Reading E

Who Can We Help?

Because-client centered therapy is not problem-centered but person-centered, clients are not viewed as instances of diagnostic categories who come into therapy with “presenting problems” (Mearns, 2003). When the therapist meets the other person as a human being worthy of respect, it is the emergent collaborative relationship that heals, not the application of the correct “intervention” to the “disorder” (Natiello, 2001). Of course, clients come to therapy for a reason, and often the reason involves “problems” of some kind. But the point is that problems are not assumed and are not viewed as instances of a priori categories. Mearns clarifies this stance:

This philosophy of the person leads us in the direction of appreciating each person as a dynamic whole. Human lives are processes evolving toward complexity, differentiation, and more effective self-world creation. In contrast, the medical model sees persons in terms of “parts” - as problematic “conflicts,” “self-defeating” behaviors, or “irrational cognitions.” Proponents of client-centered therapy see problems, disorders, and diagnoses as constructs that are generated by processes of social and political influence in the domains of psychiatry, pharmaceuticals, and third-party payers as much as by bona fide science.

Another common misconception of client-centered therapy concerns the applicability of the approach. Critics from outside the humanistic therapies dismiss this approach as (1) biased toward white, Western, middle-class, verbal clients and thus ineffective for clients of less privileged social class, clients of color, or those who live in collectivist cultures; (2) superficial, limited, and ineffective, particularly with “severe disorders” such as axis II personality disorders; and (3) using only the technique of “reflection” and thus failing to offer clients “treatments” of proven effectiveness. Students of this approach who wish to investigate both the critiques and the refutations are referred to several recent works: Lago and Thompson’s Race, Culture and Counseling (1996); Levitt’s Embracing Non-Directivity (2005); Moodley, Lago, and Talahite’s Carl Rogers Counsels a Black Client (2004); and Joseph’s Handbook of Person-Centred Therapy and Mental Health (2017). In their analysis of Rogers’s work with an African American client, Mier and Witty defend the adequacy of the theory insofar as constructs such as experiencing and the client’s internal frame of reference are held to apply universally. Tension or limitations in cross-cultural therapy dyads arise from the personal limitations and biases of the therapist (Mier & Witty, 2004, p. 104).

In therapy, some clients may define self fundamentally by their group identity - for example, family or kinship relations, religion, or tribal customs. At some points in their lives, many persons may define themselves in terms of other types of group affiliation (e.g., “I am a transsexual,” “I am a trauma survivor,” “I’m a stay-at-home mom”). These definitions of self tend to emerge in the therapy relationship and are accepted and understood as central to the client’s personal identity. However, it is an error to suppose that client-centered therapists aim to promote autonomy, independence, or other Western social values such as individualism and self-reliance. Respect for and appreciation of clients precludes therapists’ formulating goals. Consultation offers the opportunity for therapists to examine biases of all types and to progress toward greater openness and acceptance of clients’ culture, religious values, and traditions.

Feminist scholars of therapy both within the humanistic tradition and from psychodynamic traditions have criticized client-centered therapy as focusing only on the individual without educating the client to the political context of her problems. Although it is true that client-centered therapists do not have psychoeducational goals for clients, these writers fail to recognize the ways in which social and political perspectives emerge in client-centered relationships. The recent work of Wolter-Gustafson (2004) and Proctor and Napier (2004) shows the convergence between the client-centered approach and the more recent “relational” and feminist therapies.

In an interview with Baldwin shortly before his death in 1987, Rogers made the following statement that illustrates the consistency with which he endorsed the nondirective attitude: “[T]he goal has to be within myself, with the way I am… [Therapy is effective] when the therapist’s goals are limited to the process of therapy and not the outcome” (quoted in Baldwin, 1987, p. 47).

Occasionally, clients who are veterans of the mental health system may have incorporated clinical diagnoses into their self-concepts and may refer to themselves in those terms. For example, “I guess I suffer from major depression. My psychiatrist says I’m like a plane flying with only one engine.” Even though client-centered therapists do not view clients through a diagnostic lens, this self-description is to be understood and accepted like any other aspect of the client’s self-definition. Note that this kind of self-categorization can be an instance of an external locus of evaluation in which a naive and uncritical client has taken a stock label and applied it to him- or herself. Or, conversely, it may represent a long, thoughtful assessment of one’s experience and history, thus being a more truly independent self-assessment. If the client describes herself as “crazy” or “psychotic,” the client-centered therapist would not say, “Oh, don’t be so hard on yourself. You’re not crazy.” We put our confidence in the process of the therapy over time to yield more self-accepting and accurate self-appraisals on the part of the client rather than telling the client how to think because his or her thinking is clearly wrong.

