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Person-Centred Therapy

Person-centred therapy, based on the ideas of the eminent psychothera-pist Carl Rogers, is widely practised in the UK and throughout theworld. It has applications in health and social care, the voluntary sectorand is increasingly relevant to work with people who are severelymentally and emotionally distressed. This book offers a comprehensiveoverview and presents the core theories, advances and practices of theapproach in a concise, accessible form.

Person-Centred Therapy: 100 Key Points begins with a consideration ofthe principles and philosophy underpinning person-centred therapybefore moving to a comprehensive discussion of the classic theory uponwhich practice is based.

Further areas of discussion include:

· the model of the person, including the origins of mental andemotional distress

· the process of constructive change

· a review of revisions and advances in person-centred theory

· child development, styles of processing and con®gurations of self

· the quality of presence and working at relational depth.

Finally, criticisms of the approach are addressed and rebutted, leadingreaders to the wider person-centred literature. As such this book will beparticularly useful to students and scholars of person-centred therapy,as well as anyone who wants to know more about one of the majortherapeutic modalities.

Paul Wilkins is a person-centred academic, practitioner and supervisorcurrently working for Manchester Metropolitan University.

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100 Key Points

Series Editor: Windy Dryden

ALSO IN THIS SERIES:

Cognitive Therapy: 100 Key Points and TechniquesMichael Neenan and Windy Dryden

Rational Emotive Behaviour Therapy: 100 Key Points andTechniquesWindy Dryden and Michael Neenan

Family Therapy: 100 Key Points and TechniquesMark Rivett and Eddy Street

Transactional Analysis: 100 Key Points and TechniquesMark Widdowson

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Person-Centred Therapy

100 Key Points

Paul Wilkins

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First published 2010by Routledge27 Church Road, Hove, East Sussex BN3 2FA

Simultaneously published in the USA and Canadaby Routledge270 Madison Avenue, New York, NY 10016

Routledge is an imprint of the Taylor & Francis Group, an Informabusiness

Copyright Ø 2010 Paul Wilkins

Paperback cover design by Andy Ward

All rights reserved. No part of this book may be reprinted orreproduced or utilised in any form or by any electronic, mechanical,or other means, now known or hereafter invented, includingphotocopying and recording, or in any information storage orretrieval system, without permission in writing from the publishers.

This publication has been produced with paper manufactured tostrict environmental standards and with pulp derived fromsustainable forests.

British Library Cataloguing in Publication DataA catalogue record for this book is available from the British Library

Library of Congress Cataloging-in-Publication DataWilkins, Paul, 1946±

Person-centred therapy : 100 key points / Paul Wilkins.p. ; cm.

Includes bibliographical references and index.ISBN 978-0-415-45236-6 (hardback : alk. paper) ± ISBN 978-0-415-

45237-3 (pbk. : alk. paper) 1. Client-centered psychotherapy. I. Title.[DNLM: 1. Nondirective Therapy. 2. Self Concept. WM 420.5.N8

W689pb 2009]RC481.W538 2009616.89©14±dc22

2009021163

ISBN: 978-0-415-45236-6 (hbk)ISBN: 978-0-415-45237-3 (pbk)

This edition published in the Taylor & Francis e-Library, 2010.

To purchase your own copy of this or any of Taylor & Francis or Routledge’scollection of thousands of eBooks please go to www.eBookstore.tandf.co.uk.

ISBN 0-203-86518-9 Master e-book ISBN

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This book is dedicated to my grandchildren:Eleanor, Tom, Lucy and Michael

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Contents

Preface xvii

Section 1 THE UNDERLYING EPISTEMOLOGY,PHILOSOPHY AND PRINCIPLES OFPERSON-CENTRED THERAPY 1

1 The person-centred approach is a system ofideas and attitudes in which person-centredtherapy is rooted 3

2 Person-centred therapy has been from theoutset and remains a radical challenge to theprevailing medical model and the notion oftherapist as `expert' 5

3 The person-centred approach embraces afamily of person-centred therapies 7

4 There is a philosophical basis to person-centredtherapy 9

5 The principle of non-directivity underpinsperson-centred therapy 13

6 `Power' and how it is exercised are central toperson-centred therapy 17

7 The issue of the compatibility of usingtechniques in a person-centred framework isunresolved and contentious 21

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Section 2 CLASSICAL PERSON-CENTRED THEORY 238 Person-centred practice, however it is now

carried out, is founded on theory based onempirical research and observation as describedby Rogers and his colleagues in the 1940s and1950s 25

9 The actualising tendency is the crucial conceptat the heart of approaches to person-centredtherapy 29

10 The `nineteen propositions' detailed in Rogers(1951) and the classic paper Rogers (1959)provide an elegant statement of a theory ofpersonality consistent with person-centredconcepts of change 31

11 Although person-centred theory is anorganismic theory, not a self theory, thenotion of `self' remains important 35

12 The root of psychological and emotionaldistress lies in the acquisition of conditionsof worth 39

13 The proposal of six necessary and suf®cientconditions for therapeutic change is anintegrative statement describing the elementsof any successful therapeutic relationship. Itis untrue that the practice of person-centredtherapy involves but three `core conditions' 41

14 Because there is no stated or implied rankingof the six necessary and suf®cient conditionsand they are only effective in combination,it may be a mistake to favour one abovethe other 43

15 The need for (psychological) contact is anoften unconsidered pre-requisite forperson-centred therapy. To be in contact isto be in relationship 47

16 That the client is incongruent and at least tosome degree aware of that incongruence (asvulnerability or anxiety) is a necessarycondition for therapy 51

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CONTENTS

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17 Rogers' seven stages of process provides amodel for therapeutic change and guidancefor the therapist in the encounter 53

18 For therapy to be effective, the therapist mustbe congruent in the relationship. This is arequirement to `be' and not necessarily to `do' 57

19 Unconditional positive regard is the linchpinon which person-centred therapy turns but itpresents a real challenge to the therapist.However, without this quality of acceptancethere is a strong possibility that therapy willbe unsuccessful 61

20 `The ideal person-centred therapist is ®rst ofall empathic.' `Being empathic is a complex,demanding, strong yet subtle and gentle wayof being' 65

21 The effectiveness of a therapist's unconditionalpositive regard and empathic understandingdepends on the extent to which they areperceived by the client 69

22 In person-centred theory, there is noacceptance of the unconscious as a repositoryof repressed functions and primitive drives ordesires and therefore `transference' is of littleor no relevance 71

Section 3 REVISIONS, RECONSIDERATIONS ANDADVANCES IN PERSON-CENTRED THEORY 73

23 Person-centred therapy is not based on anossi®ed, mid-twentieth century theory butalive, dynamic and being actively researchedand developed 75

24 From the outset, an understanding of childdevelopment and psychotherapy withchildren and young people has beenfundamental to the person-centred approach.Theory and practice continue to be developedand re®ned 77

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CONTENTS

25 In the view of some, there are times whenthe integration of the necessary and suf®cientconditions leads to another, `transformational'quality known as `presence' 81

26 For some, in classic person-centred theorythe notion of the `individual/self' as a discreteentity is over-emphasised, incomplete and/orculture bound 85

27 The person may constitute a multiplicity of`selves' rather than a unitary self 87

28 Empathy is seen as multi-faceted and complexbut it is important to remember that empathicunderstanding is what is essential to effectivetherapy 89

29 Although the basic hypothesis does not call forit, the communication to and/or perception ofthe therapist's congruence by the client hasrecently received attention 91

30 Although it remains under-researched,unconditional positive regard has beenreconsidered and re-evaluated 95

31 Person-centred therapy is rooted in aphilosophical and ethical tradition: the workof Peter Schmid 97

32 Although diagnosis has no place inperson-centred practice, assessment may bean ethical obligation 101

33 Person-centred theory includes ways ofunderstanding psychopathology. Thesediffer from the predominant `medical model' 105

34 Pre-therapy and contact work constitute animportant, person-centred way of workingwith `contact impairment' and extreme mentaland emotional distress 107

35 Client incongruence, which can beunderstood as caused in various ways, is asource of mental and emotional distress 111

36 The client's style of processing may result inmental and emotional distress 113

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CONTENTS

37 The causes of mental and emotional distressare environmental, social and to do withpower and powerlessness. The medicalisationof distress is an error 115

38 For some, an extension to person-centredworking is embraced in the concept of`relational depth' 117

Section 4 CRITICISMS OF PERSON-CENTREDTHERAPY ± AND REBUTTALS 121

39 The theory and practice of person-centredtherapy has been subject to a great deal ofcriticism. This criticism is often based inmisunderstanding 123

40 It is untrue that person-centred theoryholds that there is an ideal endpoint tohuman development and this has implicationsfor therapy 125

41 It is untrue that the model of the personadvanced in person-centred theory isinadequate to explain psychopathology andleads to an unprofessional disregard forassessment 127

42 It is untrue that person-centred theoryincludes an unduly optimistic view ofhuman nature as fundamentally `good' andthat this leads to a naõÈve disregard fordestructive drives and an avoidance ofchallenge and confrontation in thetherapeutic endeavour 131

43 Rogers' (1957/1959) statement of thenecessary and suf®cient conditions hasbeen challenged. While many accept thenecessity of these, the suf®ciency isdoubted 135

44 Person-centred therapy is seen as arising fromand bound to a particular culture milieu andthis limits its relevance and applicability 137

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CONTENTS

45 In ignoring `transference' person-centredtherapy is seen as naõÈve and seriouslylacking 141

46 The non-directive attitude is a ®ction and anirresponsible denial of power 145

47 The concern for power in the therapeuticrelationship shown by person-centredtherapists is misconceived and misdirected 147

48 Person-centred therapy is a palliative for theworried well but lacks the depth and rigourto deal with people who are `ill' 151

49 Person-centred practice comprises solely`re¯ection' and this is a technique of littleeffect 153

50 Because of its obsession with `non-directivity'the practice of person-centred therapy resultsin harmfully sloppy boundaries 157

Section 5 PERSON-CENTRED PRACTICE 159

Subsection 5.1 The foundations of person-centredpractice 161

51 Responsible person-centred practice requiresa strong theoretical foundation and particularattitudes and personal qualities 163

52 Person-centred practice takes place in manycontexts and the terms `counselling' and`psychotherapy' apply to some of these butare often interchangeable 165

53 The ®rst step towards person-centred practiceis a thorough grounding in person-centredtheory 167

54 Person-centred practitioners work withclients, not patients 169

55 An objective of person-centred practice is tooffer a healing relationship. This comprisesseveral ingredients including the six necessaryand suf®cient conditions 171

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CONTENTS

56 Because person-centred therapy relies on howthe therapist is rather than what the therapistknows, there is professional obligation onperson-centred therapists to attend to theirown growth and development 173

Subsection 5.2 The initial processes ofperson-centred therapy 177

57 In person-centred therapy, getting startedwith a new client is an involved and involvingprocess 179

58 Contracting and structure in person-centredtherapy 181

59 Assessment in person-centred practice 18360 Establishing trust 187

Subsection 5.3 The basic attitudes underpinningperson-centred practice 189

61 Non-directivity in practice 19162 Clients are the experts on themselves and

are active agents in their own growth andhealing 195

63 The person-centred therapist's job is to followwherever the client leads, putting asidetheoretical understanding and any other`expert' knowledge 197

Subsection 5.4 The necessary and suf®cientconditions in practice 199

64 The necessary and suf®cient conditions areall it takes for successful therapy 201

65 Contact in practice 20366 The therapist's availability for contact 20567 The client's availability for contact 20768 Contacting the `unavailable' client ± contact

impairment and pre-therapy or contact work 20969 Dealing with client incongruence 21370 Being congruent or integrated in the

relationship as a therapist 215

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CONTENTS

71 Developing and enhancing therapistcongruence 219

72 Making congruent responses 22173 Being yourself, psychologically mature and

practising according to your personal style:the multifaceted nature of therapistcongruence 223

74 The therapist's self-expression andself-disclosure in person-centred therapy 227

75 Developing your unconditional positiveself-regard 229

76 Developing unconditional positive regard 23177 Unconditional positive regard in practice:

paying attention to the whole client 23578 Unconditional positive regard in practice:

the avoidance of positive reinforcement andpartiality 237

79 Unconditional positive regard in practice: theavoidance of rescuing the `helpless' 241

80 Accepting the whole of the client:unconditional positive regard andcon®gurations of self 243

81 Developing your empathy 24582 Communicating your empathic understanding 24783 Facilitating the client's perception of

therapist unconditional positive regard andempathy 249

84 The therapist-provided conditions as a whole:preparing for and facilitating `presence'and/or `relational depth' 251

Section 6 PERSON-CENTRED THEORY ANDPRACTICE WHEN WORKING WITHREACTIONS TO LIFE EVENTS 255

85 Person-centred therapy and the `one size®ts all' approach 257

86 Person-centred theory and loss andbereavement 259

xiv

CONTENTS

87 Person-centred practice with clientsexperiencing loss or bereavement 261

88 Person-centred theory and client reactionsto being abused as children 263

89 Person-centred practice is effective withclients abused as children 267

90 Post-traumatic stress and responses to criticalincidents may be understood in terms ofperson-centred theory 269

91 It is possible to offer person-centred therapyto people who have experienced a criticalincident or other traumatic event 271

