. The other part or the person, as theorised by Rogers, is the self concept. This is the learned way of being and develops through the messages we receive from others. This begins in childhood with messages we receive from our parents and continues throughout our lives through interactions within other relationships. According to Rogers, a healthy self concept exists when we experience unconditional positive regard from the other people in our lives and are not placed under any conditions of worth. In contrast, an unhealthy self concept occurs when we are effected by interjected values and conditions of worth. In this state we often experience denial and distortion which are defence mechanisms which come into play when we do not fit into the conditions of worth. In Roger's theory, psychological distress happens when there is a poor fit between the organismic self and self concept i.e. there is incongruence. There is a disintegration of the self concept and there is often experience of very serious emotions such as fear, depression and anxiety. The goal of psychotherapy is to promote the self-actualization in the client. PCT utilises the presence of the actualizing tendency in the client makes it possible for the client to control and direct the therapy process, with the facilitation of the therapist. The therapist is not guiding the therapy but aiding the client through their own particular path; in person centred therapy, there are no specific interventions made by the therapist, as such.
The Seven Stages of Change
Through empirical research, Rogers was able to recognise identifiable features that characterise positions on a continuum of personality change effected by the process of psychotherapy. It is the belief that the client goes through the seven stages of change from incongruence to congruence in therapy which, at the end of the therapy allows them to offer themselves unconditional positive regard and trust in their organismic valuing process (Rogers, 1961).
At this stage it is unlikely that the individual will present in a clinical or counselling setting. The person does not perceive themselves as having any problems and they have very rigid views of the world based on past experiences. An individual who does attend a therapeutic session at this stage is unlikely to return after the first session as the therapy seems pointless to them (McMillan, 2004)
At this stage the individual has some awareness of negative feelings and is a little more able to express this. However, there is little inner reflection and often the problem is perceived to be external to them. (Cooper et al., 2007)
This is the point where most clients enter counselling. At this stage, there is a little more inward reflection and a realisation of self-ownership, although this is not yet fully established. Often the self reflection is focussed on the past and there is a tendency to externalise present thoughts and feelings. (Cooper et al., 2007)
According to Rogers, this is where the majority of the therapeutic work will begin. The client begins to talk about deep feelings and there is an increased tendency to to experience things in the present, although this is still often uncomfortable for the client. This is when the client begins to question their thoughts and perceptions of the world. (McMillan, 2004)
At this stage the client has a true sense of self awareness. They can express present emotions and are critical of their own previous constructs, but often there is an acceptance e.g. "That was a silly thing to do, but maybe that's alright because everyone makes mistakes?" (McMillan, 2004)
T here is now a rapid growth towards congruence and the client begins to develop unconditional positive regard for other. The previous incongruence experienced by the client is now embraced and challenged by the client. (Mearns & Thorne, 2000)
The client is now a fully functioning, self actualised individual who is empathic and shows unconditional positive regard for others. It is not necessary for the client to reach this stage and very few do. (Mearns & Thorne,2000)
Rogers (1967) emphasis that the number of stages are not crucial and they are loose terms with much interplay along the continuum.
The Core Conditions
As previously stated, the therapy is based upon the belief that the client will primarily bring about change, not the therapist, and the clients' self healing will be activated as they become empowered (Casemore, 2006). Instead of making interventions, the therapist has belief in the inner resources of the client that creates the therapeutic climate for growth (Seligman, 2006). The client works within their own frame of reference and within the sessions there are six necessary and sufficient conditions which are referred to as the six Core Conditions, which must be present in order for the client to benefit from their time with the therapist and which are referred to by Rogers as "necessary and sufficient" (Rogers, 1957). The core conditions are not techniques or skills which can be learned but are regarded as personal attitudes or attributes experienced by the therapist, and communicated to the client (Gillon, 2007).
