oaches chapter 5 - baskent.edu.tr

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Chapter 5

Person-Centered Therapies

Prochaska, C. O. & Norcross, J. C. (2013). Systems of psychotherapy: A transtheoretical approach (8th edition). USA: Cengage Learning.

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A Sketch of Carl Rogers

He received his PhD in clinical psychology in 1931 from

Columbia in a highly Freudian program.

Between 1927–1928 spent 12 years as a psychologist at

a child guidance clinic in Rochester, New York.

1939 published his first book-The Clinical Treatment of the

Problem Child

In 1940, Rogers moved to Ohio State University to train

students in psychotherapy.

He moved University of Chicago in 1945.

In 1964, Rogers moved to the Western Behavioral

Sciences Institute in La Jolla, California

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Theory of Personality

One basic motivational force, a tendency toward

actualization

the actualizing tendency

• “the inherent tendency of the organism to develop all its

capacities in ways which serve to maintain or enhance the

organism.”

We are also born with organismic valuing that allows

us to value positively those experiences perceived as

maintaining or enhancing our lives and to value

negatively those experiences that would negate our

growth.

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We respond not to some “real” or “pure” reality, but

rather to reality as we experience it.

Our world is our experienced or phenomenal world

Our reality is certainly shaped in part by the

environment, but we also participate actively in the

creation of our subjective world, our internal frame of

reference.

self-concept

• includes our perceptions of what is characteristic of “I”

or “me,” our perceptions of our relationships to others

and to the world, and the values attached to these

perceptions

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As our self-consciousness emerges, we develop a need

for positive regard for our self.

• The need to be prized, to be accepted, to be loved

By the negative regard of significant others, our total

perception of how much we are loved by our parent is

weakened

The expression of positive regard by significant others is

so powerful that it can become more compelling than

the organismic valuing process.

The individual becomes more attracted to the positive

regard of others than to positive experiences that

actualize the organism.

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Soon individuals learn to regard themselves in much the

same way as they experience regard from other people,

liking or disliking themselves as a total configuration for

a particular behavior.

• Self-regard

• As a result, some behaviors are regarded positively that

are not actually satisfying, and some others are regarded

negatively that are not actually experienced as

unsatisfying

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When individuals begin to act in accordance with the

introjected or internalized values of others, they have

acquired conditions of worth

• They cannot regard themselves positively as worthy

unless they live according to these conditions.

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Theory of Psychopathology

The more conditional the love of parents, the more

pathology is likely to develop

• Because of the need for self-regard, children begin to

perceive their experiences selectively, in terms of their

parents’ conditions of worth, which have been

internalized.

• Experiences that conflict with conditions of worth,

however, are distorted in order to fit the conditions of

worth, or may even be excluded from awareness.

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As some experiences are distorted or denied, there is

incongruence between what is being experienced and

what is symbolized as part of a person’s self-concept.

• The incongruence between self and experience is the

basic estrangement in human beings. The self is

threatened.

Psychopathology reflects a divided personality, with the

tensions, defenses, and inadequate functioning that

accompany a lack of wholeness.

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As individuals live in a state of estrangement,

experiences incongruent with the self are subceived as

threatening.

• Subception is the ability of the organism to discriminate

stimuli at a level below what is required for conscious

recognition.

• Distortions such as rationalizations, projections, and

denial, to keep from becoming aware of experiences, such

as anger, which would violate conditions of worth.

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Defensive reactions, including symptoms, are developed

to prevent threatening experiences from being

accurately represented in awareness.

• People who feel unlovable for getting angry, for instance,

may deny their anger and end up with headaches

Defenses help preserve positive selfregard, at a price.

• Defenses result in an inaccurate perception of reality due

to distortion and selective omission of information.

• The more defensive and pathological the person, the

more rigid and inadequate are that person’s perceptions.

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Therapeutic Relationship

Rogers has stated very explicitly that the necessary

and sufficient conditions for therapy are contained

within the therapeutic relationship.

These and only these conditions were hypothesized to

produce therapeutic personality changes in all clients, in

all therapies, and in all situations.

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Relationship

Vulnerability

• Client lives in a state of incongruence

Genuineness

• that therapists are freely and deeply themselves, with the actual

experiences of the therapists being accurately represented in

their awareness of themselves.

Unconditional positive regard

Accurate empathy

• we sense the client’s private world as if it were our own,

without our own anger, fear, or confusion getting bound

up in the experience.

