Philosophy
Psychotherapeutic Approach
As of now, my theoretical orientation centers on a humanistic perspective. I consider this orientation to be in a process of development, and possibly always under development, as is one’s professional and personal growth. The humanistic perspective is the point of view that people are essentially good and constructive, that the tendency to self-actualize is inherent, and that given the proper environment humans will develop to their maximum potential. I view my theoretical orientation to be foundationally humanistic, integrative of Person- or Client-Centered Theory (CCT) and additive of Cognitive-Behavior Theory (CBT). Of paramount importance for me is the relationship between the therapist and the client. The quality of the relationship is critical in the creation of the experience in which client feels heard and understood, thus providing the opportunity for movement within the client. This opportunity is one in which any statements or interpretations result in the isolation of something in the directly sensed and felt complexity—experienced in the client as a distinct sense of lifting something out (Gendlin, 1988). It is this experiential process within the patient that I believe makes psychotherapy effective. To accomplish this, I believe CCT is useful because it lays out arguably necessary and sufficient conditions to be created by the therapist for this experience to occur within the client.
Major Constructs of Client-Centered Theory
At the core of this theory is the idea that there is a single force that drives attitudes, actions, and symptoms of individuals. Rogers (1951) called this force the “actualizing tendency,” but the idea of a motivating force accounting for a considerable share of behavior, actions, and symptoms is similar to that shared by other theorists such as Victor Frankl’s (1986) “self-transcendence,” Abraham Maslow’s (1999) “self-actualization,” Alfred Adler’s “striving for perfection” (Ansbacher & Ansbacher, 1964), and in Karen Horney’s (1991) Theory of Self. It seems to me that these theorists were mining the same vein of gold and the idea resonates with me.
Rogers argued that we should allow ourselves to be guided by the organismic valuing process by doing what feels natural to our real selves in what we desire for ourselves. He argues that all living things “know” what they need to exist through evolutionary lessons. Among the things that humans value are positive regard (i.e., things we value like affection, attention, etc.), and positive self-regard (i.e., a positive image of ourselves). The aspect of personality that is founded in the actualizing tendency, follows organismic valuing, needs and receives positive regard and self regard is called the real self. Maladjustment occurs when the client’s real self is contradicted by experiences in which his or her worth is judged according to the values of others (e.g., I am lovable only when I am clean). When the client minimizes, overlooks, denies, or distorts his or her real self in favor of the conceptualized, allowable, or idealized self as defined by others he or she is living unauthentically.
Client-centered theory describes five aspects of a fully functioning person. Rogers labeled these as “openness to experience,” the accurate perception of one’s experiences in the world—especially one’s feelings; “existential living,” the idea that one is living to his or her highest potential;” “Organismic trusting,” being in touch with the present reality and seeing the past as memories and the future as a wish, as they actually are; “experiential freedom,” acting as if one is free to act on one’s will, and “creativity,” a sense of obligation to contribute to the actualization of others in some way, such as through expressions of creativity or performing well in one’s occupation. Thus, a fully functioning person is open to his or her own experience, lives in the moment in an existential fashion, is fully connected to his or her thoughts and feelings, and trusts him or herself and does what “feels right” in a situation. To be “fully functioning” is not a finished state, but a direction in which one is constantly growing.
Therapeutic Change. In CCT, the therapeutic change agency resides in the client, not in the therapist or in the therapists’ training, knowledge or experience. Rogers (1951) argues there are three therapist qualities that are necessary and sufficient to assist the client in bringing about improvements: Congruence--genuineness and honesty with the client; Empathy--the ability to feel what the client feels; and Respect--acceptance and unconditional positive regard for the client. According to this theory, the client will improve if the therapist shows these qualities, regardless of additional techniques used. The technique for which CCT is best known is that of reflective listening, the mirroring of verbal communication intended to focus the client on how he or she really feels and to ensure the client feels understood by the therapist.
The purpose of the therapist is to allow the client to remove obstacles so the client can move forward for his or her normal growth and development. The mechanism is for the client to free him or herself from pursuing an ideal image of self that he or she cannot genuinely like or live up to because it does not belong to him or her. It emphasizes being fully present with the client and helping him or her feel his or her own feelings, desires, etc. Being “nondirective” lets the client deal with what he or she considers important at his or her own pace.