92 In person-centred theory, `depressed process'is preferred to the concept of depression 275

93 A person-centred way of working withdepressed process 279

94 Panic and anxiety can be understood inperson-centred terms 281

95 Anxiety and panic can be worked with in aperson-centred way 283

96 There are person-centred understandings ofthe experiencing of different realities 285

97 There are person-centred ways of workingwith people who experience reality differently 287

98 There is a person-centred understanding ofthe excessive use of drugs and/or alcohol 289

99 Person-centred work with people for whomtheir use of mood-altering substances isproblematic 293

And last but by no means least 297100 `The facts are friendly': research evidence

indicates that person-centred therapy iseffective and at least as effective as othermodalities 299

References 303

xv

CONTENTS

Preface

Since Rogers and his colleagues began to develop what wasthen called `client-centred therapy' (previously `non-directivetherapy') in the 1940s and 1950s, a family of related approacheshas been established around the original conceptions. Majorbranches of this family include focusing, experiential and process-experiential therapies. These are touched on in this book, espe-cially in relation to theory. However, the main focus is on what inthe UK is normally called `person-centred therapy', that is anapproach to therapy that has the non-directive attitude at thecentre of theory and practice and which is widely taught andpractised. This is closely related to client-centred therapy as itwas ®rst described but includes some newer ideas and practices.These include advances in understandings of person-centredpsychopathology, reconsiderations of the necessary and suf®-cient conditions for constructive personality change, develop-ments in working with people who are contact-impaired and waysin which qualitative improvements may be made to the therapist/client relationship. In taking this focus I am deliberately largelyexcluding a part of the person-centred family of approaches totherapy ± that is those that have experiencing at the core of thetherapeutic process. These include focusing-oriented approachesderived from the work of Gendlin (1978, 1996) and more recentlyaddressed by, for example, Purton (2004) and process-experiential approaches, the roots of which are in the work of

xvii

Rice (1974) and of which recent proponents include Greenbergand Elliott (see, for example, Elliott et al., 2004b), Rennie (1998)and Worsley (2002). These approaches are particularly strongthroughout continental Europe (see, for example, references toLietaer in this book) and the journal Person-Centered andExperiential Psychotherapies is a good source for original workabout them (and indeed papers covering the complete spectrumof person-centred approaches). The reason for referring minim-ally to focusing, process-experiential and related approaches issimply that they are rich enough and different enough to deservea book of their own. To attempt to include a consideration ofthem here would do neither branch of the person-centred familyjustice.

So, the 100 key points elaborated in this book cover `classical'person-centred theory, recent developments in person-centredtheory, criticisms of person-centred therapy (and rebuttals ofthese), the principles of person-centred practice, some indicativeexamples of how and why person-centred therapy may be donewith speci®c client groups (in terms of their reactions to lifeevents) and, ®nally, a brief review of the research evidence forthe ef®cacy of person-centred therapy. Of course, although itwas clear to me what the majority of points should be, forexample, that they should include a rigorous exploration ofperson-centred theory and cover the major practical implemen-tations of these as well as at least sampling mainstream theor-etical and practical advances, picking only 100 key points wasn'teasy. I hope my eventual choice satis®es my readers.

The book offers comprehensive coverage of person-centredtherapy as it is currently conceived and practised. It will be usefulnot only to people training as person-centred therapists but alsopractitioners of the approach and anybody else who wants aneasily accessible sourcebook covering the major aspects of theapproach.

xviii

PREFACE

Section 1THE UNDERLYING

EPISTEMOLOGY,PHILOSOPHY AND

PRINCIPLES OFPERSON-CENTRED

THERAPY

1The person-centred approach is a system of ideasand attitudes in which person-centred therapy isrooted

Although it is sometimes used somewhat imprecisely to refer toa way of doing therapy, the person-centred approach is a globalterm for the application of the principles derived from the workand ideas of Carl Rogers, his colleagues and successors to many®elds of human endeavour. It is one of the most striking thingsabout the method of psychotherapy originating with CarlRogers ± and which has variously been referred to as `non-directive therapy', `client-centred therapy' and `person-centredtherapy' ± that it, or rather the ideas underpinning it, gave riseto something described as an `approach'. This is the person-centred approach of which Wood (1996: 163) pointed out:

[It] is not a psychology, a school, a movement or manyother things frequently imagined. It is merely what itsname suggests, an approach. It is a psychological posture,a way of being, from which one confronts a situation.

This `way of being' (p. 169) has the following elements:

· a belief in a formative directional tendency

· a will to help

· an intention to be effective in one's objectives

· a compassion for the individual and respect for his or herautonomy and dignity

· a ¯exibility in thought and action

· an openness to new discoveries

· `an ability to intensely concentrate and clearly grasp thelinear, piece by piece appearance of reality as well as per-ceiving it holistically or all-at-once': that is to say a capacityfor both analysis and synthesis or the perception of gestalts

· a tolerance for uncertainty or ambiguity.

3

EPISTEMOLOGY, PHILOSOPHY AND PRINCIPLES

The `person-centred approach' is not only a way of doingcounselling and psychotherapy (between which person-centredtherapists do not make a distinction ± Point 52) but a way ofbeing in relationship, a relationship which can be with anotherindividual, a group, a nation, or even the planet (see Wilkins2003: 3±5). Although an in-depth consideration of them isoutside the scope of this book it is nevertheless pertinent thatperson-centred theory and practice extends into many otherareas of human endeavour. These include education, inter-personal relationships, political, cultural and social change andapproaches to research. That the person-centred approach is(for example) concerned with social justice and social changetends to impact on person-centred therapy. Also, the importantelements of the approach are the drive for `growth', that is theformative and actualising tendencies (Point 9) and theconsideration of people as inherently trustworthy, capable ofautonomy and to be deeply respected which has implications forthe exercise of power (Point 6). This too goes to the heart of thepractice of person-centred therapy. Thus knowledge of theapproach as a whole informs person-centred practice.

The ®rst section of this book outlines some of the funda-mental aspects of the person-centred approach especially as theyrelate to the theory and practice of person-centred therapy.

4

PERSON-CENTRED THERAPY: 100 KEY POINTS

2Person-centred therapy has been from the outsetand remains a radical challenge to the prevailingmedical model and the notion of therapist as`expert'

Person-centred therapy was originally developed in the 1940s byCarl Rogers and his colleagues. From the outset, Rogers'intention was to provide a radical alternative to the prevailingpsychodynamic and behavioural approaches to psychotherapyand also to psychiatry and the medical model in which all thesecan be seen as rooted. This was initially called `non-directivetherapy' and by 1951 his preferred term was `client-centredtherapy'. In the 1960s when he began to apply the principlesderived from his approach to therapy to other realms of humanrelationship, the term `person-centred approach' gained cur-rency. This in turn led to the term `person-centred counselling/therapy' which is currently the preferred term in the UK butwhich may also be taken to embrace a `family' of relatedapproaches based on client-centred theory (Point 3).

In the various names given to the approach to therapydescribed by Rogers (1942, 1951, 1959) a radical alternative to(then) current approaches is indicated. In the names alone,Rogers is indicating the centrality of the relationship to thetherapeutic endeavour, the focus on the client rather than ontheory or technique and the importance of the therapist trackingthe experience of clients rather than imposing on them.Furthermore, in his statements of the necessary and suf®cientconditions for therapeutic change (1957, 1959) (Point 13), Rogersdescribed six elements about which he (1957: 101) claims that, ifthey are present, positive change will occur regardless of theorientation of the practitioner `whether we are thinking of classi-cal psychoanalysis, or any of its modern offshoots, or Adlerianpsychotherapy, or any other'. Thus Rogers was making an

5


integrative statement about psychotherapy, not de®ning client-centred therapy.

So, a way of reading the statement of the necessary andsuf®cient conditions is as a challenge to all the elaborate theoriesand practices of the myriad approaches to therapy. `Believewhat you want and, providing it doesn't con¯ict with the neces-sary and suf®cient conditions, do what you want, but unless thesix conditions are present, change will not occur, if they are,constructive change will occur regardless.' Not only that, Rogers(1957: 101) explicitly states that psychotherapy is not a specialkind of relationship ± the conditions can be and are met inrelationships of many other sorts. Implicitly, these relationshipstoo can be the spur to therapeutic change. Herein lays a radicalchallenge to psychotherapy and psychiatry. This challenge isabout power and how it is exercised (Points 5 and 6).

Person-centred therapy eschews diagnosis (but not necessarily`assessment' ± see Wilkins 2005a: 128±145 and Point 32) and themedicalisation of distress. However, there is an argument madeby, for example, Sanders (2005: 21) to the effect that `coun-sellors have abdicated the radical position occupied by Client-Centred Therapy (CCT) in the 1950s'. As Sanders (2006a: 33±35) states and explains, `distress is not an illness'. Rather than a`disease' model of mental distress as may be seen as dominatingpsychiatry or notions of `psychosis' and `neurosis' as may beprevalent in other approaches to psychotherapy, in the con-temporary person-centred tradition there are four positions tomental ill-health. These are those based on (Wilkins 2005b: 43):

1. (psychological) contact2. incongruence3. styles of processing4. issues of power.

These conceptualisations challenge not only the medicalisedelement of the psychiatric and psychotherapeutic professions butalso the powerful pharmaceutical industry.

6


3The person-centred approach embraces a family ofperson-centred therapies

The approach(es) to therapy based on person-centred principlesare various. They include focusing, experiential psychotherapy,process-experiential psychotherapy and creative and expressiveforms too. Even the form originating directly from Carl Rogersand which has variously been referred to as `non-directivetherapy', `client-centred therapy' and `person-centred therapy'has shifted and adapted along the way. So just what is it thatcharacterises the person-centred therapies?

Sanders (2004: 155) listed the primary and secondary prin-ciples of person-centred psychotherapy; the former are `required'for person-centred practitioners and de®ne the broad family thatis the person-centred approach, the latter `permitted' in the sensethat they bring practice closer to the classic client-centredapproach as it was de®ned in the 1940s and 1950s. Adapted ascharacteristics of the approach, these are as follows.

Primary principles

· The actualising tendency has primacy. It is required tobelieve that the process of change and growth is motivatedby the actualising tendency and an error to act otherwise.

· Constructive, growthful relationships are underpinned bythe active, attentive inclusion of the `necessary and suf®-cient' conditions established by Rogers (1957).

· The non-directive attitude has primacy. It is mistaken todirect the content of experience either explicitly or implicitly.

Secondary principles

· There is a right to autonomy and self-determination. It is amistake to violate the internal locus of control of another/others.

7


· A `non-expert' attitude underpins relationships with others.It is a mistake to imply expertise in the direction of contentand substance of the life of another. In this sense at least`equality' is fundamental.

· The non-directive attitude and intention have primacy inthat it is a mistake to wrest control of the change processfrom the actualising tendency in any way whatsoever.

· The therapeutic conditions proposed by Rogers (1957) aresuf®cient to enable encounter. It is a mistake to includeother conditions, methods or techniques.

· Holism ± it is a mistake to respond to only a part of theorganism.

Although Sanders presented his principles in terms of therelationship between therapist and client, if it is to be person-centred, at least the primary principles apply to any relationshipbetween individuals, an individual and a group, society ornation, groups of all kinds and individuals and groups andecologies of all levels.

Sanders (2007a: 107±122) revisits the `family' of person-centred and experiential therapies, explaining how the corevalues are seen by different authors (pp. 108±111), and charac-terising different approaches to:

· Person-centred/client-centred therapy emphasising thecentrality of the actualising tendency, the necessary andsuf®cient conditions and principled non-directivity (pp.111±114);

· Experiential therapies including focusing-oriented andprocess-experiential psychotherapies in which experiencingis at the core and the therapist is an expert processfacilitator/director (pp. 114±117);

· Pre-therapy ± not a therapeutic approach as such but asystem of techniques to come before therapy per se withclients for whom `contact' is problematic (pp. 117±118).

8


4There is a philosophical basis to person-centredtherapy

The person-centred approach can be considered as rooted in oneor more of a number of philosophical or epistemological para-digms. If it is accepted that there are three dominant meta-paradigms underpinning modern Western thought as to thenature of human beings (Modernism, Romanticism andPostmodernism), it is possible to make an argument for theperson-centred approach as drawing or having drawn on each.For example, the early development of client-centred therapywas very much in accord with empiricism and positivism. It wasclearly about trying to establish what constituted effectivetherapy and how therapy worked best through a process ofconstructing and testing hypotheses ± that is the scienti®cmethod and is a Modernist perspective. However, the actual-ising tendency and ideas about the existential freedom of theperson and the valuing of experiencing are more aligned withRomanticism. Equally, it seems to me (Wilkins 2003: 26±30)there is a case for the person-centred approach as Postmodern atleast in as much as knowledge is subjectively de®ned, dependingon the nature and approach of the knower. In person-centredterms, there is no objective truth waiting to be revealed butmeaning is constructed ± or, more likely, co-constructed.

It is not possible to point to one of these major paradigmsand to say categorically `the person-centred approach belongsthere'. Thus, the person-centred approach is not `humanistic'(which may be considered as of the Romantic paradigm) eventhough it has been assigned as such and has some characteristicsin common with humanistic approaches. For example (drawingon Spinelli 1994: 256±260), that person-centred therapy is`humanistic' implies that the following are emphasised:

· the client's current experience rather than past causes whichmay `explain' that experience

9


· the totality of the client rather than a particular `problem'

· the client's personal understanding and interpretation oftheir experience rather than the therapist's

· the client's freedom and ability to choose how to `be'

· an egalitarian relationship between the client and thetherapist

· the therapeutic relationship as intrinsically healing and/orgrowth-inspiring

· integration of self-concept and the `self ' per se

· the client's inherent actualising tendency and innately posi-tive nature

· the client's core, unitary self as a source for individualdevelopment.