Although client-centered therapy is nondiagnostic, client-centered therapists work with individuals diagnosed by others as psychotic, developmentally disabled, panic disordered, bulimic, and the like, as well as with people simply seeking a personal growth experience. This assumption that the therapy is generally applicable to anyone, regardless of diagnostic label rests on the belief that the person is always more - that it is the person’s expression of self and his or her relation between self and disorder, self and environment, that we seek to understand.

Rogers states unequivocally that the diagnostic process is unnecessary and “for the most part, a colossal waste of time” (Kirschenbaum & Henderson, 1989, pp. 231-232). Rogers elaborates on the issue:

When therapists do not try to dissuade clients from asking direct questions by suggesting that clients should work on finding their own answers, clients may occasionally request help from the therapist. Although there is some disagreement within the person-centered therapeutic community about answering questions, many client-centered therapists believe that following the client’s self-direction logically requires responding to the client’s direct questions. But, crucially, a therapist’s responses to questions emerge from the client’s initiative and the therapists have no stake in gaining “compliance” from the client with their offerings.

Client-centered therapists have worked successfully with a myriad of clients with problems in living, including those of psychogenic, biogenic, and sociogenic origins. The common thread is the need to understand the client’s relationship to the problem, illness, or self-destructive behavior; to collaborate with the client in self-healing and growth; and to trust that the client has the resources to meet the challenges they faces. Within a partnership of respect and acceptance, the client’s inner relation to the behavior or negative experience changes in the direction of greater self-acceptance and greater self-understanding, which often leads to more self-preserving behavior.

In spite of the stereotype of client-centered therapy as applicable only to “not-too-severe” clients, several client-centered scholars and practitioners have written about the success of this approach with clients whose lives have been severely afflicted with “mental illness.” For example, Garry Prouty’s work with clients who are described as “psychotic” is described in his book Theoretical Evolutions in Person-Centered/Experiential Therapy (1994). In her book The Client-Centered Therapist in Psychiatric Contexts: A Therapist’s Guide to the Psychiatric Landscape and its Inhabitants, Danish clinician Lisbeth Sommerbeck (2003) presents the issues she deals with as a client-centered therapist in a psychiatric setting in which her colleagues treat “patients” from the traditional medical model.

In contrast to long-term therapy, the current trend with persons diagnosed with schizophrenia has focused on social skills training, occupational therapy, and medication. It is rare for such a person to experience the potency of a client-centered relationship in which she or he is not being prodded to “comply” with a medication regimen, to exhibit “appropriate” behavior and social skills, and to follow directives that are supposedly in the person’s interest as defined by an expert. In the client-centered relationship, the person can express her or his own perceptions that the medication isn't helping without the immediate response “But you know that if you stop the medication, you will end up back in the hospital.” This respect of the person’s inner experience and perceptions empowers the person as someone with authority about self and experience. This is not to deny the positive aspects of skills training, psychotropic medications, and psychiatry. If medications and programs really do help, then clients can be trusted to elect to use them; if they are forced to do so by their families and therapists and by institutions of the state, then they are being treated paternalistically, as less than fully capable of deciding their own course in life.

A case that stuck in Rogers’s memory over the years was that of Jim Brown, also known as “Mr. Vac,” who was part of the Wisconsin study of chronically mentally ill patients (Bozarth, 1996; Rogers et al., 1967). In the course of a detailed description of two interviews with this patient, a “moment of change” is described in which the patient’s hard shell is broken by his perception of the therapist’s warmth and caring, and he pours out his hurt and sorrow in anguished sobs. This breakthrough followed an intense effort by Rogers, in two interviews a week for the better part of a year, to reach this 28-year-old man, whose sessions were filled with prolonged silences of as long as 20 minutes. Rogers stated, “We were relating as two…genuine persons. In the moments of real encounter the differences in education, in status, in degree of psychological disturbance, had no importance - we were two persons in a relationship” (Rogers et al., 1967, p. 411). Eight years later, this client telephoned Rogers and reported continued success on his job and general stability in his living situation, and he expressed appreciation for the therapeutic relationship with Rogers (Meador & Rogers, 1984).