Perception of genuineness

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Consciousness Raising

The Client’sWork

Clients, rather than therapists, direct the flow of therapy

This is the primary reason Rogers (1942) originally used

the label nondirective to describe his therapy.

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TheTherapist’sWork

Reflection is the basic tool

• “You feel….”

• “You feel disappointed in your father for leaning on

alcohol,”

• “You feel envious because your roommate has a special

boyfriend and you wish you did.”

The therapist is free to listen actively and reflect

accurately the clients’ feelings.

With such a caring and congruent mirror, clients

become more fully conscious of experiences that

previously were partly distorted or denied

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The therapist first serves an attentional function.

• By reflection of the therapists, the client’s experiences,

especially threatening experiences, can be held in

awareness for further processing.

As a surrogate information processor for the client, the

therapist also helps the client adopt a more optimal

mode of organizing information.

• As clients approach feelings that threaten self-regard, they

typically become anxious, confused, or defensive, and may

be unable to find adequate words for organizing and

integrating such feelings into conscious experience.

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Catharsis

The Client’sWork

When feelings are talked about early in therapy, clients

are described as past experiences that are external to

self

Clients will talk about emotional problems, but describe

such problems as coming from outside themselves.

• “My studies are giving me a bad time”

Later in therapy, clients begin to fully express their

feelings of the moment. These feelings are owned and

accepted as coming from within the person.

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Catharsis

The release and acceptance of genuine feelings are

frequently vivid, intense, and dramatic as clients discover

an internal basis for directing their own lives rather than

having to be dominated, distorted, and threatened by

the internalized values of others.

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Catharsis

TheTherapist’sWork

the therapist’s work seemed to be simply to allow

clients to get in touch with their basic feelings by

demonstrating an attitude of unconditional prizing of all

the clients’ feelings.

As the therapist explicitly reflects back to the client the

essence of what the client is feeling implicitly, the client

eventually attends to and feels the emotion and the

meaning of experiences.

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Therapeutic Content

Anxiety and Defenses

Anxiety is not the cause of people’s problems but the

troubling consequence of a divided life.

In practice, person-centered therapists respect the

potentially disorganizing effects of anxiety, and thus do

not flood a client with threatening emotions. Instead, they

allow a more gradual corrective emotional experiencing

to occur.

The defense against anxiety-arousing experiences is

either to deny them, banishing them from awareness

entirely, or to use a whole range of distorting perceptions,

such as projection or rationalization.

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Therapeutic Content

Self-esteem

Rogers placed the need for self-esteem at the center of

intrapersonal problems, only he called it self-regard.

Low self-esteem is directly proportional to the gap

between who we think we were and who we really are.

Rogers’s solution lies not in increasing self-esteem based

on what we are supposed to be but rather in expanding

our conditions of worth so that we can prize all that we

can be.

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Therapeutic Content

Interpersonal conflicts

Intimacy and sexuality

• Intimacy is therapeutic, and therapy is intimate.

• To love and to feel intimate, most people must distort their

perceptions of their partners to fit their conditions of what

is worthy of love, just as they distort their perceptions of

themselves.

• Our society has traditionally placed narrow conditions on

our sexual worth.

• Much performance anxiety reflects the restrictive

conditions of worth that say we must be sexually successful

rather than sexually natural.

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Interpersonal conflicts

Hostility

• Hostility is not an inherent drive that must be controlled.

It is, in part, a reaction to being overcontrolled by the

restrictive conditions of parental regard.

• It can also manifest itself when people cannot express

angry feelings without feeling guilty or unworthy.

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Beyond Conflict to Fulfillment

fully functioning person

• The fully functioning person does not process experience

through structured categories—through a rigid concept

of self, for example.

existential living

• people let the self and the personality emerge from

experience:They discover a sense of structure in

experience that results in a flowing, changing organization

of self and personality.

• Self is thus experienced as a process—a rich, exciting,

challenging, and rewarding process—rather than a

constricted structure that can process only what is

consistent with internalized conditions of worth.

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Practicalities of Existential Therapy

The central focus of person-centered therapy on self-

authority tends to mitigate against the use of

psychometric tests and routine assessment in

psychotherapy.

• The client may request testing

• Clinic policy may demand that tests be administered

• Tests may be administered as an “objective” way for the

client and clinician to consider a decision for action, as in

making vocational and career choices

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Practicalities of Existential Therapy

Therapists from diverse backgrounds are welcomed.