Therapist-Client Psychological Contact
One of these six core conditions is therapist-client psychological contact. This means a relationship between client and therapist must exist, and it must be a relationship in which each person's perception of the other is important (Casemore, 2006). In other words, a real relationship must be established between the therapist and Margaret, rather than simply just being in a room together. Prouty, Van Werde & Porter (2002) have emphasised that such a relationship cannot simply be assumed and must be worked upon or, arguably, the whole therapeutic framework will fail. Establishing a psychological relationship with a client may be initially difficult, particularly for an individual who has previously had a bad experience of therapy, or simply finds it difficult to talk to other people about the issues they may be having, even those close to them. The rejection of help from people in pre-established relationships, such as friends or family members might suggest that there may be hesitation by the client, in establishing a relationship where the purpose is to gain help. Conversely, building a relationship which will provide an individual with the ability to help themselves may be appealing for such a person, and particularly when person-centred therapy removes the conditions of worth placed on an individual by their family and friends. (Todd & Bohart, 1994) . The relationship between the therapist and the client is crucial to the person-centred approach and it cannot just be assumed but must be worked on (Prouty, 2002).
It is also a core condition that the client is in a state of incongruence, being vulnerable or anxious. It is only when this core condition is present that there is a need for change. This idea of knowledge of need for change is important, because the condition implies that, as a result of the experience of vulnerability or anxiety, the client is aware that they are encountering difficulties. (Singh & Tudor, 1997) It is important for the client to be aware of their own difficulties as the therapy is based upon the client helping themselves without obvious intervention from the therapist. Without the knowledge of their problems and difficulties, it becomes impossible for the client to confront their problems and work through them. Often, the fact that an individual has asked for help from a primary care service which has referred them to therapy, or have chosen to privately visit a therapist demonstrates an awareness of their problems. If a client is not in therapy voluntarily, is hostile toward the process and the therapist, and is noncommittal about attending sessions, the likelihood of a positive outcome from the therapy diminishes drastically. Conversely, if a client enters the therapeutic relationship feeling a strong need to obtain help, are open and willing to give therapy a try, attend their sessions and establishes a helpful therapeutic relationship with their therapist, it is much more likely that they will benefit from PCT (Corsini,Wedding & Dumont, 2007).
Conversely, in order for the therapy to be effective the therapist must be congruent or integrated in the relationship. Congruence means that the therapist's outward responses match their inner awareness and feelings; that they are genuine, real, open, authentic and transparent (Casemore, 2006). Rogers (1957) stressed that congruence is not a question of the therapist blurting out compulsively every passing feeling; rather it is a state of being. These feelings should only be expressed when they are persistent and of great strength and when communication of them assists the therapeutic process (Rogers, 1966, p185). By building this self-awareness not only does the therapist build trust with the client but it also reduces the likelihood that a therapist's own experiences in relation to a client, such as distress or anger, will not be influenced by his/her own incongruence and thus conditions of worth being imposed. (Gillon, 2007) For example, if there is a persistent feeling of irritation from the therapist in regard to how they perceive their client's behaviour, (such as the client rejecting help from family members being perceived as avoiding taking responsibilities for their own problems) this issue will need to be addressed in order to maintain congruence in the therapist in the relationship, and hence maintain a central core condition, to enable effective therapy sessions.
The concept of phenomenology must be taken into account in such a situation. The multiple reality theory is defined as a subjective view of the world, constructed by each individual's collective experiences (Rogers, 1951). As a result, no other human being can possibly determine what is the correct or incorrect behaviour for any other individual. Therefore, the therapist must respect this, remain non-directive and supportive, and allow each individual the freedom to live according to this reality and to make all decisions about their growth and direction. (Kensit, 2000) It is notable that this feeling will have an effect on the core condition of congruence which the therapist must bring to the relationship within therapy. It is important for a therapist to be aware of what inner experiences to expose to the client during therapy and in what manner to do so. (Gillon, 2007) Taking the previous example of a feeling of irritation in the therapist, it can be seen that this feeling the therapist is experiencing is not only putting the therapeutic relationship at risk but it may be an option, if this feeling persists, for the therapist to disclose this feeling to the client in a tactful way, as it may ultimately aid her in therapy. Congruent therapist self disclosure has been shown to achieve a more favourable perception of the therapist, and a higher attractiveness perception, as well as a greater desire to choose a therapist practicing congruent self disclosure over incongruent self disclosure. (Knox, Hess, Peterson & Hill, 1997; Nyman & Daugherty, 2001; Audet & Everall, 2003) Self disclosure not only allows the therapist to remain in a congruent state in the therapeutic relationship but also a self disclosure by the therapist in relation to an issue which the client may be having difficulties confronting, may encourage the self healing process. However, within this solution lies a further problem, as sharing this information may evoke strong feelings from the therapist which could damage the therapeutic relationship which has been built with the client. It is a decision which the therapist must regard carefully and personally make the decision as to whether or not to share the information, by balancing the benefits and risks of this self-disclosure. Further to this it is important for the therapist to decide how much information is sufficient to share without overwhelming their client, or placing conditions of worth within the relationship. As previously mentioned, studies have shown that congruent therapist self disclosure is often a positive thing and so should not be shied away from (Knox, Hess, Peterson & Hill, 1997; Nyman & Daugherty, 2001; Audet & Everall, 2003). However, it must be emphasised the importance of careful consideration before engaging in this technique, as if the self disclosure is misread by the client the relationship will be jeopardised, and the client's progress halted.