However, it seems that the principles of client-centred therapywere established before those of humanistic psychology (seeMerry 1998: 96±103) and possibly contributed to the develop-ment of that line of thought rather than being derived fromit. Also, person-centred theory is an organismic theory, not aself theory (see Tudor and Merry 2002: 92). That is, it is con-cerned with the sum total of the biochemical, physiological,perceptual, cognitive, emotional and interpersonal behaviouralsubsystems constituting the person rather than a psychologicalconstruct, the self, which may be considered to be a particularand peculiar, `culturally embedded ethnocentric concept' (seeSanders 2006b: 31) unique to Western thought.

Because it is concerned with subjective experiencing, `being inthe world', `being in the world with others' and the whole personor organism (see Becker 1992: 13±18), there is a case for theperson-centred approach as phenomenological. Although it pre-dates it, phenomenology shares something with Postmodernism.In my view, the person-centred approach draws more onphenomenology than any other branch of philosophy. This isclearly indicated by the ®rst two of Rogers' (1951: 483±484)propositions:

1. Every individual exists in a continually changing world ofexperience of which he is the center.

2. The organism reacts to the ®eld as it is experienced andperceived. The perceptual ®eld is, for the individual, `reality'.

10


Does it matter that it appears dif®cult or even impossible topigeon-hole the person-centred approach in terms of a particularphilosophy or meta-paradigm? Well, no. This is both because itsits well with the `anti-establishment' origins of the approachand the notion that it is a revolutionary paradigm and becausethroughout the history of the approach, theory has been derivedfrom and modi®ed in the light of practice. The person-centredapproach is not theory-driven but neither is it atheoretical.Thinking clearly about the approach, being fully conversantwith its theory and, for example, tracing the conceptual andlinguistic development of person-centred thought as it relates tothe Western intellectual tradition as has been done with greateffect by Schmid (see, for example, 1998a, 1998b, 2002a, 2003and Point 26) are all very important but ultimately the value oftheory lies more in its construction than in its propagation. In asense, even the implementation of theory is, for some, secondaryto a concentration on the relationship. Theory informs practicebut does not dictate it and is, or should be, out of immediateawareness in the moment of encounter.

11


5The principle of non-directivity underpins person-centred therapy

In many ways, that the therapist has a non-directive attitude isthe fundamental and original precept of person-centred therapy;however, it is and has been controversial more or less fromRogers' early statements of the principle in, for example, theclassic Counseling and Psychotherapy (1942). It seems that mostof this controversy centres on just what is meant by `non-directivity'. For example, that the non-directive therapist is a`non-expert' in the sense that clients are the experts on themselveshas been confused with a lack of expertise. Clearly, person-centred therapists are required to have expertise in the sense ofadherence to practices rooted in a particular theory andspeci®cally to those derived from the statement of the necessaryand suf®cient conditions for constructive personality change(Rogers 1957: 96, 1959: 213) and a way of being in relationship.Also, being non-directive has sometimes been operationalised asa set of passive behaviours in the therapeutic encounter where thetherapist does little but mechanistically `re¯ect' what has beenheard or (worse) simply signals non-verbally `I am listening' ± theso-called `nodding dog' effect. Empathic responding, which is atthe heart of classical client-centred therapy and therefore of anon-directive approach, requires much more of the therapist thanthese simple behaviours (Point 20).

Rogers (in Kirschenbaum and Henderson 1990a: 86±87)wrote:

Nondirective counselling is based on the assumption thatthe client has the right to select his own life goals, eventhough these may be at variance with the goals his coun-sellor might choose for him. There is also the belief that ifthe individual has a modicum of insight into himself and hisproblems, he will be likely to make this choice wisely.

13


This is a statement of the right of the client to autonomy andof a belief in the constructive nature of human beings. It is notabout passivity on the part of the therapist nor does it implyparticular techniques. What is intended by `non-directivity' is anattitude not a set of behaviours (see Brodley 2005: 1±4). That is,the therapist has no desire and makes no attempt to direct thecourse or content of the therapy or to decide goals or a desirableoutcome.

Cain (2002: 366±368) challenges this conceptualisation ofnon-directivity as ìn¯exible' and limiting of clients and (p. 369)argues that `nondirectiveness is neither a de®ning nor essentialcomponent of person-centeredness'. However, others (forexample Brodley 2005: 1±4; Levitt 2005: 5±16) take a clearlydifferent view. This seems to be at least in part a matter ofinterpretation. Grant (2002: 371±372) addresses this and comesup with two understandings of non-directiveness, instrumentalnon-directiveness and principled non-directiveness. The former (p.371) ìs seen as essentially a means of facilitating growth', whilethe latter (p. 371) ìs essentially an expression of respect'. InGrant's (2002: 373±377) conceptualisation, instrumental non-directivity characterises `person-centred' therapies, i.e. thoseconforming to Sanders' (2004: 155) primary principles, whileprincipled non-directiveness is (Grant 2002: 371) èssential toclient-centered therapy' by which he means what can be calledclassical client-centred therapy.

Grant (2002: 374±375) makes it very clear that principlednon-directiveness does not involve self-abnegation or passivityon the part of the therapist. Rather, he describes what he sees as`the paradox' of this attitude as being that the therapist maycomply with a client's request for `direction, advice, interpreta-tions, or instructions' not because of the therapist's view of `theclient's needs, best interests, diagnosis, or learning style' butdepending on `whether the therapist wants to honor the request,judges himself or herself competent to honor it, and believes itmoral to do so'.

Sanders (2006b: 82) describes Grant as having developed anèthics-only' approach to therapy `wherein the [therapist] has nogoals or clinical objectives ± the [therapist] operates entirely froman philosophical/ethical stance' (original emphasis) and states

14


that students of person-centred therapy `should regard Grant'swritings as essential'. Drawing on the work of Grant andBrodley amongst others, Sanders (2006b: 82) characterises acontemporary understanding of non-directivity in the (slightlyadapted) following way:

· Whilst it is not formalised in Rogers' theory it is none-the-less implicit in his work.

· It is an attitude not a set of behaviours or techniques. Inexperienced therapists it is an aspect of character.

· It ®nds expression through the therapeutic conditions and isinseparable from them ± all therapist responses should be`tempered' by non-directivity.

While for some, the ethical imperative on which principlednon-directivity is founded is enough to justify it, Sanders (2006b:84±85) points out that there are arguments for the therapeuticbene®ts of non-directivity. Brie¯y, drawing on person-centredtheory, he shows that (p. 85):

non-directivity is an attitude that fosters self-suf®ciencyand works against the client becoming dependent on thecounsellor. It also requires the counsellor to be constantlyreviewing the issue of power in the counselling relation-ship. In a formal helping relationship nothing can removethe structural power imbalance between the helper and theperson being helped, but a commitment to non-directivityhelps keep the counsellor's awareness of power dynamicshigh.

Lastly, it is relevant to note that, even though he was aware ofthe arguments with respect to non-directivity occurring in his lifetime and in the face of Cain's (2002: 366) observation that theword `non-directive' did not appear in the title of any of Rogers'published works after 1947, it seems that Rogers held to theprinciple in his later years. In Evans (1975: 26), Rogers stated:

I still feel that the person who should guide the client's lifeis the client. My whole philosophy and whole approach is

15


to strengthen him in that way of being, that he's in chargeof his own life and nothing I say is intended to take thatcapacity or opportunity away from him.

Thus, the non-directive attitude is and was always aboutpower in the therapeutic relationship and a belief that to exertpower over another (even with good intentions) is actuallycounter-therapeutic.

16


6`Power' and how it is exercised are central toperson-centred therapy

In the study of human relationships, power and in¯uence areproblematic. How they are understood has to do with theor-etical and philosophical stance as well as practical experience(Proctor et al. 2006 is a good source for thoughts about powerwritten from a person-centred perspective). There is no way anyof us can divorce ourselves from the power (or lack of it)bestowed on us by our gender, class, ability, wealth, ethnicity,education, professional role and so on. All these factors affectthe practice of person-centred therapy and must be acknowl-edged and addressed. However, at the risk of appearing naõÈvelyto set them aside, there is something worth saying about funda-mental person-centred attitudes and `power' in the therapeuticrelationship.

As indicated in Point 5, power in the therapeutic relationshiphas long been a contentious and dif®cult issue for person-centred therapists. The whole approach is predicated on theassumption that it is counter-therapeutic for the therapist topresent as an `expert' at least in the sense of knowing what isbest for the client. This is about who has power in the rela-tionship and the nature of that power. Quite what this meansin practice may be understood differently depending on thebranch of the person-centred family to which the practitioneradheres and according to personal interpretation. At least forthose practising in (or close to) the `classic' client-centredtradition, this is also a matter of ethics. For example, Shlien(2003: 218) describes the client-centred method as the only`decent' one and I (Wilkins 2006: 12) have described choosingto practise in a person-centred way as `to make an ethicalchoice, to take a moral position'. This is about an aspect ofpower ± however, power takes many shapes, some benign, someless so.

17


I (Wilkins 2003: 92) have argued that to be effective as aperson-centred therapist it is essential to be fully present asa powerful person in the therapeutic relationship without deny-ing or subjugating that personal power. This brings an obli-gation to be acutely aware of that power and to seek to exerciseit in a constructive, in¯uential way but to consciously avoiddirecting and dominating the other person. This is in accordwith Natiello (2001: 11) who states Ì believe that a therapistneeds to bring a strong sense of self and of personal power[original emphasis] to the facilitative relationship.' Elsewhere,Natiello (1987: 210) de®nes personal power as:

the ability to act effectively under one's own volitionrather than under external control. It is a state wherein theindividual is aware of and can act upon his or her ownfeelings, needs, and values rather than looking to othersfor direction.

Arguably, personal power is innate ± that is human beingsare born with the facility to self-direct. Circumstances (forexample conditions of worth ± Point 12) can cause people tolose touch with their personal power but, given the right con-ditions, it can be discovered or reclaimed. However, the notionof empowering another is nonsense because it would involve theexercise of power, the `doing' of something to another and istherefore a contradiction. Rogers (1977: 289) wrote ìt is not thatthis approach gives power to the person; it never takes it away'.Similarly, Grant (2002: 374) points out that `the liberation thatcan come from client-centered therapy is accomplished byrespecting clients as autonomous beings, not by making themautonomous beings'. A task of person-centred therapists is thento avoid disempowering their clients, hence the importance of thenon-directive attitude.

Proctor (2002: 84±103) deals at length with the issue of powerin person-centred therapy. She:

· agrees (p. 87) that the non-directive attitude leads to àradical disruption of the dynamics of power in therapy'

18


· indicates (p. 89±90) that the therapist exercising personalpower (in the form of empathic understanding) can beliberating for the client

· discusses (p. 90) the demysti®cation of therapy explicit inthe person-centred approach as contributing to a lack ofdisempowerment of the client

· states (p. 92) the importance of the therapist's intent tofollow but not interpret the client's experience and to beprepared to `self disclose' as contributing to an egalitarianrelationship.

However, she (pp. 94±95) also warns of the danger ofignoring the power implicit in the therapist's role, stating:

There are different powers attached to [the role of clientand the role of therapist], and this inequality is establishedin the institution of therapy. It seems that person-centredtheory may be emphasising the agency of individuals at theexpense of missing the effect of structures of power onindividuals. The potential implications for person-centredtherapists of ignoring structural power are that they couldmiss opportunities to help clients from their own position,and they could underestimate or misunderstand the effectson clients' lives of any structures of power.

Proctor (p. 103) reaches the conclusion that `person-centredtherapy certainly challenges the fundamental inequality in theroles of therapist and client' and that `there is radical potentialfor PCT to challenge and question the orthodox model ofmental illness'. While she agrees that the facilitative conditionsdescribed by Rogers tend to increase a sense of personal power,she warns that:

there is the danger in focusing on equality from thisperspective, of ignoring other aspects of power. What mustalso be considered are the material realities of possibleinequalities in social structural power, and in the insti-tutional and structural `power-over' [original emphasis] stillattached to the role of therapist, however a therapist maybehave.

19


7The issue of the compatibility of using techniquesin a person-centred framework is unresolved andcontentious

Because it is seen as to con¯ict with the principle of non-directivity (Point 5) and involve the exertion of power by thetherapist (Point 6), the use of techniques within person-centredtherapy is, to say the least, contentious. Certainly, there arethose who argue that the use of any technique is incompatiblewith person-centred therapy (see, for example, Fairhurst 1993:25±30). This is because, from a classical client-centred pointof view, the therapist's sole role is to attend to the client'sexperience and process. To do anything else may be counter-therapeutic. However, many others who adopt the label `person-centred' deviate from the classical view. For example, experi-ential and focusing therapists have no problems with the notionof directing clients' attention towards aspects of their experienceand process while others proactively introduce activities drawingon a range of creative and expressive techniques. For example,Natalie Rogers (2007: 316±320) describes `person-centredexpressive arts therapy', Silverstone (1994: 18±23) discussesperson-centred art therapy and in Wilkins (1994: 14±18) I makea case for person-centred psychodrama.