Therapeutic stance. In CCT one is to avoid the appearance of an authoritarian. However, the therapist is permitted to state his or her own position clearly, as well as listening carefully to the client. If disagreement arose in a session with Rogers, he would deflect the argument by asking “What can we learn from each other?” Though the therapist may state a position or observation, the therapist should avoid control over decision-making for the client so the client becomes responsible for him or herself. The control over decision-making and the responsibility for decisions are placed in the hands of the client. The client is allowed to have his or her own feelings, values, and goals, which of course may differ from that of the therapist.
Therapeutic Technique. Though the reflection technique noted above is not required in therapy it is widely used by therapists using this approach. As other techniques are also permissible, I have found it useful in some circumstances to implement cognitive techniques intended to offer alternative ways of looking at problems for the client to consider. I see this approach as an addition to the foundation of the CCT approach that I find so appealing.
In cases where clients are experiencing particular distress from problems such as family troubles, unsatisfying work, or other sources of unhappiness, I have found clients looking to therapy for more consultation that reflective listening. I have sometimes found it helpful to identify possible irrational or self-limiting beliefs, or possible alternative perspectives for them to consider. Techniques such as these are widely used in cognitive-behavioral approaches, such as Rational Emotive Behavioral Therapy (REBT) developed by Albert Ellis (Ellis & MacLaren, 1998). REBT is intended to help people address both practical and emotional problems suggesting to the client that certain beliefs and attitudes may contribute their distress as well as alternative possibilities. This information is provided in a client-centered, caring and supportive way, without providing a specific solution to a given problem. These techniques are never used in a confrontational or controlling way. Instead, they are offered in the way of a consultation for the client to consider. The client is always assumed to be the most competent to decide the goals of the client and the values by which the situation should be judged.
The use of a humanistic approach together with some cognitive behavioral techniques may at first glance seem odd to be used together. Yet, this approach has felt most natural to me as a therapist, and I believe I am beginning to see possible theoretical fittings. Both approaches place responsibility and agency of change squarely on the shoulders of the clients and his or her feelings and beliefs, and both methods involve helping the client see his or her own impediments toward normal growth and development. Albert Ellis might agree with this, as the Albert Ellis Institute (2005) mission statement currently characterizes REBT as a “humanistic, action-oriented approach to emotional growth…which emphasizes individuals' capacity for creating their emotions [and] the ability to change and overcome the past by focusing on the present.” The therapeutic goal for cognitive-behavioral therapy might be stated as facilitating the client in discovering the ways one’s perception may have impaired one’s behavior or emotions. In describing the mechanism of achieving this goal in existential-humanistic therapies, (Bugental & Sterling, 1995, P. 247) wrote the following:
The fundamental change agency in all human experience is changed perception. When we see familiar situations freshly, we see possibilities previously invisible. The central task of existential-humanistic psychotherapy is to help the client discover the ways he has limited his or her perception of important life areas.
Strengths and Limitations
Strengths of CCT include the importance placed on the person, how that person experiences the world, and relationship between client and therapist. The theory emphasizes agency and free will and the principle that we can all grow to our potential—that everyone is on his or her own path to full functioning. Limitations of the theory include the fact that concepts of congruence, empathy, and unconditional positive regard are open to interpretation and may therefore not be consistently implemented among therapists. In addition to lack of specificity of some terms and concepts, the theory does not address stages of development, the unconscious, elaborate description of defense mechanism or interpersonal communication, or intra-psychic life.
This approach is likely most effective with individuals of intellectual and cultural backgrounds compatible with this type of therapy. The populations demonstrating best outcomes are those with higher pre-therapy levels of general social skills, assertiveness, and affiliation, and those who are internally oriented (Grawe et al’s study as cited in Asay & Lambert, 2001). A particular point of difficulty is the fact that psychopaths may not benefit from this type of therapy because they may not feel guilt, discomfort, or anxiety. It also seems to assume that every person can become fully functioning, even if there is little capacity for creativity and free expression, such as may be possible with those who are cognitively impaired, though this may be addressed if the term fully functioning is interpreted as relative full functioning. Further, the model does not address possible biological components of disorders, and particular shortcoming, in my opinion.
Research Support
There is considerable research over the past 50 years showing that therapist facilitative skills such as acceptance, warmth, empathy, and genuineness are fundamental in establishing good therapist-client relationship and are related to positive outcomes (Horvath, A., & Symonds, D. 1991; Lambert & Bergin, 1994). A recent review of outcomes research found that successes were attributable to both extra therapeutic variables of client resources and circumstances and to variables of the client-therapist relationship (Hubble et al., 1990). Upon reviewing decades of research of CCT, and especially on the necessary and sufficient conditions of therapeutic personality change, Bozarth et al. (2001) conclude that the real potency of successful therapy is the client, and the therapist’s attention to the individual client’s frame of reference fostering the client’s utilization of inner and outer resources.