Unconditional Positive Regard
Another important core condition which must be present during a therapy session is that the therapist should experience unconditional positive regard for the client. This means that the therapist offers the person respect, acceptance (although it does not have to be approval) caring and appreciation regardless of the client's attitude or behaviour (Gillon, 2007). This non-judgemental attitude and acceptance of the client is important because it challenges the clients' beliefs that they are only valued if they behave as required by significant others (conditions of worth). There is no longer any need for the client to shy away from aspects of their inner self which may be painful or that they may see as shameful because they learn that it is possible to be truly themselves and still be accepted. This is an important aspect of person centred therapy as it opens up the opportunity for the client to explore their anxieties and accept them within their own frame of reference. This, in turn, allows for the self-healing process which is central to person-centred therapy.
Another core condition which must be achieved is that the therapist experiences an empathic understanding of the client's internal frame of reference and endeavours to communicate this experience to the client. In other words, the therapist enters into the client's world as if it were their own and has increased awareness of how an event or situation has affected the client. This will show the client that they understand them and that their views, feelings and thoughts have value. This will henceforth reinforce the idea that the client is accepted and will allow the therapeutic relationship to flourish to enable a deeper exploration of the self concept. This empathic understanding is often demonstrated to the client through the use of techniques such as reflection and paraphrasing. It has been demonstrated through meta analyses that empathy is a core component of most therapeutic approaches, despite various definitions and uses (Feller and Coccone , 2003). However, contrary to the ideas of Rogers, empathy appears to be necessary, but, not sufficient, for therapy to produce positive outcomes. An extensive review of research on empathy over the 1950's to the 1990's (Duan & Hill, 1997), notes a decline in academic interest in the concept of empathy in therapy, since the 1980s. They found that that this appeared to stem from continuing methodological problems, which generally appeared to arise from difficulty is defining the various aspects of empathy. A further meta-study, which examined commonalities across various therapy types, found further support for the idea of empathy as a core concept throughout therapies (Beutler, 2000). As above, this does not require the therapist to experience the same emotions as the client, but to understand and respect those emotions.
Client Perception of UPR and Empathic Understanding
Arguably, the most important condition is that the client perceives this unconditional positive regard and empathic understanding of the therapist through the way the therapist is in session. This can be demonstrated through warmth, and techniques such as reflection, paraphrasing and clarifying. Not only will this reassure the client that they are being understood and so do not have to explain themselves, but it may also trigger further realisations about thoughts and feelings, which in turn will help the client to move through the self healing process with the prospect of increasing congruence. Todd and Bohart (1994) studied a group of patients in psychiatric care, suffering from varying degrees of psychopathology. It was found that when a therapist did not put conditions of worth on (i.e., judge) the patient they responded with more confidence and less hostility. This is an important finding when relating this therapeutic approach to practice, particularly for individuals who may be reluctant to obtain help from friends and family; who are often the source of conditions of worth. By removing these conditions of worth an individual may be more open to getting help for their problems. As these conditions are actively removed in a person-centred therapy session, it is suggested that such an environment will encourage an individual to feel comfortable enough to open up and explore their thoughts and feelings within their own internal framework.