Bozarth (1996: 363) takes a `yes but' position with respect tothe use of techniques. He is of the opinion that while theorymilitates against the use of techniques it may be possible to dothis in a person-centred way. His hesitation with respect totechniques rests on the fact that they may distract the therapistfrom the world of the client. In other words the therapeuticendeavour moves from being client-centred to being technique-centred. Brodley and Brody (1996: 369) come to a similar con-clusion but (p. 373) qualify this stating that techniques are notcompatible with `true client-centered psychotherapy' if `they arethe result of the therapist's having a diagnostic mindset'. Rogers

21


(1957: 103) sees `no essential value' to the use of `such tech-niques as interpretation of personality dynamics, free associa-tion, analysis of dreams, analysis of the transference, hypnosis,interpretation of life style, suggestion, and the like'.

What Rogers is sceptical about are techniques of interpreta-tion, those which involve therapists intervening from their ownframes of reference. This seems also to lie at the heart of thereservations of Fairhurst, Bozarth, and Brodley and Brody andthe like. It is clear that anything centring on therapists and theirframes of reference is something other than person-centredtherapy. However, the `techniques' of (for example) person-centred expressive therapists, person-centred art therapists andperhaps even person-centred psychodramatists can be viewed asthose of communication, not interpretation. There is an argumentto be made that the implicit direction of the classic client-centredtherapist `talk to me' is in reality no different from the `direction'of the person-centred expressive therapist `dance with me' or`draw with me'. People communicate and express themselvesvia many media and to restrict them to one channel may bemistaken. Perhaps what matters is that the therapist's attention isfocused on the client's experience which is responded toempathically and acceptingly regardless of the medium employed.

22


Section 2CLASSICAL PERSON-

CENTRED THEORY

8Person-centred practice, however it is now carriedout, is founded on theory based on empiricalresearch and observation as described by Rogersand his colleagues in the 1940s and 1950s

One of the early and proud boasts of the founders of person-centred therapy is that its theory was ®rmly rooted in theempirical observation of practice and that this was unique. Also,Rogers and his early students saw themselves as scientists whosought to establish a basis for their beliefs and practices byactively engaging in research. Rogers was not alone in this early,innovative research work. For example, Barrett-Lennard (1998:11±12) recorded that in the 1940s each graduate studentworking with Rogers at Ohio State University typically con-tributed `a discovery in method, technique or theoretical formu-lation in the previously uncharted ®eld of empirical research onpsychotherapy'. Rogers moved to the University of Chicago in1945 and from there to the University of Wisconsin where hewas from 1957 to 1963. McLeod (2002: 88) writes that:

During the whole of this 25-year period Rogers wasthe leader of a systematic programme of research into theprocesses and outcomes of client-centered therapy. Theclient-centered research group comprised the largest centrefor research in psychotherapy then in existence.

The ®rst intent of Rogers and his students and colleagues wasto seek to understand the process of therapy and what led toconstructive change. Rogers (1967: 244) framed the theory ofclient-centred therapy `not as dogma or as truth but as a state-ment of hypotheses, as a tool for advancing our knowledge'. Theconcepts underpinning person-centred therapy were beingconstantly revised in the light of clinical experience and research.Rogers' clinical experience and research led him to hypothesise

25

CLASSICAL PERSON-CENTRED THEORY

(1957: 96) an integrative statement of the necessary and suf®cientconditions of any successful therapeutic relationship regardless ofthe orientation of the therapist (see Bozarth 1996: 25±26; Wilkins1999: 57±58) not merely a formula for person-centred practice.

The fruits of the intense research activity of the 1940s werepublished in a variety of journals and doctoral theses but themost accessible accounts are in Rogers (1951). This book con-tains many references to and descriptions of the research intoperson-centred therapy carried out to that date. These includestudies of therapist techniques and attitudes (pp. 30±31, pp. 51±52), statements as to the nature of self and self-concept (pp.136±137), process and outcomes in play therapy (pp. 267±275)and the training of therapists (pp. 444±462) as well as studies ofthe process of therapy and client `change'. There is also a review(pp. 56±64) of the evidence for the basic hypothesis (p. 56)`concerning the capacity of the individual for self-initiated,constructive handling of the issues involved in life situations'.Although the term was not in use at the time, this looks like anearly reaching towards the notion of the actualising tendency(see Point 9). There is also an account of `The Early Period ofResearch' in Rogers (1967: 247±266).

It was from this early research that the theoretical proposi-tions underpinning the person-centred approach ®rst came to bestated. Throughout the 1940s, as Rogers (1951: 15) states, mostof the theoretical constructs proposed by those researchingclient-centred therapy had centred on the nature of the self. Forexample, Rogers (1951) culminates in (pp. 481±524) the state-ment of `a theory of personality' derived from clinical experienceand the research studies illuminating the nature of self and theprocess of therapy. This statement is as nineteen propositions(Point 10). However, there was also important research into thenon-directive approach.

Following on from the classic statement of the principles ofclient-centred therapy (Rogers 1951) the next landmark texts areRogers' 1957 paper and his 1959 chapter. In Rogers (1959) thereis a comprehensive statement of a theory of therapy and per-sonality change, a theory of personality (including child devel-opment) and a theory of interpersonal relationships. Rogers(1957) is presented in terms of a statement of a hypothesis and

26


its implications although throughout the paper references aremade to the empirical observations underpinning the hypothesis.Rogers (1959) comprises a fuller statement of the hypothesis ofthe necessary and suf®cient conditions and hypothesises manyother elements of person-centred theory. Following eachstatement, Rogers makes ®rst a commentary on it and thenoffers an account of the evidence from research that supportsthe hypothesis. In the ®nal section of this chapter (pp. 244±251),Rogers reviews `the theoretical system in the context of research'considering, amongst other things, what has been investigatedand how.

27


9The actualising tendency is the crucial concept atthe heart of approaches to person-centred therapy

In the theory and practice of person-centred therapy, it is heldthat an innate tendency within the client constitutes the soleagent for growth, `constructive personality change' (Rogers 1957:96), achievement of potential and so on. This agent is called theactualising tendency. Of this tendency, Rogers (1951: 487) wrotethat the human species `has one basic tendency and striving ± toactualize, maintain, and enhance the experiencing organism'.However, it is clear from Rogers' later writing (see, for example,Kirschenbaum and Henderson 1990a: 380) and (for example) thecommentary of Barrett-Lennard (1998: 75) that the actualisingtendency is not seen as a uniquely human characteristic but thatit `is present generally in complex life forms'.

As the ®rst of his `primary principles of person-centredtherapies', Sanders (2004: 155) indicates the primacy of theactualising tendency. He goes on to state `it is a therapeuticmistake to believe, or act on the belief, that the therapeuticchange process is not [original emphasis] motivated by theclient's actualising tendency'. Thus the actualising tendency isfundamental to and de®ning of the person-centred approach.

The actualising tendency is a biological force common to allliving things. It directs all organisms towards survival, main-tenance and growth where growth is understood as increasingcomplexity and the ful®lment of potential. In person-centredtheory, the actualising tendency is the sole motivation fordevelopment and behaviour in human beings and beings ofother kinds. In terms of `classical' person-centred therapy, theactualising tendency in human beings propels the organism ±that is the sum total of the biochemical, physiological, per-ceptual, cognitive and interpersonal behavioural subsystemsconstituting the person ± in the direction of increasing inde-pendence and towards developing relationships. While this may

29


at ®rst appear to be a contradiction, in reality it is only as aperson moves towards being psychologically free that therecan be a corresponding movement towards open and honestencounter. Moreover, there is an increasing propensity forunfettered relating, that is, towards relationships that are mutualand equal and in which `manipulation' plays no part. This isalso because human beings are of an inherently social natureand thus, under optimal conditions, the actualising tendencydrives towards constructive social behaviour. However, asRogers (1959: 196±197) makes clear, as an individual develops aself structure so the general tendency to actualise `expresses itselfalso in the actualization of that portion of the experience of theorganism which is symbolized in the self'. This is self-actualisingtendency. When there is a signi®cant difference between self andorganismic experience the self-actualising tendency may con¯ictwith the actualising tendency and a state of incongruence arises(see Point 11).

The actualising tendency can be viewed as a springing fromthe formative tendency that is a directional tendency towardsincreasing order, complexity and interrelatedness found through-out the natural world and which is postulated to be (literally)universal. Rogers (1980: 134) stated that, for him, the formativetendency `is a philosophical base for the person-centeredapproach'. Implicit in the notion of the formative tendency isthe interconnectedness of all things and thus this must also betrue of the actualising tendency.

30


10The `nineteen propositions' detailed in Rogers(1951) and the classic paper Rogers (1959) providean elegant statement of a theory of personalityconsistent with person-centred concepts of change

In Rogers (1951: 483±522) nineteen propositions amounting to aperson-centred theory of personality and behaviour are setforth. Sanders (2006b: 17), in `deliberately colloquial' language,describes these theoretical statements as being `about humanpsychological development, the nature of human mental life, thestructure of personality, how this structure can be prone toweaknesses, the nature of psychological distress, and how dis-tress can be put right'. About his theory of personality, Rogers(1951: 532) wrote the following:

This theory is basically phenomenological in character,and relies heavily on the concept of the self as an explana-tory construct. It pictures the end-point of personalitydevelopment as being a basic congruence between thephenomenal ®eld of experience and the conceptual struc-ture of the self ± a situation which, if achieved, wouldrepresent freedom from internal strain and anxiety, andfreedom from potential strain; which would represent themaximum in realistically oriented adaptation; which wouldmean the establishment of an individualised value systemhaving considerable identity with the value system of anyother equally well-adjusted member of the human race.

As well as the original statement of these propositions byRogers, there are neat summaries of them in Merry (2002: 34±37),including (p. 34) `some explanations in different and perhapsmore familiar terms', and Tudor and Merry (2002: 98±99).

The nineteen propositions demonstrate the person-centredview of the person as continually in process ± that is personality

31


is ¯uid, not ®xed. Explicit in this theory is that harmful and/orinhibiting early experiences give rise to `conditions of worth' (seePoint 12) and that these give rise to emotional or psychologicaldistress. However, people have the potential to become free ofconditioning and to move towards being `fully functioning'.

In Rogers (1959: 221±223) the person-centred theory of per-sonality is re®ned and restated. The following aspects ofpersonality are considered:

· postulated characteristics of the human infant

· the development of the self

· the need for positive regard

· the development of the need for self-regard

· the development of conditions of worth

· the development of incongruence between self andexperience

· the development of discrepancies in behaviour

· the experience of threat and the process of defence

· the process of breakdown and disorganisation

· the process of re-integration

· speci®cation of functional relationships in the theory ofpersonality.

Rogers (pp. 232±233) goes on to consider the researchevidence for his theory of personality.

Drawing together threads from Rogers' theoretical state-ments, Sanders (2006b: 21±24) characterises person-centredpersonality theory as:

· A phenomenological theory: it emphasises the subjective,experiential world of the individual.

· A perceptual theory: because an individual's reality is basedon the perception of the world, then a change in perceptionleads to a change in experience and behaviour.

· A humanistic theory: it is rooted in (p. 23) `a naturalisticphilosophy that rejects all supernaturalism and reliesprimarily on reason and science, democracy and humancompassion'.

32


· A holistic theory: the organism is central ± human beings are(more than?) the sum total of their parts.

· A ful®lment of potential, growth-oriented theory: the person-centred metaphor for recovery is not `cure' or `mending' or`reprogramming' but of growth or development to a newway of being.

· A process theory: neither personality nor self are ®xed`things', rather, being human is a process, not a state.

33


11Although person-centred theory is an organismictheory, not a self theory, the notion of `self 'remains important

Although person-centred theory centres on the concept of theòrganism', that is the whole person comprising a number ofsubsystems including biochemical, physiological, perceptual,emotional, behavioural and relational systems, rather than the`self' (see Rogers 1951: 484±488; Rogers 1959: 221; Barrett-Lennard 1998: 74±76; Tudor and Merry 2002: 91±93), andTudor and Merry (2002: 92) state that person-centred theorymay justi®ably be considered as an organismic psychologyrather than a self psychology (that is an understanding of psy-chology which puts self at the centre ± see Tudor and Merry2002: 159±160), the notion of the self has importance andcurrency.

While person-centred theorists have offered and continue tooffer re-conceptualisations of the self (for example, in terms ofquantum physics) and challenges to the concept as `culture-bound' (see Wilkins 2003: 30±34) and it is acknowledged that`self' is a process, ¯uid rather than ®xed, in classic client-centredtheory the term is used in two principal ways. Firstly, there isthe emerging or developing self. This Rogers (1959: 200) de®nedthus:

The organized, consistent conceptual gestalt composed ofconceptions of the characteristics of the Ì' or `me' andthe perceptions of the characteristics of the Ì' or `me' toothers and to various aspects of life, together with thevalues attached to these perceptions. It is a gestalt which isavailable to awareness though not necessarily in aware-ness. It is a ¯uid and changing gestalt, a process, but atany given moment it is a speci®c entity . . .

35


In a way, this `self', the experiencing self, is what is differ-entiated from the organism (as a total openness to experiencingas may be the lot of an infant) through interaction with theenvironment and, especially, signi®cant others. Tudor and Merry(2002: 126) add `[t]he self is thus the inner, experiencing personwith re¯ective consciousness'. In the vernacular of Westernsociety, this conceptualisation of the self may be equated with theindividual.

Secondly, there is the self-concept which, in the simplestterms, is the view one has of one's self. The move towards astate of full functioning depends on the degree of congruencebetween the organism and the self-concept (any incongruencearising from conditions of worth; Point 12). The person forwhom there is a notable disparity will tend to anxiety, at least adegree of emotional distress and a rigidity of personality whilethe person for whom there is greater accord will be propelled bythe actualising tendency in the direction of becoming a fully-functioning person. Related to the self-concept is the `ideal self'(Rogers 1959: 200) which is the self-concept the person wouldmost like to possess, the perceived person they would most liketo be. In terms of therapy, clients probably have the aim ofbecoming as close as possible to their ideal selves but theorysuggests that it is greater congruence between self and organismthat will correlate most strongly with the relief of distress.

