ساعت 1:22 صبح چهارشنبه 26/10/1386

A Client-Centered Psychotherapy Practice

My intent here is to provide a brief deion of the principal features of my client-centered psychotherapy practice. My practice has evolved from my attempt to embody Rogers" ideas about helping relationships in my work with clients over many years. In preparing this paper I hope some other client-centered therapists will be stimulated to describe their own practices so we can have discussion of the similarities and differences among us.
I subscribe to Rogers" first principle - the actualizing tendency inherent in persons (1980a Chapt. 6). I view this tendency as the sole and original motivating principle in human beings which brings about growth, differentiation, development, self-maintenance and change. I also subscribe to Rogers" theory of the necessary and sufficient conditions of therapeutic personality change (1957). These conditions are the attitudes of congruence, unconditional positive regard and empathic understanding of the client"s internal frame of reference. I view the actualizing tendency and these attitudinal conditions to be applicable to all therapeutic relationships with all individuals.
I also subscribe to a set of values which are implicit or explicit in Rogers" theoretical writings  (1) Human nature is intrinsically constructive. (2) Human nature is intrinsically social. (3) Self-regard is a basic human need which, along with autonomy and individual sensitivity, is to be protected in helping relationships. (4) Persons are motivated to perceive realistically and to pursue the truth of situations. (5) Perceptions are a major determinant of personal experience and behavior. Thus, to understand a person one must attempt to understand him/her empathically - from the perspective of his/her own perceptions. (6) The individual person is the basic unit and the one related to in situations intended to foster growth and change. Not groups, not family groups, not organizations, etc. (7) The concept of the "whole person" is part of the helper"s experience of the person in therapy. (8) In helping relationships, the pursuit of control or authority over other persons is abdicated. Instead, there is a commitment to share power and control. (9) A belief that persons are realizing themselves and protecting themselves as best they can under the internal and external circumstances that exist at the time. (10) In helping relationships, the helper is committed to honesty in relation to him/herself. This honesty is a major means for the helper to maintain and enhance his mental and emotional health and the health of his relationships.
Through the years I have thought about my work with clients a great deal. I made many observations of the effects I was having on my clients. And I tried to determine whether or not I was working consistently with Rogers" theory. I have adjusted my behavior with clients when it seemed inconsistent with the theory and did not seem helpful to my clients. The following discussion is about the main features of the practice that has evolved.

The Conception of Goals and Implementations

The principle of an actualizing tendency, the specific theory of the attitudinal conditions for therapeutic change and the value/assumptions which I have described are active elements in the therapist"s mind and feelings throughout the therapy relationship. These elements also function before the specific therapy relationship begins. They influence the conscious, a priori choices that I make about goals and about how they are implemented. Out of my reading of Rogers and out of my experience as therapist I subscribe to the following conceptions which are general and prior to relating to any client.

My a priori goal for my client is to help my client realize his/ her own goals. These client goals may be clear from the beginning of the work and may or may not change during the course of our work. Or they may be unclear and tentative and evolve and change during the course of our work. Usually these goals involve gaining relief from psychological pain or suffering, making changes in the client"s self in ways the client perceives as growthful or more healthful, and making changes in the client"s life situations such that the situations are more conducive to the well being and effectiveness of the client and close others. But I never have specific goals in mind for my client not at the beginning nor at any point in the therapy. I work only from my awareness of the client"s goals, although I do not adopt even those.
I do have specific goals for myself that are prior to and apply to all my therapy relationships. I try to provide the interpersonal conditions which I believe are - if experienced by the client - productive of growth, change, health and relief from pain. My immediate and constant goal for myself in the relation with my client living and experiencing of the three attitudinal conditions and living my respect for the client and his rights in the relationship. I want to be congruent, to be accepting in an unconditional way and to empathically understand my client - all of these to the greatest extent possible and I want to express these attitudes so the client has the opportunity to experience me as having these attitudes in the relationship. Conscious and unconscious disciplines are involved in realizing these personal goals in relationships with clients. Wanting does not, alone, make it so.
What are my a priori conceptions about the implementation of the ideas and attitudes that have been mentioned? In answering this question I feel I must address my view of what it is that is therapeutic in my client-centered therapy work with clients - that is, what the mechanisms of change involve.