• Counseling psychology, counseling, social work, and pastoral

counseling

• Personal therapy is seen as desirable, though not essential.

• Aspiring person-centered therapists are strongly

encouraged to participate in growth-oriented experiences.

The terms brief and person-centered therapy were rarely

used in the same sentence during Rogers’s lifetime.

The most common practice was to see clients individually,

once a week for 6 to 12 months.

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A Major Alternative and Extension:

Motivational Interviewing (MI)

William R. Miller

MI is a person-centered, directive approach that

enhances intrinsic motivation to change by helping

clients explore and resolve ambivalence

MI expands on person-centered therapy by

incorporating therapist goals about desirable changes

and by providing specific methods to move the patient

toward behavior change

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Four principles of motivational interviewing.

• Express empathy

• Develop discrepancy between the client’s deeply held

values and current behavior

• Roll with resistance by meeting it with reflection rather

than confrontation

• Support self-efficacy

Therapists who respond to client resistance with

confrontation or arguments are said to be exhibiting

counterresistance

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Instead of seeking to persuade directly, the therapist

systematically elicits from the client and reinforces

reasons for concern and for change.

The therapist maintains a warm and empathic

atmosphere that permits patients to explore ambivalent

feelings about changing.

Underlying this process is a goal of developing with the

client a motivational discrepancy between present

behaviors (real self) and desired goals (more ideal self)

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Four specific skills are used in MI to foster client safety,

acceptance, and change. These skills are summarized by

the acronym OARS:

• Open questions

• Affirmation

• Reflective listening

• Summaries

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MI has at least three applications.

• It is used early in or as a prelude to treatment, in order

to enhance client motivation for change.

• MI is used as a stand-alone brief intervention.

• MI is used with other treatments.

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Effectiveness of

Person-Centered Therapies

He is widely regarded as one of the parents of

psychotherapy research, particularly for initiating the

rich tradition of process research

Process research concerns the interactions between

client and therapist, whereas outcome research tracks

the success or effectiveness of therapy.

Two separate lines of research on the effectiveness of

person-centered therapy

• The necessary and sufficient conditions

• The overall efficacy of person-centered therapy

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Effectiveness of

the Facilitative Conditions

Facilitative interpersonal conditions are valuable

contributors to outcome but are neither necessary nor

sufficient

Client perception of their therapist’s empathy is the

single strongest therapist determinant of successful

psychotherapy

The facilitative conditions represent the core of the

nonspecific or common factors across diverse forms of

psychotherapy

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Effectiveness of

Person-Centered Therapy

Smith and Glass (1977; Smith et al., 1980) meta-analysis

found that person-centered therapy showed an average

effect size of 0.63. This was interpreted as a respectable

and moderate effect, clearly superior to no treatment,

but just barely higher than the average effect of 0.56 for

placebo treatment

Person-centered therapy was found to be comparable in

effectiveness to psychodynamic and other insight-

oriented therapies, but slightly below—some would say

negligibly below—that of behavioral treatments

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Effectiveness of

Motivational Interviewing

Compared to wait-list or no treatment, the four meta-

analyses found that MI produced average effect sizes

between 0.27 and 0.40.

Compared to alternative active treatments, the four

meta-analyses found that MI performed as effectively or

a bit more effectively, with average effect sizes between

0.04 and 0.32 favoring MI.

Strongest support by far for MI efficacy is in the area for

which it was originally designed: substance abuse among

adults and adolescents

MI appears to be particularly effective with two

populations: ethnic minority clients and resistant clients

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Criticisms of

Person-CenteredTherapies

From a Cognitive-Behavioral Perspective

A treatment based on a fuzzy form of extinction?

• the client’s distress will gradually fade if the therapist

ignores conditions of worth

• The client is allowed to talk on and on about troubled

behavior without being reinforced or punished

From a Psychoanalytic Perspective

• What person-centered therapy actually provides is a

transference relationship that has all the elements of an

idealized maternal love

• To pretend to be unconditional in our love is to do our

clients a disservice; the real world is, in actuality,

conditional with love

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Criticisms of

Person-CenteredTherapies

From a Cultural Perspective

Preoccupation with selfhood, individuation, and self-

actualization is culture specific.

His position both reflects and reinforces the high value

that Western culture places on individualism

Not all cultures share this emphasis on “self.” In at least

one culture, the term for “self” does not even exist

Rogers’s characterization of the ideal individual does

not apply across cultures.

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