Research has been also been conducted using cognitive-behavioral techniques within the CCT framework. Termed “constructive confrontation” (an unfortunate label from my perspective), several German studies have defined this as an experience-activating technique in which the therapist picks up discrepant messages from the client (See Tscheulin, 1990). In this view, the therapist offers the client a perception that differs from his or her own. This form of “confrontation” offered in an empathic relational context is viewed as an extension of empathy. This research shows that clients who are action-oriented experience more positive change and more helpful interactions with their therapist than those in a control condition. Finally, CCT has been used with patients experiencing severely reduced functioning. In a review of use of this approach with individuals with schizophrenia, Prouty (2001) argues that there is evidence that it has value in treatment for this population, but that many studies have failed to use adequate measures and control populations, especially concerning medications, though exceptions can be found. A particular study successful in matching controls (Mosher et. al., 1995) found outcomes in a humanistic low-drug residential program to be equivalent to a high-drug inpatient program—demonstrating that some psychotic patients in the study were successfully treated without medications.
In a recent review of CBT approaches in clients with schizophrenia and other psychotic disorders, Hollon and Beck (1994) conclude that there is little reason to believe that CBT interventions can control “florid psychotic turmoil,” but believe they may help reduce delusional thinking in clients who are stabilized on medication or are otherwise in remission. They suggest that delusions represent an attempt to make sense out of troublesome or puzzling experiences and that the psychotic client is in some way open to reason or evidence. This is done through indirect and gradual approaches encouraging the client to consider alternative explanations for the antecedent experiences that led to the formation of the delusion, or targeting less strongly held among the delusional beliefs for which to consider alternative explanations for their experiences and subsequently evidence supporting the delusional beliefs, helping the client systematically test their accuracy and plausibility. Such methods have been found to be effective in some medicated schizophrenic patients (See Alford & Beck, 1994; Chadwick & Lowe, 1990; Hole, Rush, & Beck, 1979; Kingdon & Turkington, 1991).
To reduce the possibility that clients suppress or avoid their thoughts as an ineffective coping strategy, Bach and Hayes (2002) argue that clients should directly address the etiological experiences and feelings that created the need for the delusion. Their approach, Acceptance and Commitment Therapy, encourages clients to accept events, to identify and focus on actions directed toward valued goals, defuse odd cognitions by just noticing thoughts rather than treating them as either true or false. On the premise that delusions are themselves avoidance strategies (possibly as explanations for personal failures that attribute blame to external factors, or are a method of control in psychotic patients), it is the antecedent feelings of failure, depression, or anxiety that the delusions help regulate and are susceptible to reduction using this technique. Their demonstration of this technique reduced symptoms and re-hospitalization rates for clients, except those who denied having symptoms.
Terrier, et al. (2000) examined the effects of CBT, “supportive counseling” and treatment as usual in psychotic clients. The CBT was conceptualized as coping strategies aimed at reducing positive symptoms, problem-solving training, and relapse prevention strategies. The supportive counseling was defined as providing emotional support through the development of a supportive relationship, fostering rapport, demonstrating unconditional regard for the client, and social interaction. Their extended description of this therapy sounded even more similar to CCT, though they do not use this label. Therapies were delivered over a course of 3 months and at a two-year follow-up, clients receiving either CBT or supportive therapy were equally improved and remained significantly improved over patients who received treatment as usual.
The potential for improving cognitive therapy may be realized through recent research demonstrating the relationships among reasoning processes, anxiety, and the severity of delusional conviction. Garety et al. (2005) suggest that reasoning biases (belief inflexibility, jumping to conclusions, and extreme responding) are related to delusional conviction and may be ameliorated using targeted reasoning approaches. In a fairly comprehensive review of CBT therapies (including reframing, offering alternative explanations, normalization, and skills building) Lecomte and Lecomte (2002) focus on isolating the underlying factors that can account for the therapies’ apparent effectiveness. They conclude that the interaction between the therapist and client, specifically the ability to establish a working alliance and to be compatible in therapy are essential predictors of therapeutic effectiveness. Because of the strong effect of the therapeutic alliance, they recommend future research into the interaction between specific CBT techniques, client variables, and therapist variables.
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