Rogers (1959: 223±224) explains how the self develops. He(p. 223) tells how, as a function of the actualising tendency, partof the experience of an individual becomes differentiated andsymbolised in an awareness of being and functioning. Thisawareness he called `self-experience'. It is through interactionwith the environment, particularly signi®cant others, that thisrepresentation in awareness develops into the self concept. Asthis awareness emerges, the individual develops a need forpositive regard. Rogers (1959: 223) states that this need `isuniversal in human beings, and in the individual, is pervasiveand persistent'. So powerful is this need for positive regard thatit can overwhelm the organismic valuing process or the actual-ising tendency and thus de¯ect the individual from becoming afully functioning person. As the individual continues to develop,a need for self-regard arises. Tudor and Merry (2002: 130)

36


equate self-regard with self-esteem which (p. 129) they de®ne as`the value an individual has of her/himself which, in turn, relieson a self concept to which to attach the value or esteem'.

Technically, self-regard is positive regard experienced by theindividual independently of positive regard transactions (whethersatisfying or frustrating) with social others. Rogers (1959: 224)writes that a need for self-regard `develops as a learned needdeveloping out of the association of self-experiences with thesatisfaction or frustration of the need for positive self regard' and`the individual thus comes to experience positive regard or loss ofpositive regard independently of transactions with any socialother [and] in a sense becomes his own signi®cant social other'. Inother words, the attitude of the individuals towards themselves isno longer directly dependent on others. However, when a selfexperience is sought or avoided only because it enhances ordetracts from self-regard the person is said to have acquired a`condition of worth' (Point 12).

37


12The root of psychological and emotional distresslies in the acquisition of conditions of worth

Individuals have a need for positive regard (Point 19) ± inparticular from `signi®cant others', that is important people inthe immediate environment such as parents and other principalcarers. As the self develops, there is also a need for positive self-regard which Merry (2002: 25) indicates as being necessary to`develop a sense of trust in the accuracy and reliability of ourown inner experiencing'. That is to say that positive self-regardallows individuals to trust their own perceptions and evaluationsof the world as they experience it. In terms of person-centredtheory, this position is having an `internal locus of evaluation'.However, the need for positive regard from others, especiallythose to whom the individual looks for care, protection andnurture, is so strong that this internal evaluation of experiencecan be easily overwhelmed if love and acceptance is withheld orthreatened to be withheld ± that is if they become `conditional'.So, in order to gain and maintain the positive regard of others,the individual disregards or inhibits the expression of aspects ofinner experiencing that con¯icts (or seems to con¯ict) with theneeds and opinions of others because to do otherwise would riskthe withdrawal of love and acceptance. When this happens,individuals rely on the evaluations of others for their feelingsof acceptance and self-regard. They develop an `external locus ofevaluation', distrusting inner experiencing even to the pointof abandoning it altogether. In this way, individuals learn thatthey are only acceptable, loveable and prized, that is `worthy', aslong as they conform to the demands, expectations and positiveevaluations of others. In this way `conditions of worth' areacquired. In order to maintain a feeling of being valued andaccepted, individuals seek or avoid experiences according tohow well they ®t with their conditions of worth. Experiencesthat match these conditions of worth (and therefore the self

39


concept) are perceived accurately and accepted, ones that do notare perceived as threatening and are distorted or denied (`dis-tortion' and `denial' are the two `defence mechanisms' describedin classic person-centred theory ± see Rogers 1959: 227). Thisleads to `incongruence' (Point 16) between the self and experi-ence and in behaviour. (Note: there are other propositions as tocauses of incongruence, see Point 35.) It is the process of defencethat leads to some expressions of emotional or psychologicaldistress. Rogers (1959: 228) lists these as including:

not only the behaviors customarily regarded as neurotic ±rationalization, compensation, fantasy, projection, compul-sions, phobias and the like ± but also some of the behaviorscustomarily regarded as psychotic, notably paranoid beha-viors and perhaps catatonic states.

However, sometimes the process of defence is unable tooperate successfully. This can lead to a state of disorganisation(see Rogers 1959: 229). It is postulated that this may lead toacute psychotic breakdown. Thus incongruence arising fromconditions of worth can be seen as the root of emotional andpsychological distress. The client's incongruence, leading tofeelings of vulnerability or anxiety, is the second of Rogers'(1959: 213) `necessary and suf®cient conditions' for constructivepersonality change (Point 13).

While it is theoretically possible that if a person experiencedonly unconditional positive regard that therefore no conditionsof worth would arise and there would be no con¯ict betweenpositive regard from others and positive self-regard, it is sup-posed that this never occurs in reality.

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13The proposal of six necessary and sufficientconditions for therapeutic change is an integrativestatement describing the elements of anysuccessful therapeutic relationship. It is untrue thatthe practice of person-centred therapy involves butthree `core conditions'

One of the most widespread misassumptions about person-centred theory is that there are three `core conditions' (usuallynamed as èmpathy', `congruence' and àcceptance' or ùncondi-tional positive regard'), the practice of which de®nes person-centred therapy. This is not so. The famous hypothesis of thenecessary and suf®cient conditions for therapeutic change(Rogers 1957: 95±103, 1959: 213) comprises six statements.From Rogers (1957: 96) these conditions are:

1. Two persons are in psychological contact.2. The ®rst, whom we shall term the client, is in a state of

incongruence, being vulnerable or anxious.3. The second person, whom we shall term the therapist,

is congruent or integrated in the relationship.4. The therapist experiences unconditional positive

regard for the client.5. The therapist experiences an empathic understanding

of the client's internal frame of reference and endeav-ours to communicate this experience to the client.

6. The communication to the client of the therapist'sempathic understanding and unconditional positiveregard is to a minimal degree achieved.

Rogers states that, if these conditions are present, positivechange will occur regardless of the orientation of the practi-tioner. Thus he is making an integrative statement. From aperson-centred perspective, this explains why in comparative

41


studies of the ef®cacy of different approaches to therapy such asStiles et al. (2006) there is no signi®cant difference betweenthem. The assumption must be that when the hypothesis of thenecessary and suf®cient conditions is met and other elements ofthe particular therapeutic style of the practitioner do not sig-ni®cantly con¯ict with them, the effects of therapy will bebroadly the same. What is important to note is that the hypoth-esis depends on all six conditions not merely the so-called coreconditions. Exclude any and the proposition falls. Rogers (1957:100) states this quite unambiguously: `if one or more of [the sixconditions] is not present, constructive personality change willnot occur'. Although in Rogers (1959: 213), these conditions arestated slightly differently, with respect to the basic hypothesis,this is not of much signi®cance (see Wilkins 2003: 64±65) andthe same arguments apply. However, as well as including a(nintegrative) statement of the necessary and suf®cient conditionsfor successful therapy the 1959 paper comprises a statement ofperson-centred theory.

The assumption that there are `core' conditions has ledpeople to act, write and think as if it is only these which matteror at least that they are in some way more important than theother three. Actually, no ranking of the conditions is stated orimplied in the original hypothesis or elsewhere in Rogers'writings. However, Rogers (1957: 100) does offer a furtherhypothesis to the effect that `If all six conditions are present,then the greater the degree to which Conditions 2 to 6 exist, themore marked will be the constructive personality change in theclient.' This still means that it is only collectively and in com-bination that the conditions are necessary and suf®cient (see alsoTudor 2000: 33±37). This is of great importance when anyevaluation of person-centred therapy is attempted because, if asis often the case, to concentrate only on the therapist conditionsof empathic understanding, congruence and unconditional posi-tive regard severally or together is to fail to put the hypothesis tothe test.

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14Because there is no stated or implied ranking ofthe six necessary and sufficient conditions andthey are only effective in combination, it may be amistake to favour one above the other

As stated in Point 13, the hypothesis of the necessary and suf®-cient conditions rests on the presence of all of them. Even so, itis not uncommon to read that `congruence takes precedence'(for example, Rogers interviewed by Hobbs 1989: 21) or thatunconditional positive regard (UPR) is the curative condition(for example, Bozarth 1998: 83) or descriptions as to howempathy cures (for example, Warner 1996: 127±143) or that it isthe communication or perception of empathy and/or UPR thatmakes for constructive personality change (for example, Wilkins2000: 33±34). However, in some ways such statements areunhelpful or even misleading ± certainly they seem open tomisinterpretation. It is clear from Rogers' original formulationthat no one condition is more important than the other. So howand why have people come to make statements that appear tocontradict this?

When being interviewed by Hobbs (1989: 19±27), Rogers didindeed indicate that congruence takes precedence; however, thiswas a quali®ed statement. What he (p. 21) actually said was`Empathy is extremely important in making contact withanother person but if you have other feelings then congruencetakes precedence over anything else.' Two things immediatelystrike me about this. Firstly, it is only if the therapist hasfeelings other than an empathic sensing of the experience of theother that congruence takes precedence. The inference from thisis that sometimes, if the therapist cannot maintain contact withthe experiential world of the client because of some feeling,thought or sensation that is clearly in their own frame ofreference then some action is called for. Haugh (2001: 7) offerssome criteria for making a judgement about this. Perhaps in

43


operational terms and from a classic client-centred perspective,what is happening in such circumstances is that the therapist iscountering or avoiding incongruence by saying or doing some-thing from their own frame of reference so that they are able tobe empathic and accepting. Secondly, there has been someconfusion between `precedence' and importance. Certainly, whattakes precedence precedes but what comes ®rst is not necessarilymore important than what follows. Again, congruence comesbefore the other therapist conditions only because without it theothers cannot be trusted ± or are dif®cult or impossible to hold.So, it is not that congruence is more important than the otherconditions but that therapists must be congruent in the rela-tionship before and if their empathy and unconditional positiveregard is to be perceived by clients as trustworthy.

With respect to the stated or implied greater importance ofthe other conditions, the state of affairs is more complex.Sometimes the apparent favouring of one condition overanother is analogous to the situation with respect to congruence.For example, when Rogers (1959: 208) writes that UPR `seemseffective in bringing about change' or Bozarth (1998: 83) statesthat it is `the curative factor in client-centred therapy' they arenot ranking it above the other conditions. What is happeninghere and with respect to similar statements about empathy andthe communication or perception of the therapist conditions ismore likely to be attempts to understand and explain the processof therapeutic change. In a way, this is precisely what Rogerswas doing when he set out the six conditions. However, fromboth practical experience and theoretical consideration I havecome to believe that it is a mistake to think of the therapistconditions as unitary fragments, independent of each other.Really, as Bozarth (1998: 80) states, the three therapist con-ditions are functionally one condition. Freire (2001: 152) echoesthis, arguing that `empathic experience and unconditional posi-tive regard are ultimately the sole and same experience'. Mearnsand Thorne (2007: 149) put it slightly differently, expressing theopinion that, in combination, the therapist conditions become`something much larger than the parts'. Following from this itcan be postulated that there is but one therapist super-conditionof which congruence, UPR and empathy are but facets. This is

44


why the issue of the importance of the conditions with respect toone another is a spurious consideration. It is also why attemptsto research any single condition, while it may have value, cansay nothing about the hypothesis of the necessary and suf®cientconditions (see Wilkins 2003: 66±67).

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15The need for ( psychological) contact is an oftenunconsidered pre-requisite for person-centredtherapy. To be in contact is to be in relationship

As Sanders (2006b: 33) states, the ®rst of Rogers' necessary andsuf®cient conditions, the requirement that `contact' (Rogers1959: 213) or `psychological contact' (Rogers 1957: 96) existsbetween client and therapist, is consistently overlooked in mostbooks about therapy and often in the training even of person-centred therapists. This seems to be an important oversightbecause what is being expressed in this condition is that success-ful therapy depends upon there being a relationship between theclient and the therapist. Rogers (1959: 207) makes this clear inhis de®nitions of terms:

Contact. Two persons are in psychological contact, or havethe minimum essential of a relationship, when each makesa perceived or subceived difference in the experiential ®eldof another.

Another way of understanding this is that for therapy to besuccessful each person involved must, to some small degree andon some level, be aware of the presence of the other (even if notconsciously) and that this awareness constitutes a relationship.Rogers (1957: 96) writes:

The ®rst condition speci®es that a minimal relationship, apsychological contact, must exist. I am hypothesizing thatsigni®cant positive personality change does not occurexcept in a relationship.

Because human beings are innately relational, we have astrong need for psychological contact. Warner (2002: 92) pointsout that `even moderate increases in psychological contact are of

47


great personal and psychological value to clients'. In otherwords, contact with another person, a sense of being with ratherthan apart, however ¯eeting, can lessen anxiety and existentialloneliness.

In their exploration of the concept of contact, Wyatt andSanders (2002: 8) point out that, from their reading of Rogers,`the minimal connection between two persons ± before it can besaid that they are ``in relationship'' ± is that both have a desireand intention [original emphasis] to be in contact with eachother'. This implies that mindfulness is a necessary element ofrelationship, i.e. each person must make a perceptible impact onthe awareness of the other. This seems to contradict the ideathat a subceived impact is suf®cient to constitute contact ± if tobe in contact is to be in relationship. Wyatt and Sanders presenta view of contact as a necessary precursor to relationship andtherefore to any prospect of successful therapy. This is indeedthe normal situation. However, because contact can also besubceived, it is possible to build on and strengthen it. This is, forexample, what lies behind pre-therapy (see Prouty 2002a, 2002b)where the therapist works in a systematic way to discover andstrengthen subceived contact between the therapist and clients ofimpaired functioning due to (for example) psychosis, moreextreme learning disability, dementia or brain damage (throughorganic disease or injury). Indeed, Prouty (2002a: 55) describespre-therapy as a theory of psychological contact although hismeaning is slightly different because he includes contact withthe self.