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ساعت 1:21 صبح چهارشنبه 26/10/1386

The Mechanisms of Change

I believe the change processes in the client are the result, directly, of the attitudinal conditions being provided and experienced to some significant degree by the client. The mechanism is the process of adoption, by the client, of the attitudinal conditions in him/herself and toward him/herself. The process of adoption of the attitudinal conditions by the client into self frees and enhances the capabilities and energies of the client. This process brings out the client"s wisdom about himself and arouses potentialities to be realized more fully in his/ her life.
The explorations, understandings, insights, the releases of tensions, the actions the client takes in new ways outside the therapy session and other things that happen in the process of therapy - are the concrete ways the particular client lives in and experiences the attitudinal conditions. These ways are not only stimulated by the therapy relationship, but also are new experiences because they are occurring in the context of the therapist"s attitudinal conditions. The interaction between the client"s behavior/experience while in therapy and the client"s sense of the attitudinal conditions as context results, I think, in the gradual absorption and adoption of the attitudinal conditions.
Rogers (1984) expressed this idea of the mechanisms of change. He said that he thought the mechanisms basically involve the client taking on the three therapeutic attitudinal conditions in himself and toward himself and others. Looking at the therapy process and its effects over the years, this seems the truest accounting to me. The processes are immensely variable and the ways people feel progress and change appear to be so different from person to person. What stands out as the most constant observable in all that variability is the way in which clients become more congruent, more accepting towards self and others, and more empathic towards themselves and others.
An important implication of this view of what it is that works to make therapeutic change happen - is that it does not matter from the perspective of creating change what the client talks about or expresses. Or whether or not the client talks about his most serious or significant issues. Whatever level of risk or emotional engagement the client offers is that client"s concrete participation in the relationship. It is the basis, then, of the client"s interaction with me with the attitudinal conditions being a salient expression of myself in the relationship. The therapist does not need to be concerned or worry about whether or not the client is "getting at" what "he should get at". Thus the therapist is truly freed of concerns that can result in directiveness and judgmentalness.
Returning to the idea of implementations - what, given my above stated conception of the mechanisms of therapeutic change, are my a priori ideas bout implementation of the attitudinal conditions and attitude of respect for the client?
The truest theoretical answer is that the implementation of the therapeutic attitudes depends upon the state of the client, the nature of the client"s participation, and upon the capabilities and imagination of the therapist. In other words, there is no standard or inevitable way in which the therapeutic conditions are lived out or expressed in client-centered therapy.
There is, however, a very likely way of implementing the attitudes in my work with individual clients, given the type of client I am likely to meet and given my capabilities and imagination.
The clients I see, and have seen for the most part of the past twenty six out of thirty two years of doing therapy, are clients who are able and willing to discuss or explore their concerns, problems and personal experiences. With these clients the form of interaction which seems to me most natural and effective as an implementation of the therapeutic conditions is the empathic understanding response process (Temaner, 1977). This is the way of working illustrated by Carl Rogers in his films, demonstrations and types of therapy sessions.

I shall discuss this major form of interaction in the next section, but now wish to state a perspective which I would like the reader to keep in mind as he/she reads along. First, the way of working I am discussing and describing as my own is not being put forward as the only way of working that can be based on Carl Rogers" theory. This presentation is intended to communicate the main features of my way of working from Rogers" theory. It may coincide with the way other client-centered therapists work or it may not, although I expect there would be at least overlap between my way and the way of others. Second, I am discussing only individual therapy in this paper. Third, my use of the empathic understanding response process as my major form of implementation with clients who feel a need for help and who are able to talk about their concerns is not meant to imply that this is the only or inevitable implementation of Rogers" theory with such clients.

The Empathic Understanding Response Process

The empathic understanding response process is the salient form of my therapeutic work with clients. Within this form there is a unique and spontaneous interaction between myself and each client. There are always great differences in the qualities of interactive expressiveness and the use of language between me and each client. Each relationship is unique and different in many ways. But the form within which all this uniqueness and differences take place does have certain regular or consistent characteristics:
The therapist is experiencing congruence and unconditional positive regard in relation to the client and experiencing the intention to empathically understand the client.