The theory and necessary and sufficient core conditions which construct person-centred therapy will allow an individual to increase congruence and ultimately reduce the levels of psychological distress they feel. Through talking to the therapist within a session which incorporates the six necessary and sufficient conditions, it is hoped they will go through the seven stages of change and at the end of the therapy can be regarded as a fully functioning person, as described by Rogers (1961).
Criticism and Limitations
A frequent criticism of this approach is that the core conditions as outlined by Rogers, is what any good therapist does anyway. Superficially, this criticism reflects a misinterpretation of the real challenges of consistently manifesting unconditional positive regard, empathic understanding and congruence (Malhauser, 2010). This is particularly the case in regard to congruence, to the extent that some therapeutic techniques used in some other approaches are dependent upon the therapist's willingness to suppress, mentally formulate hypotheses about the client, or constantly maintain a professional front, hiding their own personal reactions, there is a real challenge in applying these techniques with the openness and honesty which defines congruence. Nevertheless, as previously discussed, much of the meta-analysis research being carried out is showing the common factor of an accepting therapeutic relationship to be the pivotal aspect of any therapeutic approach.
A PCT therapist may often run the risk, due to the nature of the role of the therapist in the relationship, to be very supportive of their clients but not challenge them. If a therapist directs the client to discuss contents that the therapist believes to be central to the process, the therapy is not client-centered. If the therapist arranges the ways in which clients relate to their concerns or to how they express those concerns, the therapy is directive and not client-centered. In this respect, client-centered therapy stands alone within the family of person-centered and humanistic therapies (Witty, 2007). Kahn (1999) discusses the concept of nondirectivity in person-centered theory. He argues that, since personal and theoretical biases are unavoidable, it is impossible for a therapist to be consistently nondirective. Furthermore, the concept of nondirectivity, with its focus on the psychology of the client, implies that person-centered therapy is a one-person rather than a two-person psychology. The article quotes therapists who believe that when a client's autonomy is respected, a wide variety of therapeutic interventions are possible. The argument is made that therapist shortcomings may be a more relevant concept than nondirectivity. With the fallibility of the therapist and a respect for the autonomy of the client, Kahn postulates that therapeutic responses can become more flexible and innovative, increasing the power of the person-centered approach.
It has been said that the only limitation to person centred therapy is the limitations of the therapist themselves (Dryden, 2007) and it is postulated that perhaps this is the key to effective person centred therapy. There has been criticism of the nondirective attitude associated with this particular therapeutic approach. There is also research that indicates that the personality of the therapist is a better predictor of success than the techniques used (Boeree, 2006). In saying that the techniques used are just as personal to the therapist and are often effected by their personality. As laid out in the core conditions, the therapist themselves must be congruent and authentic and so therefore must be constantly aware of their role in a session. It is important that self disclosure is considered and evaluated before brought into a session but similarly it is important that to both challenge and reassure the client, that it does occur at some point. It is a difficult balance to get right but is crucial to the outcome of therapy for the client.
Cognitive behavioural therapy (CBT) is often regarded as the most effective therapeutic framework practiced by counselling psychologists. This is due to high volumes of research into the effectiveness of CBT to treat a wide range of psychological problems which individuals may have. A recent development has seen NICE (National Institute for Health and Clinical Excellence) recommending computerised cognitive-behavioural therapy as a cost-effective and clinically effective practice (NICE, 2006; Mental Health Foundation, 2006). Although the benefits and effectiveness of cognitive-behavioural therapies are undeniable, and cannot be overlooked, it has, as with any therapy, its limitations and comparative research is showing that very little actually stands between CBT and other therapeutic therapies. The person-centred approach has been successful in treating many different psychological problems including anxiety disorders, alcoholism, psychosomatic problems, agoraphobia, interpersonal difficulties, depression, and personality disorders (Bozarth, Zimring & Tausch, 2002). It is not, however, a suitable therapy to help someone who is suffering from more severe mental health issues such as severe psychosis, as it is unlikely that they will be able to engage with their own thoughts enough to guide their own therapy. As previously stated, it has also been shown to be as equally effective as CBT when used to help an individual who is suffering from major depression (Osatuke, Glick, Stiles, Greenberg, Shapiro & Barkham, 2005); with the client in the aforementioned study being helped using CBT managing her needs better and the client being helped using person-centred therapy, accepting her needs more. The authors concluded that despite the qualitative differences, the success was equal in each case and suggest that there is more than one way of being psychologically healthy.