Without the requirement for contact being met, the otherconditions would have no meaning and no effect. In putting therelationship at the heart of the therapeutic endeavour, Rogerswas making a radical statement. Because to this day in thepractice of person-centred therapy the relationship is valuedabove all else the radical challenge remains. Increasingly, evi-dence from outcome research indicates that, in counselling andpsychotherapy as a whole, apart from `client variables' ± that iswhat the client brings to the interaction ± it is the relationshipbetween client and therapist which correlates most strongly withsuccessful outcome (see, for example, Krupnick et al. 1996).This places contact at the very centre of understanding what

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happens in psychotherapy. From a person-centred perspective,this awareness has led to a reconsideration of the nature ofcontact. For example, whereas the classic client-centred positionis that contact exists or it does not (what Sanders 2006b: 36describes as `a binary, all-or-nothing, on-off event') others arguethat there are levels of contact and/or that there are types ofcontact different in nature and degree. So, Cameron (2003a: 87)considers that contact may be of various depths, writing `[t]hedepth of contact is what makes the difference between a rathermechanical and lifeless therapeutic relationship and one thatshimmers with energy and involvement'. In two chapters, she(2003a, 2003b) names and describes four levels of psychologicalcontact:

· Basic contact is `meeting', mutual encounter of perhaps themost rudimentary kind in which each person perceives theother and is affected by them.

· Cognitive contact is about sharing meaning and involvesmental processes and at least a degree of mutual under-standing.

· Emotional contact is `being closer', an openness to one'sown feelings and a willingness to receive and respond to thefeelings of the other.

· Subtle contact or intimacy which has an equivalence with`presence' (Rogers 1980: 129), tenderness (Thorne 1991: 73±81) or even `working at relational depth' (Mearns 1996).

These could just as well be thought of as characterisingdifferent qualities of relating.

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16That the client is incongruent and at least tosome degree aware of that incongruence (asvulnerability or anxiety) is a necessary conditionfor therapy

The second of Rogers' (1957) necessary and suf®cient conditionsfor successful therapy demands that the client is (p. 96) `in astate of incongruence, being vulnerable or anxious'. In technicalterms, incongruence is a discrepancy between the self as per-ceived and the actual experience of the organism. Rogers (1959:203) indicates that such a discrepancy results in a state oftension and internal confusion because in some respects beha-viour is regulated by the actualising tendency and in others bythe self-actualising tendency. This gives rise to `discordant orincomprehensible behaviors'. Incongruent individuals feel atleast a degree of confusion because there is con¯ict between theirfeelings and behaviour and what they consciously `want'.According to Tudor and Merry (2002: 72), incongruence can beconsidered to manifest as one of three process elements: `ageneral and generalised vulnerability, a dimly perceived tensionor anxiety, and a sharp awareness of incongruence'.

When individuals are unaware of their incongruence they arepotentially vulnerable because a new experience which demon-strates the discrepancy between self and organism is threateningand the self-concept cannot assimilate it and thus it becomesdisorganised. When individuals are aware of an uneasiness ortension of unknown cause they may be considered as anxious.What is happening in such circumstances is that the incon-gruence between the self-concept and the organism is approach-ing awareness (i.e. it is subceived). The resulting anxiety resultsfrom a fear that the discrepancy may enter awareness and soforce a change in the self-concept. This is one of the manyreasons why therapy is a scary business. A `sharp awareness ofincongruence' is exactly what it says. Whatever its precise

51


nature, incongruence may be considered as arising from theacquisition of conditions of worth and a lack of unconditionalpositive regard (Point 12).

Rogers' second condition states unambiguously that theclient's incongruence is a necessary condition for constructivepersonality change to occur but he also quali®es this with therequirement that the incongruence manifests as vulnerability oranxiety. Sanders (2006b: 43) interprets this as `the client needshelp, and knows it'. This raises the question as to whether it ispossible to be incongruent without being vulnerable or anxiousor, to use Sanders' form, if it is possible `that the client needshelp but doesn't know it'. If so, condition two would not be metand so some individuals at some stage of their process could beconsidered as unsuitable for therapy. Wilkins and Bozarth(2001: ix±x) consider this at greater length. However, Barrett-Lennard (1998: 79) states `some degree of vulnerability andanxiety seems bound to apply to anyone voluntarily in therapyand, perhaps, in most people'. While Wilkins and Bozarth agreewith this, they (2001: x) also ask `Does condition two imply thattherapy will only be successful if, in some way and on somelevel, the person in the client role is suf®ciently aware of andtroubled by incongruence to persist in the [therapeutic] endeav-our?' They go on to say `almost certainly'. In the context ofassessment, Wilkins (2005a: 141) puts this in the form of aquestion: `[i]s my potential client in need of and [originalemphasis] able to make use of therapy?' Rogers' (1967: 132: 155)consideration of the seven stages of process is helpful inanswering this question (Points 17 and 32).

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17Rogers' seven stages of process provides a modelfor therapeutic change and guidance for thetherapist in the encounter

In person-centred terms, a person's process is their way ofexperiencing and encountering the world, their way of makingsense of all the stimuli and information to which they areexposed. Process is cognitive, behavioural, emotional and (argu-ably at least) spiritual. It is both in and out of awareness and itmay be re¯exive or spontaneous.

Rogers (1967: 132±155) proposes a continuum of personalitychange as seven stages of process. These are also described andillustrated in an accessible way by Merry (2002: 58±63). Brie¯y,at the relevant stage the client:

1. is very defensive, and extremely resistant to change;2. becomes slightly less rigid, and will talk about external

events or other people;3. talks about her/himself, but as an object, avoiding dis-

cussion of present events;4. begins to talk about deep feelings and develops a relation-

ship with the therapist;5. can express present emotions, and begins to rely more on

their own decision making abilities and increasingly acceptsmore responsibility for their actions;

6. shows rapid growth toward congruence and begins todevelop unconditional positive regard for others;

7. is a fully functioning, self-actualised individual who isempathic and shows unconditional positive regard forothers. This individual can relate their previous therapy topresent day real-life situations.

The stages of process indicate something about the indi-vidual's likely way of being and so what is appropriate from the

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therapist. Although Merry (2002: 59) points out that there `is agreat deal of variation and individual differences in clients'processes' and Rogers (1967: 139) states that `a person is neverwholly at one or another stage of process', knowing somethingabout a client's stage in the process continuum can inform thetherapist and help in making appropriate ethical and profes-sional decisions. For example, whether therapy is likely to beeffective and should therefore be offered at all, whether pre-therapy may be a more appropriate strategy (Point 34) orwhether the client is close enough to being fully functioning notto need therapeutic interventions at all.

Brie¯y, because they have a limited awareness of their incon-gruence (Point 16), people in the ®rst two stages of processingare unlikely to willingly contract for therapy or, if they do, arelikely not to stay the course. Individuals in stage three, the pointat which Rogers (1967: 136) believed many people who seek`psychological help' are at or around, are likely to commit to atherapy contract. According to Merry (2002: 60), clients in stagethree of process `need to be fully accepted as they presentthemselves before moving deeper into stage four'. Much ofcounselling and psychotherapy occurs with clients who are instages four and ®ve and Rogers (1967: 150) describes stage six ashighly crucial. It is at this stage that irreversible constructivepersonality change is most likely to occur. Arguably, by stageseven, clients no longer need the companionship of a therapiston their journey towards being fully functioning. Of stage seven,Rogers (1967: 151) writes `this stage occurs as much outside thetherapeutic relationship as in it, and is often reported ratherthan experienced in the therapeutic hour'.

In the seven stages of process, there is not only a guide towhen and for whom therapy is appropriate but an indicationthat different `ways of being' by the therapist in the encountersuit different stages. Implicit in the scheme is that, for example,there are qualitative differences of intent required of thetherapist dealing with a client in stage three than one at stage six(although at all stages the emphasis is on the non-directiveattitude and the provision of the therapist conditions). It istherefore important that person-centred therapists have someunderstanding of these stages.

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In the ®rst stage of process, the individual is ®xed and remotefrom organismic experiencing. Rogers (p. 133) understands thisremoteness from experiencing in terms of blockages of bothinterpersonal and intrapersonal communication and points outthat individuals at this stage of processing do not experiencethemselves as having problems or, if they do, these problems areperceived as being entirely external. At the second stage of pro-cess, individuals can experience themselves as fully received andbegin to express themselves with respect to topics not directlyconnected with their selves. However, amongst other things,problems are still perceived as external, there is no sense ofpersonal responsibility with respect to problems and feelings arenot recognised or owned. Rogers (1967: 132) states that a personin stage one of process is unlikely to enter therapy voluntarilyand that while some people in stage two do present voluntarily,working with them is successful only to a very modest degree. Inother words, it is only clients in stage three process or laterstages who are likely to meet Sanders' criteria. This has impli-cations for contracting with clients.

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18For therapy to be effective, the therapist must becongruent in the relationship. This is a requirementto `be' and not necessarily to `do'

There is a great deal of misunderstanding about the third ofRogers' necessary and suf®cient conditions that the therapist becongruent in the relationship. This seems to be because there isa tendency to think about and to attempt to operationalise`congruence' as action but congruence does not involve thecounsellor in doing anything. It is a way of being in whichoutward behaviour is an accurate re¯ection of inner state, thatis there is a matching of awareness and experience. Brodley(2001: 56±57) concludes from the original formulations ofcongruence by Rogers that it is de®ned in terms of distinctionbetween self and experience, not in terms of the therapist'sbehaviour. She (p. 57) also points out that, according to thestatement of the necessary and suf®cient conditions, there is norequirement that the client perceive the congruence of thetherapist. So, although it is a necessary condition for therapy itis not necessary that it is communicated. However, it seems tome (see Wilkins 1997a: 38) incongruence does jar and is morelikely to be directly perceived or at least subceived in such away as to disrupt the therapeutic endeavour. Cornelius-White(2007: 174) is of the opinion that congruence (and thereforeincongruence) is perceived largely through unconscious bodylanguage.

Strictly speaking, the therapist's congruence is not about aninterpersonal interaction but an intrapersonal state. Whereasempathy and unconditional positive regard are, congruence isnot the product of the therapeutic relationship although it maybe affected by it. It is possible to be congruent alone. Congruenttherapists are not necessarily doing, saying or expressinganything; they are being totally themselves and are fully presentand aware of the ¯ow of their experiencing.

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According to Haugh (1998: 45), the requirement for con-gruence on the part of therapists is not so that clients experiencethem as real and genuine but to facilitate their ability to beempathic and to hold unconditional positive regard for theirclient. In terms of the client experience, it is a sensing of thetherapist's congruence (whether in awareness or subceived) thatgives credence to and con®rms these attitudes. A congruenttherapist is a trustworthy therapist.

Although it is often confused with honesty, directness andself-disclosure, being congruent is not about communicating thefeelings and experiences of the therapist to the client. However,Rogers did make repeated references to the importance of thetherapist's willingness to express feelings and attitudes. This hasled to what some (for example Haugh 1998: 46 and Bozarth1998: 74±78) consider the erroneous conclusion that there aretherapist behaviours which would convey the therapist'scongruence. However, there is agreement that at least sometimes(even if rarely) one or more things may be necessary to maintaincongruence (Points 70, 71 and 72).

Haugh (2001: 7) draws together statements about congruencefrom Rogers' work and presents an overview of the charac-teristics of the practice of a congruent therapist. She offers foursuggestions as to the timing of congruent responses:

1. when the therapist's feelings are interrupting the coreconditions

2. when these feelings are persistent3. when to not do so would result in the therapist not being

`real' in the relationship4. when it is appropriate ± appropriateness is to be assessed on

the preceding points.

Generally speaking, at least in terms of classic client-centredtherapy, therapist responses are con®ned to attempts to com-municate an understanding of the client's experience. But, asHaugh indicates, there may be times when, because congruencetakes precedence (because an incongruent therapist is unlikely tobe or to be perceived to be empathic and accepting), it isincumbent upon therapists to respond from their own frame of

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reference. Nevertheless, `being congruent' is not a licence toconfront, contradict or express an opinion about the client noris it about offering an emotional reaction to the client or theclient's material. Furthermore, self-disclosure has nothing to dowith being congruent. Although there appears to be some placefor the former in person-centred therapy, Barrett-Lennard(1998: 264±267) reporting a study conducted in 1962 shows thatthe hypothesis that the therapist's `willingness to be known'would relate to positive outcome in person-centred therapy wasunproven.