This account emphasizes the person-centered rather than problem-centered nature of this approach. Rogers often stated his belief that what was most personal was the most universal. The client-centered approach respects the various ways in which people deal with fear of being unlovable, fear of taking risks, fear of change and loss, and the myriad nature of problems in living. Understanding the range of differences among us, Rogers saw that people are deeply similar in our wish to be respected and loved; our hope for belonging, for being understood; and our search for coherence, value, and meaning in our lives.

Client-centered therapists are open to a whole range of adjunctive sources of help and provide information to clients about those resources if asked. These would include self-help groups, other types of therapy, exercise programs, medication, and the like limited only by what the therapist knows about and believes to be effective and ethical. The attitude toward these psychoeducational procedures and treatments is not one of urging the client to seek out resources of any kind but rather to suggest them in a spirit of “You can try it and see what you think.” The client is always the ultimate arbiter of what is and is not helpful and of which professionals and institutions are life enhancing and which are disempowering.

Because the therapist is open to client initiatives, clients may at times wish to bring in a partner, spouse, child, or other person with whom they are having a conflict. Client-centered therapists are flexible and are often open to these alternative ways of working collaboratively with clients. The ethical commitment, however, is to the client, and it may be appropriate to refer others for couple or family therapy within the client-centered framework. Several authors – including Nathaniel Raskin, Ferdinand van der Veen, Kathryn Moon and Susan Pildes, John McPherrin, Ned Gaylin, and Noriko Motomasa – have written about working with couples and families in the person-centered and client-centered approach.

This lack of concern with a person’s “category” can be seen in person-centered cross-cultural and international conflict resolution. Empathy is provided in equal measure for Catholics and Protestants in Northern Ireland (Rogers & Ryback, 1984) and for blacks and whites in South Africa, although Rogers commented that extending empathy to a white policeman stretched his capacity to its limit (Rogers, 1986b), Conflict resolution is fostered when the facilitator appreciates the attitudes and feelings of opposing panics, and then the stereotyping of one side by the other is broken down by the protagonists’ achievement of empathy. Marshall Rosenberg, a student of Rogers at the University of Wisconsin, has developed an important approach to conflict that he calls “nonviolent communication” (Rosenberg, 2003). This approach to communication implements the client-centered conditions in ways that do not dehumanize the other person or group.

If the reader has followed Rogers’s arguments against the “specificity hypothesis,” it will come as no surprise to find that client-centered therapists have reacted with skepticism to arguments supporting the necessity of culture-specific approaches to each racial, cultural or ethnic group; gender identity; sexual orientation; or social class identity. Attempts to sensitize student therapists to cultural differences have often led to simplistic stereotypes about differing groups. We argue that within-group differences may exceed between-group differences, that groups’ self-definitions are constantly under construction, and that group members are usually members of multiple groups leading to ever-increasing permutations of identity (Patterson, 1996).

A client-centered approach does not assume “difference” except as the client asserts how he or she experiences self as different. At the same time, those of us working from this approach understand that each person is completely unique in terms of what his or her history, ethnicity, religion or lack of it, and racial identity mean. The task, as always, is empathic understanding of the client’s communicated meanings about self and about the world he or she perceives and constructs.

Does this mean that client-centered therapy has a one-size-fits-all approach? The answer is complex. We answer “Yes” to the extent that uniqueness of the person is universal. We answer “No” to counteract the prevalent color-blind assertion “We’re all human beings!” This seemingly benign assertion has masked many covert biases that therapists whose master statuses are dominant and “unmarked” have carried into therapy. The multicultural therapy movement has served to sensitize and challenge this kind of status quo thinking and practice. Client-centered therapists are just as prone to bias as therapists of differing theoretical orientations. We suspect there is a qualitative difference in the empathic understanding process of the therapist who has been challenged on his or her biases and the therapist who is still denying them. Research has yet to be done regarding this contention, but it seems to us probable that the quality and depth of empathy are affected by the therapist’s own growth of understanding about his or her location in the various social hierarchies of dominance.

Our basic practice remains true to the core conditions no matter who our client may be. We also assert that our ability to form an initial therapeutic relationship depends on our own openness to and appreciation of and respect for all kinds of difference.