1. The client is communicating to the therapist talking and expressing about him/herself.


2. The therapist is able to experience specific empathic understandings of the particular client"s internal frame of reference.


3. The therapist attempts, from time to time, to check the correctness of his/her felt understanding by making empathic understanding responses, or by making responses that summarize what the client seems to have been expressing, or by asking questions for clarification of the client"s meanings.


4. The client feels understood, feels accepted-(not judged or evaluated) by the therapist, and experiences the therapist as genuine in their relation.


5. The client develops feelings of freedom and personal power in the relation with the therapist, has feelings of safety from punishment by the therapist, has feelings of being stimulated to explore and think more deeply about his/her concerns, and has feelings of affection and attachment to the therapist.


6. The client continues to talk and express and explore his her problems more deeply and expansively; and the client feels he/she is making progress.


7. As the interaction continues with the qualities described above, the therapist has a strengthened and higher level experience of the therapeutic attitudes and builds a richer empathic experience of the client in his/her own experience/memory.

The empathic understanding response process can be superficially identified or recognized by the salience of empathic understanding responses, summaries and questions for the purpose of clarification by the therapist. And by the appearance of a self-exploratory process in the client"s communication. Although it may be difficult to identify with certainty, the empathic understanding response process is only genuine and full of the potency of the genuine process if the therapist is experiencing the therapeutic attitudes at a high level and the client is feeling them.
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ساعت 1:20 صبح چهارشنبه 26/10/1386

Other Forms and Kinds of Interaction

The empathic understanding response process has always been the salient and, to me, the most natural and effective implementation of the therapeutic attitudinal conditions. In my early years of doing therapy - perhaps at least the first ten years from 1955 to 1965 - I felt uneasy and uncertain about other forms of interaction with my clients. Although I engaged in these other forms on some occasions.
I answered questions, for example. But I would be very aware of the possible misunderstandings that could come from my answers, and aware of the judgments or values that could be read in my answers. I feared I was violating the atmosphere of acceptance and understanding that I was committed to providing by bringing in, even implicitly and with care not to do so, my ideas and values in answering questions.
I was committed to the therapeutic relation as a genuine person-to-person relation. I did not want to play a role or act as if I had a right, because of my expertise or status, to assert authority over my clients. It seemed, therefore, that I had no alternative, when asked, but to answer any question as honestly and well as I could. But then I felt I might be destroying the feelings of safety and of freedom I was, otherwise, stimulating in my client. It was a dilemma I suffered with for a long time.
The discussion that follows, about other forms, comes out of having resolved my earlier feelings of dilemma. I accepted that there could be other forms of interaction with my clients than empathic understanding response process. And I discovered I could still be being faithful to client-centered theory and values.
There are, with many of my clients, sequences of interaction which are interspersed within the empathic understanding respond process. They are breaks or intermissions in that process. These breaks may be very brief and/or rare with some clients, while with others one or more of these forms of interaction may be extensive and/or frequent. The forms to which I am referring, here, are: (1) Therapist-presenting in response to client questions. (2) Accommodations requested by clients. (3) Initiation by the therapist of thoughts, feelings or reactions about the client, including (a) responses out of persistent feelings and (b) spontaneous responses.
So far, I have described the empathic understanding response process and indicated that there are these other forms of interaction I engage in when doing therapy. Now, in order to communicate to the reader the nature of these other forms I need to elucidate an attitude that is present in my work which, I believe, is inherent in Rogers" theory. This attitude informs and influences any implementation of the theory of therapy. This attitude is called the "non-directive attitude".
The idea of client-centered therapy as "non-directive" has become problematical because some teachers and therapists have made rigid and incorrect interpretations of the element of non-directiveness in client-centered therapy I must risk some of the bad associations which now adhere to the idea of "non-directive" because I believe the non-directive attitude is a significant element in Rogers" theory of therapy and in my own work.
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