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19Unconditional positive regard is the linchpin onwhich person-centred therapy turns but it presentsa real challenge to the therapist. However, withoutthis quality of acceptance there is a strongpossibility that therapy will be unsuccessful

The unconditional positive regard (UPR) of the therapist forthe client is a necessary condition for constructive change.Moreover, some writers (for example Bozarth 1998: 88, Wilkins2000: 33±34) indicate that it is the active facilitator ofconstructive change and Freire (2001: 152) describes it as `therevolutionary feature of the person-centered approach'. How-ever, UPR presents real personal, ethical and professionalchallenges to the therapist. This is partly because, howeveraccepting of others we believe ourselves to be, it is likely that atleast to some extent we carry prejudice and fear. A glancethrough a history book or the news headlines would seem toindicate that the world is full of hostile, reprehensible, male®cindividuals. How can they possibly be acceptable to anybody?Masson (1992: 234) in his critique of person-centred therapyasks: `Faced with a brutal rapist who murders children, whyshould any therapist have unconditional regard for him?' Ofcourse there is no reason at all why any therapist should butwithout being able to offer UPR the therapeutic endeavour willbe pointless. The hypothesis of the necessary and suf®cientconditions asserts that if a person, regardless how `bad', con-sistently experiences the six conditions and perceives theempathic understanding and unconditional positive regard ofanother then change will occur. However, it may very well bethat this is a big `if '. In such cases, it is important to realise thatthis does not prove that the hypothesis is correct or that somepeople are beyond redemption but rather that the limitation is inthe therapist. Luckily, although human beings share a tendencyto be unaccepting of some things, these are not necessarily the

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same things. Thus a client to whom, for whatever reason, onetherapist ®nds it dif®cult to offer UPR may ®nd the qualities ofacceptance, warmth and prizing easily extended by another.Also, it seems that by addressing our own fears and unresolvedissues so increasing our unconditional positive self-regard andby working to increase our understanding of how the conditionsof worth of others arise we can increase our ability to offer UPRto others (see Wilkins 2003: 73±74). Herein lays some of thepersonal, ethical and professional challenges referred to above.For example, these challenges lead to an ethical requirementto reach some assessment as to the likelihood of the therapistbeing able to offer enough UPR to facilitate change and aprofessional responsibility to `refer on' or decline the contract ifnot and a personal and professional responsibility for thetherapist to continually address anything that limits the abilityto practise.

The requirement to offer UPR is a challenge in another way.Within this condition and the hypothesis of the necessary andsuf®cient conditions as a whole there is what appears to be oneof the `necessary paradoxes' of person-centred therapy. Thehypothesis is about change, therapists tend to have an aim tofacilitate change in their clients and yet the fourth conditionrequires that the therapist accepts the client as the client is.There can be no requirement or even anticipation on the part ofthe therapist that the client will change because this would beunaccepting. Freire (2001: 145) presents the `paradox of uncon-ditional positive regard' as `that a person must accept herself inorder to change'. The client's acceptance is contingent on theacceptance of the therapist. She (p. 152) goes onto summarisefeatures of person-centred therapy that relate to UPR. These(slightly adapted) are:

1. Therapists do not try to change clients. The unconditionalacceptance of the client's experience is the therapist'ssole aim.

2. The greater the extent to which the therapist can trustthe actualising tendency of the client, the greater will be theextent to which the therapist can experience UPR forthe client.

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3. Therapists experience UPR for clients to the extent thatthey have unconditional positive self-regard.

These features require that person-centred therapists `let go'of any desire or demand that their clients change and that theycontinually address their unconditional positive self-regard.

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20`The ideal person-centred therapist is first ofall empathic.' `Being empathic is a complex,demanding, strong yet subtle and gentle wayof being'

The above heading is constructed from words used by Rogers(1975: 4±6) in his updating of his views on empathy. They re¯ectthe widespread person-centred belief that empathy is an essentialattribute of a successful therapist. In Rogers (1957: 101), beingempathic is de®ned as `to sense the client's private world as if itwere your own, but without ever losing the ``as if'' quality'. Thatis to say being empathic is to perceive the internal frame ofreference of the other with accuracy while at the same time notbecoming absorbed in it or overwhelmed by it. Sanders (2006b:66) makes a useful distinction between perceiving the world ofanother person and experiencing it. He writes `I cannot feelsomeone else's hurt, fears and joys. I can, though, see theirthoughts and feelings accurately and understand them.' It is thissensing and the communication of it to the client that con-stitutes the empathic process in therapy. To passively sense andunderstand is not enough, however accurate the understanding.In his later paper, Rogers (1975: 4) offers a richer de®nition:

The way of being with another person which is termedempathic has several facets. It means entering the privateperceptual world of the other and becoming thoroughly athome in it. It involves being sensitive, moment to moment,to the changing felt meanings which ¯ow in this otherperson, to the fear, rage or tenderness or confusion orwhatever he/she is experiencing. It means temporarilyliving his/her life, moving about in it without makingjudgements, sensing meanings of which she is scarcelyaware, but not trying to uncover feelings of which theperson is totally unaware, since this would be too

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threatening. It includes communicating your sense of his/her world as you look with fresh and unfrightened eyes atelements of which the individual is fearful.

This is asking a lot and Rogers goes on to point out howcomplex and demanding the task of being empathic is, referringto it (p. 4) as a `strong yet subtle and gentle way of being'. It isthese things but, because it involves real contact with theexperience of another, it can also be richly rewarding.

An important element in Rogers' statement is the notion thatbeing empathic involves the communication to the client of thetherapist's sense of their experience (Point 21). In other words,unless the client perceives the therapist's deep understanding oftheir experience it is unlikely to be helpful, however accurateand complete it may be. The practice of empathy is addressed inPoints 81 and 82.

Empathy is probably the most written about and researchedof the six conditions. Rogers (1975: 5±6) published a review ofempathy research, the ®ndings of which may be summarisedthus:

The ideal therapist is ®rst of all empathic.

· Empathy is correlated with self-exploration and processmovement.

· Empathy early in the relationship predicts later success.

· The client comes to perceive more empathy in successfulcases.

· Understanding is provided by the therapists, not drawnfrom them.

· The more experienced the therapists, the more likely theyare to be empathic.

· Empathy is a special quality in a relationship and therapistsoffer de®nitely more of it than even helpful friends.

· The better integrated the therapists are within themselvesthe higher degree of empathy they exhibit.

· Experienced therapists often fall far short of beingempathic.

· Clients are much better judges of the degree of empathythan are therapists.

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· Brilliance and diagnostic perceptiveness are unrelated toempathy.

· An empathic way of being can be learned from empathicpersons.

By and large, after over 30 years, these statements remainbroadly true but needless to say thinking and researchingempathy has continued. Sanders (2006b: 69±73) offers anaccessible overview of the work of those who have built on theclassical client-centred view of empathy.

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21The effectiveness of a therapist's unconditionalpositive regard and empathic understandingdepends on the extent to which they are perceivedby the client

Together with the `contact' prescribed in condition one (andprobably more than it), the elements of condition six, the com-munication to and/or perception by the client of the therapist'sUPR and empathic understanding is relatively little understoodor discussed and yet Rogers is very clear that unless this happensto at least a minimal degree change will not occur. In Rogers(1957: 96) the sixth condition is articulated in terms of thecommunication to the client of the therapist's empathic under-standing and UPR while in Rogers (1959: 213) the emphasis ison the client's perception of these from the therapist. These twodifferent formulations are not in con¯ict but together aid acomplete understanding of the desired process. In effect, whatthis condition states is that change depends on the client beingand feeling understood and accepted, however dimly. Not onlymust the therapist have an understanding of the client's experi-ence and have unconditional positive regard for that client, theclient must be aware of and receive these at least to some extent.If the latter does not occur then condition six has not been metregardless of how empathic and accepting therapists believethemselves to have been. This places the client at the centre ofthe therapeutic endeavour but it also lays a responsibility on thetherapist. In some way, therapists must communicate (or makeavailable) to the client their understanding of the client'sexperience and UPR for the client. To be effective, this cannotbe a mechanistic or uniform process. It need not be verbal but itmust involve high quality attention to the client's process and aperceivable intention to understand the client's experience andboth of these must be presented in a climate of warmth, regardand genuineness. `Communication' as a therapist behaviour is

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explored in Points 82 and 83. However, there is more to thesixth condition than a requirement for particular behavioursfrom the therapist.

It is in the sixth condition that the `super-condition' postu-lated in Point 25 may be seen to operate. Essentially, the clientexperience is of being received `warts and all' and yet not foundwanting, being seen with faults and fears but not judged and allthis within the framework of the therapist's genuineness. Thiscan be a singularly powerful experience for both parties and itcan result in a `moment of change'. Various attempts to explorethis `high level' experience have been made and terms such as`presence', `tenderness' and `relational depth' have been appliedto it. These are returned to in Points 25 and 38.

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22In person-centred theory, there is no acceptance ofthe unconscious as a repository of repressedfunctions and primitive drives or desires andtherefore `transference' is of little or no relevance

While the possibility of an ùnconscious' faculty to the humanmind is not denied in person-centred theory, classically, whetheror not it exists is seen as largely irrelevant to the process oftherapy. This is because person-centred therapy is phenomen-ological, concerned only with the client's current experiencing.Anything of which a client is unconscious or unaware is byde®nition unknown and therefore unknowable to the therapist.Any view as to the ùnconscious' processes of the client orinterpretation of them could only come from the frame ofreference of the therapist. This is at odds with person-centredpractice. Also, the notion of a particular structure to the mind(for example, id, ego, superconscious) does not ®nd wideacceptance amongst person-centred theorists. When it is dis-cussed at all, writers are likely to take the view that there is aconstant ¯ow between the `conscious' and the ùnconscious' andto suggest a process model for the human mind (see, forexample, Coulson 1995, Ellingham 1997 and Wilkins 1997a). Inreality, it is only with respect to `transference' that theunconscious causes much of a stir in person-centred theory.

It is largely true that person-centred theorists tend not to paymuch attention to transference. There are two basic positionswith respect to it. Either transference may (sometimes) be a partof the interaction between client and therapist but that to `work'with it would be counter-therapeutic or it is an artefact of thepsychoanalytic mind set which has no reality. Rogers' ownposition seems to have been close to the former. He (seeKirschenbaum and Henderson 1990a: 129±130) thought that ifand when transference feelings occurred, the normal process ofperson-centred therapy would move through them and that

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there was absolutely no need for the therapist to permit thedependence that is seen as legitimate, even encouraged andsupported, in other approaches to therapy. That is to say, thetherapist should continue to be present as an empathic, accept-ing and congruent person and not be changed in response to thetransferential process of the client.

Some other person-centred theorists are not as inclined toaccept the psychodynamic notion of transference as Rogers mayhave been. Most notably Shlien (1984: 153±181) offered a`countertheory of transference' which he hoped would be instru-mental in developing a person-centred model of the uncon-scious. Shlien (p. 151) was of the view that `transference is a®ction, invented and maintained by the therapist to protecthimself from the consequences of his own behaviour'. Thispaper was responded to by Lietaer (1993: 35±37) who took theview that not only does transference exist but that it is relevantto practice. The situation with respect to countertransference issimilar except that in Wilkins (1997a: 38) many of the processesdescribed as countertransference may, in terms of person-centred theory, be described as empathy.

One way in which supposedly unconscious material maybecome relevant in the course of person-centred therapy hasbeen suggested by Mearns and Thorne (2000: 175±176). Theypropose a recon®guration of the classic view of the concept ofself such that it includes subceived material; that is materialwhich is in some way impacting on the person even though it isnot in awareness (and so is not accepted by the person as part ofthe self concept). Rogers (1959: 200), in his de®nition of sub-ception, writes `it appears that the organism can discriminate astimulus and its meaning for the organism without utilizing thehigher nerve centres involved in awareness'. Mearns and Thorne(p. 175) use the term `edge of awareness material' and de®ne selfas `self-concept + edge of awareness material'. This formulationis, as they point out themselves (p. 176), a departure from thephenomenological position at the core of person-centred theory(self = self concept amongst other things). They also write of thepotential danger that `this widening conception of Self couldlose its discipline in holding to the edge of awareness andwander into the unconscious'.

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Section 3REVISIONS,

RECONSIDERATIONSAND ADVANCES IN

PERSON-CENTREDTHEORY

23Person-centred therapy is not based on anossified, mid-twentieth century theory but alive,dynamic and being actively researched anddeveloped

While there is a view that much of what needs to be knownabout the practice of classic client-centred therapy was statedmore or less completely in the works of Rogers and his col-leagues published in the 1950s, this is probably held by aminority of people describing themselves as person-centred. Forthe most part, there is an acceptance that Rogers did notprovide all the answers and a certainty that he did not addressall the issues raised in and by the practice of counselling andpsychotherapy in the modern world. More or less from the daysof the Chicago Center, person-centred theory has been thoughtabout and re¯ected on and modi®ed in response. For example,Eugene Gendlin, one of Rogers' leading colleagues and whosebackground was in philosophy, became more and more inter-ested in how clients were facilitated to express, symbolise andarticulate experience. From this interest ¯owed the developmentof focusing and thence (with other in¯uences) experientialpsychotherapy which many see as the second major branch tothe person-centred family of therapies. Others also took thebasic ideas of client-centred therapy in different directions.Notable amongst them was Laura Rice who incorporated someideas from cognitive therapy traditions in her work. This led toan increased interest in the micro-processes of psychotherapyand ultimately to a way of doing and understanding psycho-therapy which is sometimes called process-experiential therapyand the notion that those therapists in the broader person-centred tradition are process experts. This process of review,revision and expansion continues with, for example, the moveinto `Emotional-Focused Therapy' as a derivative of theprocess-experiential strand (see Elliott et al. 2004b).