It has always been characteristic of the person-centered approach to illustrate its principles with verbatim accounts. This has the advantage of depicting the interaction between therapist and client exactly and gives readers the opportunity to agree or differ with the interpretation of the data. The following interview took place at a cross-cultural workshop in Szeged, Hungary, in July 1986. John Shlien, former colleague and student of Rogers, had convened a group to learn about client-centered therapy, and Barbara Temaner Brodley, who had practiced client-centered therapy for more than 30 years at that time, volunteered to do a demonstration interview. A young European woman who had recently earned a master’s degree in the United States volunteered to be the client. There were several English-speaking participants in the observing group and eight or 10 Hungarians. The Hungarian participants clustered together in a corner so as not to disturb the interview while they were receiving a simultaneous translation. The interview was scheduled for 20 minutes, more or less, depending on the client’s wishes.

The Demonstration Interview

^{1 Reproduced with permission from Fairhurst (1999).}

Brodley comments about the interview:

Commentary

This interview illustrates, in concrete form, several principles of the process of client-centered therapy. The client’s first statement, “You are my first woman therapist” precedes her direct question “Did you know that?” Barbara responds immediately, “I didn’t know.” Clearly, the client is implying that interacting with her first woman therapist is significant to her. Whereas some therapists might have immediately answered the question with another question, such as “Why is that significant?” client centered therapists, in keeping with the nondirective attitude, do not prompt or lead their clients. The client here is free to pursue why it is significant or not to do so. She does say that Barbara’s being a woman is important “because it sort of relates to what I’m going to talk about” but does not explain it more fully until later in the interview. And even then, she has a new awareness that she cannot really put into words. In C24, she states, “I said at the beginning that you were my first woman therapist. I was avoiding women therapists like hell. All the therapists I had were men so far and now I know why. I can’t put why to words but I know why.”

Commitment to nondirectiveness should not be understood as a tense, conscious inhibiting of what one might wish to say to a client. As therapists mature in the approach, the nondirective attitude is often described as involving an experience of relief. The therapist who has formerly felt responsible for the interaction trusts the client to decide how much to disclose and when to disclose it. In this interview, the client clearly directs the conversation toward a concern of great moment to her - the trip she will be making in a matter of weeks to see her parents, whom she had promised herself never to see again. She explains that she has been in the United States for the preceding two years as she studied for a master’s degree and had not returned to her home country or her family. She explains that she had left home in a state of intense anger toward her parents - and now is wondering how it will be to see them after this absence that was more a voluntary exile than simply a peaceful time away.

During this part of the interview, the therapist makes several empathic remarks following responses to check her understanding of the content of the story and also the client’s immediate meaning. It is not until the therapist tentatively grasps the point of the client’s narrative that it becomes possible to experience empathic understanding. In T5, the therapist says, “You’re making it [the return trip] gradual and yet at a certain point you will be there and what will that be…you have an anticipation or fear or something like that.” This response is accepted, and the client moves on to tell of the encounter she had 3 days ago in which her attention was captured by an older woman in the streets of Budapest. Although it is unclear to the client why she associated this older woman with her own mother, she reports being strongly affected by the spontaneous perception of her mother in the future as old and weak. “So she was not this powerful, domineering person that she used to be in [her country] who I was so much afraid of.” The therapist’s response in which she says “old and weakened and diminished” is an example of an accurate empathic response that exactly captures the client’s immediate experiencing. This is an important difference between recounting an emotion (as the client had earlier when she recalled how angry she had been upon leaving her home and her parents) and the direct experiencing of the emotion. After the therapist’s response, she replies, “Diminished. That’s the word. That’s the word.” At this moment she has access to deeply sensed though unidentified emotions.

Client-centered therapy, in this way, spontaneously stimulates the unfolding of the inner experiencing of the client. In experiential terms, the “felt sense” has been symbolized and is carried forward, allowing a new gestalt of experiencing to arise (Gendlin, 1961). But unlike process-directive and emotion-focused therapists’ aims, the therapist was not aiming to produce focusing, nor was she trying to “deepen the felt sense” or to do anything except understand what the client was communicating. In this way, the powerful focusing effects that frequently occur in client-centered therapy are serendipitous and unintended. The stance of the nondirective therapist is expressive, not instrumental (Bradley, 2000/2011). Barbara’s use of the term diminished captures the client’s perception of her mother in the future, and the client begins to weep.