A recent study (Stiles, Barham, Twigg, Mellor-Clark & Cooper, 2006) into the effectiveness of cognitive-behavioural, person-centred and psychodynamic therapies as practised in the NHS, took into account over 1300 patients, across 58 NHS care sites over a period of 3 years. They found that each of the therapeutic frameworks, either by itself or in conjunction with another therapy such as art, averaged similar marked improvement in individuals' well being. This finding suggests that different approaches tend to have equivalent outcomes, an idea which is also demonstrated in other research in the area. (Shadish, Navarro, Matt & Phillips, 2000; Holmes, 2002; Stirman, DeRubeis, Crits-Christoph & Brody, 2003). For example, Lambert and Bergin (1994) carried out a meta-analysis of studies on psychotherapeutic efficacy, in which they found that there is only a small amount of evidence which weights one particular therapy above another and that most of a client's improvement is related to factors common to all therapeutic approaches. They also propose that it is not the form of therapeutic style a therapist uses, but the therapist themselves which is the main impacting factor on the outcome of a therapeutic treatment.
This finding can be considered to be a result of the 'Dodo bird verdict'; a phrase conceived by Rosenzweig (1936). It is often extensively referred to in literature as a consequence of the common factors theory, which proposes that the specific techniques that are applied in different therapeutic approaches serve a very limited purpose and that most of the positive effect that is gained from psychotherapy is due to factors that the schools have in common. This is often the therapeutic effect of having a relationship with a therapist who is warm, respectful and empathic. Meta-analyses by Luborsky (2002) shows that all therapies are considered equal and "all must have prizes". On the other hand, scientists who believe in empirically supported therapies (EST) challenge the concept. Chambless (2002) emphasises the importance of remembering that specific therapies are there for specific people in specific situations with specific problems and postulates that grouping problems and therapies, detracts from the overall importance and individuality of therapy as a whole. Whilst there is much agreement about this, the "Dodo bird verdict" is still very much accepted within research and is especially important because policymakers have to decide on the usefulness of investing in the diversity of psychotherapies that exist, as demonstrated by the rise of CBT as the therapy of choice in the NHS. Cooper, Elliot, Stiles and Bohart (2008) released a joint statement at the Conference of the World Association for Person-Centred Psychotherapies and Counselling in which they stated that they believe it is scientifically irresponsible to continue to imply and act as though CBTs are more effective than other therapies. They base this opinion on the fact that more academic researchers subscribe to a CBT approach than any other therapy and these researchers get more research grants and publish more studies on the effectiveness of CBT, in comparison to researchers in other areas of psychotherapeutic practice. They also take into consideration the previously mentioned research in which scientifically valid studies demonstrate that when established therapies are compared to one another the most common result is that both therapies are equally effective.
In conclusion, the person-centred approach is an effective and well researched therapeutic method. It has been shown to have no less standing or effectiveness than cognitive behavioural therapy, despite being pushed to one side within the NHS. It is suggested that an increased scientific research evidence base may increase the likelihood of it being propelled to the same stature within health services as CBT, however as the therapy does not use standardised assessment, measures or clearly defined goals, it would be difficult to measure the effectiveness to the same degree. It is also argued that by researching the approach in such a scientific way it is deviating away from the core principles of the approach itself, which are humanistic. The principles of person-centred therapy are applicable out with the therapeutic relationship and the core conditions which Rogers defines as being necessary for effective treatment, are a valuable tool in allowing an individual to gain self awareness and aid their own recovery. It is successful in numerous settings such as family and couples counselling, as well as teaching and management and has been shown to be effective in conflict resolution. The person-centred approach is continuing to develop e.g. relational depth and configurations as outlined by Mearns and Thorne (2000), and will undoubtedly continue to do so with the continued work of key psychologists in the field.
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