As she moves further into the experience of her perception of the older woman, the client tells Barbara that what she saw in the woman's eyes was fear - a fear that she now realizes had been present in her own mother’s eyes, although at the time she had seen it without being aware of having seen it, an instance of what Rogers has termed subception. Barbara checks her understanding of this event, which occurred only days ago and involved a stranger in the present but someone who, for the client, represented her mother in the future, noting that the client’s perception of fear in the woman’s eyes “had some great impact on you.” The client responds with immediacy and deep feeling: “Yeah, because I felt that this woman needed me,” and she continues to cry. With her immediate experiencing openly available to her, she notes, “It feels good that I am crying now. I’m feeling very well that I am crying.” A moment later she places her hand over her abdomen saying “It feels right here," letting the therapist know that she is having a direct, bodily awareness of her experiencing and that it feels good to her to allow herself to cry.

We infer that the therapist’s embodiment of the therapeutic conditions has facilitated the deeply felt expression of this experience. It is also possible to infer, although we can’t be sure, that the fact that the client has been to several male therapists indicates that Rogers’s second condition (that the person be vulnerable and anxious) may apply to the client because of the risk she is taking to work with a woman for the first time, even though this is a single therapy session. She may be vulnerable regarding this experience, but she is actively seeking an opportunity for personal growth in the possibly intimidating setting of a public workshop.

Another way to look at this experience is in terms of its complexity. The client is feeling and expressing both sorrow and pity for her mother in the future and, at the same moment, is aware of a sense of well-being or fullness in the expression of the pain. Clients can be trusted to relate what is meaningful to them, moving toward the points they wish to bring out that embody meaning. At the same time as they are giving “content,” they are experiencing themselves expressing meaning, and so there is a self-reflexive aspect of the communication that may remain implicit. In this instance, the client makes her relation to her own experiencing and expression explicit. The aim of empathic understanding is not so much to catch the underlying, implicit feeling as much as to fully grasp both the narrative and the client’s inner relation to what is being expressed. The agency or intentions of the person are to be understood simultaneously with the explicit content (Brodley, 2000/2011; Zimring, 2000).

In the next part of the interview, the client reveals that as she stood looking at the Hungarian woman, and as she felt like taking the woman in and preparing herself, she recognized that her anger toward her parents had dissipated entirely. She says, “Suddenly I realized that all this anger I had was gone. There was nothing left. It was gone.” In this instance, she is recounting a powerful experience she had had a few days before the interview. And shortly she relates that she felt sorry for her mother in the midst of this perception - a feeling she did not welcome had previously been unable to discriminate from love. In C19, there is what Rogers calls a moment of movement in which the client says,

The chance encounter with the Hungarian woman stimulated the client’s recognition that her perception of her mother has shifted from someone she had resisted, feared, and seen as a figure of authority to someone whom she is perhaps ready to encounter as a human being who is “just a woman, just another woman in the street.” The result of this shift is enhancing to her sense of herself as a person. In C25 she says, “But at this point, I’m perceiving everybody as another person, and that makes me feel more of a person as well.” One way to look at this interview is that there is movement from not being sure she is ready to see her mother’s need to “maybe I'm ready… (pause)… ready to get there.” It is possible that as she interacts with the therapist in this climate of acceptance and empathic understanding, she begins to feel more of her own strength and coping capacity.

Another aspect of this situation is the client’s fear of women therapists, which is clearly related to her fear of and anger toward her mother. Again, it is possible that in her immediate interaction with a woman therapist onto whom she has projected negative feelings in the past she experiences quite different emotions and reactions: the warm acceptance and presence of a real woman therapist. This allows a restoration of personal congruence in that we infer she is not reacting with anxiety and fear in the interview. This integrative experience may directly interact with the reorganization she experiences toward the feared mother from the past to the vulnerable, human mother in the future who will need her. Thus, she may be experiencing a greater sense of autonomy; she is no longer in the grip of anger, and she is now ready or almost ready to encounter her mother as a vulnerable person. As Ryan and Deci point out, autonomy may be thought of in terms of volition as well as in terms of independence (Ryan & Deci, 2000, p. 74). The client’s increasing sense of her freedom and her emerging sense of readiness to return leads to an increase in personal authority or power, as well as to an increased sense of her own humanity as someone who is at last perceiving other persons not as “figures” but simply as individual human beings. The client appears to have greater access to her own inner subjective context and, within the psychologically facilitative environment of the client-centered core conditions, to have become more of an authentic person in her own right.

When the client-centered therapy process persists over time, clients are likely to experience a deepening sense of self-authority and personal power. They become more capable of resistance to external authority, particularly when it is unjust, and more capable of deep connections with others. These changes in self-concept lead to more effective learning and problem solving and to enhanced openness to life.