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REVISIONS, RECONSIDERATIONS AND ADVANCES

After a period of doldrums through, in particular, the 1970sand the 1980s, there have been many efforts to understand andexplain the processes of person-centred therapy, to explore itseffectiveness and to ®ll some of the gaps in knowledge throughactive, empirical research. Some of this research has addressedthe ef®cacy of the classical non-directive approach (see, forexample the work of Brodley, Bozarth, Freire and Sommerbeck)but a great deal of it has been directed towards expandingperson-centred theory and/or understanding person-centredpractice in wider and different contexts. These include clari®-cation of child development, reconsideration of incongruence,examinations of the client/therapist relationship and ideas aboutpsychopathology.

Although there has been a great deal of research by experi-ential and process-experiential therapists (see the journal Person-Centered and Experiential Psychotherapies for contributions tothese ®elds of endeavour as well as to person-centred therapyper se) and this has cast light on the effectiveness of person-centred therapy as a whole, this is outside the remit of thisbook and the rest of this section addresses revisions, recon-siderations, expansions and additions to mainstream person-centred therapy only.

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24From the outset, an understanding of childdevelopment and psychotherapy with children andyoung people has been fundamental to theperson-centred approach. Theory and practicecontinue to be developed and refined

It is frequently assumed that person-centred theory has noposition with respect to child development. This is an error. It isoften forgotten that, at the start of his career, Rogers was achild psychologist and that his ®rst major publication (Rogers1939) was The Clinical Treatment of the Problem Child. Not onlythat but early luminaries of the approach such as ClarkMoustakas and Virginia Satir were child psychotherapists. It isreasonable to assume that the development of person-centredtheory was informed by practice with children and done in thelight of contemporary knowledge of child development andchild psychopathology. Also, in Rogers' classic statement ofclient-centred theory (1959: 221±223) he considers the followingaspects of personality:

· postulated characteristics of the human infant

· the development of self

· the need for positive regard

· the development of the need for self-regard

· the development of conditions of worth

· the development of discrepancies in behaviour

· the experience of threat and the process of defence

· the process of breakdown and disorganisation

· the process of reintegration

· the speci®cation of functional relationships in the theory ofpersonality.

More speci®cally, Rogers (1959: 222) postulated that:

The individual, during the period of infancy, has at leastthese attributes:

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1. He perceives his experience as a reality. His experienceis his reality.

a. As a consequence he has greater potential awareness ofwhat reality is for him than does anyone else, since noone else can completely assume his internal frame ofreference.

2. He has an inherent tendency toward actualizing hisorganism.

3. He interacts with his reality in terms of his basicactualizing tendency. Thus his behavior is the goal-directed attempt of the organism to satisfy the experi-enced needs for actualization in the reality as perceived.

4. In this interaction he behaves as an organized whole,as a gestalt.

5. He engages in an organismic valuing process, valuingexperience with reference to the actualizing tendencyas a criterion. Experiences which are perceived asmaintaining or enhancing the organism are valuedpositively. Those which are perceived as negating suchmaintenance or enhancement are valued negatively.

6. He behaves with adience toward positively valuedexperiences and with avoidance toward those nega-tively valued.

All this amounts to a comprehensive theory of the develop-ment of the human organism from which ways of understandingchild development and psychotherapeutic practice with childrenmay be easily derived. For example, from Rogers' statement ofthe necessary and suf®cient conditions, Biermann-Ratjen (1996:13) derives the necessary conditions for development in earlychildhood. These are:

1. That the baby is in contact with a signi®cant other.2. That the baby is preoccupied with evaluating experience

which might possibly arouse anxiety.3. That the signi®cant other person is congruent in the relation-

ship to the baby, does not experience anything inconsistentwith her self concept while in contact with the baby when itis preoccupied with evaluating his experience.

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4. That the signi®cant other is experiencing unconditional posi-tive regard toward the baby's processes of evaluating hisexperience.

5. That the signi®cant other is experiencing an empathic under-standing of the baby's experiencing within his internal frameof reference.

6. That the baby gradually perceives both the unconditionalpositive regard of the signi®cant other person for him andthe empathic understanding so that in the baby's awarenessthere is gradually a belief or prognosis that the unconditionalpositive regarding and empathically understanding objectwould when reacting to other experiences of the baby alsoexhibit positive regard and empathic understanding.

Cooper (1999: 64) and Mearns and Thorne (2000: 106±108)link the need for positive self-regard to the development ofplural `selfs' or con®gurations of self (Point 27). In their con-sideration of relational depth (Point 38), Mearns and Cooper(2005: 8) argue that infants have a basic need `not only to bondwith others, but also to interact and communicate with them . . .They want to be loved, but they also want to interact with thatother and that love, to give as well as to receive, and to experi-ence an immediate and engaged contact'. They (pp. 17±34) goon to explain how dif®culties in adulthood may be linked to afailure to experience `relational depth' in infancy and childhood.Biermann-Ratjen (p. 14) is clear that positive regard is theprecondition for self development and she links her model topsychopathology. Warner (2000: 149±150) also examines andexplains links between child development and psychopathology,relating styles of processing (Point 36) to the development ofattachment and the experience of empathic understanding. She(p. 150) notes that empathic failure in childhood seems to be acause of `fragile' processing in adults.

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25In the view of some, there are times when theintegration of the necessary and sufficientconditions leads to another, `transformational 'quality known as `presence'

Over the years, there have been indications from some person-centred writers that there are times in the therapy session whenthere is a kind of peak experience, transforming both client andtherapist. In his later years, Rogers (in Kirschenbaum andHenderson 1990a: 137) described this quality and named it`presence'. He wrote:

When I am at my best, as a group facilitator or a therapist,I discover another characteristic. I ®nd that when I amclosest to my inner, intuitive self, when I am somehow intouch with the unknown in me, when perhaps I am in aslightly altered state of consciousness in the relationship,then whatever I do seems to be full of healing. Then simplymy presence is releasing and helpful.

Rogers indicates that presence is a medium for personalgrowth and that it is a self-transcending aspect of therapy.Thorne (1991: 73±81) tells of something very similar and usesthe expression `the quality of tenderness' to describe the activeprinciple of transformation. Both Rogers and Thorne indicatethat there is a transcendental, spiritual or mystical dimension tothis quality. While no way denying this, Schmid (1998a: 82)identi®es presence with encounter (Point 31). He (2002b: 182±203) expands on this with respect to the requirement for contact/psychological contact and (pp. 198±199) states that presence `isthe proper term for the ``core conditions'' in their interconnect-edness as the way of being and acting of the therapist'. Schmid'sview can be seen as emphasising `presence' as the (inevitable?)outcome of high quality attention in the therapeutic endeavour.

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That is presence is a result of a peaking of the therapist con-ditions (or perhaps the super-condition alluded to in Point 14).Also, because Schmid sees person-centred therapy in terms ofdialogue, that is encounter, presence must ¯ow from that andnot from the therapist per se.

Although it has been described as `the fourth condition'(more properly the fourth therapist-provided condition), thereseems to be consensus that it is the product of the therapist-provided conditions as they are ideally, not something èxtra'and distinct from them. For example, Barrett-Lennard (2007:130) states that presence ìmplies ``being all there'', absorbed inthe immediate relation with one's whole, deeply attentive andconnecting self' and Wyatt (2007: 150), while acknowledging theèxtra-dimensional' quality of presence and that it can bedescribed (amongst other things) as electric, intense and/ortransformative, also notes that àt these times all of Rogers'conditions are simultaneously present'. None of this takes awayfrom the transformative, transpersonal effect of the experienceof presence. However, Mearns (1994: 7±8) points out thatalthough presence can be described in terms of mystical lan-guage, it is equally possible to refer to it in terms of classicalperson-centred theory. He says that presence arises from thecombination of two circumstances. The ®rst of these is a blend-ing of high degrees of congruence, unconditional positive regardand empathic understanding and the second (p. 8) is:

that the counsellor is able to be truly still within herself,allowing her person to resonate with the client's experi-encing. In a sense, the counsellor has allowed her person tostep right into the client's experiencing without needing todo anything to establish her separateness.

His understanding of presence has been instrumental inleading Mearns to develop the idea of working at relationaldepth (Point 38).

However presence arises, it is the ultimate manifestation ofthe person-centred therapist's intention to be with the clientrather than to do something to them, for them or even withthem. In my experience, for all that it arises from them, it

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transcends the therapist-provided conditions and it is transfor-mative. I also see it as being co-created and co-experienced, notsomething engendered by the therapist alone. However, thisdoes not mean that the experience of `presence' cannot be pre-pared for or encouraged. Geller and Greenberg (2002: 75±77),while stating that the experience of presence cannot be assuredin a session, indicate that the capacity for it can be enhancedthrough preparation (Point 84).

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26For some, in classic person-centred theory thenotion of the `individual/self ' as a discrete entity isover-emphasised, incomplete and/or culturebound

Even though it is in many ways de®ned as ¯uid and changingand the concept of the organism is more important (Point 11),even within the person-centred tradition the concept of `self' iscriticised, questioned and/or found wanting. For example,Holdstock (1993: 229±252) indicates that it may be necessary torevise the person-centred concept of the self in order to takeaccount of how the self is perceived in other cultures andparadigms. Of the concept of self in other cultures, Holdstock(p. 230) writes:

the extended concept of the self may even include thedeceased as well as the larger universe of animals, plantsand inanimate objects. Power and control are not con-sidered to rest predominantly with the individual butwithin the ®eld of forces within which the individual exists.

Subsequently, others echoed this challenge. Brie¯y, what isquestioned is `self ' as a unitary, demarcated entity in some wayseparate from the world. What is proposed is a `relational' selfintertwined not only with other people but the environment. Forexample, Mearns and Cooper (2005: 5) argue that people are`fundamentally and inextricably linked with others' and Cooper(2007: 85±86) draws attention to and discusses the view that (p.85) `human beings [are] fundamentally woven into their social,political and historical context rather than separable from it'. Itis this awareness of and emphasis on the relational aspects ofbeing in the world over the `individualistic' view of peopleimputed to Rogers' original theory of personality and develop-ment that leads Mearns and Thorne (2000: 182±183) to proposea process of `social mediation'.

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Social mediation is proposed as a counter-balance or (Mearnsand Thorne 2007: 24) `a restraining force' to the actualisingtendency. The idea springs from the recognition that peopleare in relationship and that a free, unmediated, unmoderatedexpression of the actualising tendency may be detrimental to theperson. This restraining force works in such a way as to ensurethat the person not only moves towards being fully functioningbut does so in such a way as to preserve, maintain (and possiblyeven enhance) the social contexts in which they exist. This isthen the basis for further growth. Mearns and Thorne (2007: 24)encapsulate their development of theory thus `the person takesother people in their life into account in the course of their ownmaintenance and development' (original emphasis).

Cooper (2007: 86±88) also considers `self-pluralistic perspec-tives' as a divergence from Rogers' original conceptualisationsof personality and human development. He points out thatperson-centred theorists and those of related `tribes' persuadedby these ideas `have argued that a focus on the individual notonly overlooks the multiplicity of which the individual is a part,but also the multiplicity by which the individual is constituted '(original emphasis). That is to say, people are comprised of anumber of facets, each of which manifests differently in theworld. These facets are named differently in different thera-peutic modalities, for example, psychosynthesists talk in termsof `subpersonalities', psychodramatists in terms of `roles' but aterm popularised in person-centred circles by Dave Mearns is`con®gurations of self' (Point 27). There is nothing intrinsicallyunhealthy about `self as a multiple entity' but emotional distressmay arise when con®gurations are in con¯ict or relate to eachother in abusive ways.

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27The person may constitute a multiplicity of `selves'rather than a unitary self

Recently, a number of person-centred scholars (for example Keil1996; Cooper 1999; Mearns and Thorne 2000: 174±189; Mearns2002 and Warner 2005) have explored what they believe to bethe limitations of the classical model of self as unitary andproposed revisions to this. Not all these authors are of exactlythe same view but for each of them the notion of `self-plurality'has important rami®cations for practice and requires adapta-tions to theory. However, it is of particular importance to notethat advocates of the `multiple self' model all see this as healthyand normal, not pathological. Cooper (2007: 86±88) presents ahelpful discussion of these views and the differences andsimilarities between them. By way of example, one way in whichthe idea of a plural self has reached particular prominence isthrough the work of Mearns (1999, 2002) and Mearns andThorne (2000, 2007).

The notion of self as a constellation of self concepts is whatMearns (1999: 126) calls `con®gurations of self' and de®nes as `anumber of elements which form a coherent pattern generallyre¯ective of a dimension of existence within the Self'. Con-®gurations of self are explained more fully in Mearns andThorne (2000: 101±119). Mearns and Thorne (2007: 33) re-present the notion of con®gurations in the context of `self-dialogues'. They refer to `self-pluralist theory' `where the personappears to symbolise their self as comprising different parts,voices, subpersonalities, sub-selves' or, in their terms, con®gura-tions. They (pp. 34±38) contextualise their ideas in relation toself-pluralist theory and offer four theoretical propositionsconcerning con®gurations. These are:

1. Con®gurations may be established around introjectionsabout self.

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2. Con®gurations may also be established around dissonantself-experience.

3. Formative con®gurations assimilate other consistent ele-ments.

4. Con®gurations interrelate and recon®gure.

What this means is that quasi-independent elements of theself concept can arise in one of two ways (although Mearns andThorne 2000: 117 state `there may be other pathways'). Theseare through the incorporation of an evaluation taken fromothers which may be positive or negative or through the encap-sulation of an experience which is at odds with other aspects ofthe self-concept. Once established, a con®guration can expandand grow by incorporating similar elements. Moreover, con-®gurations are dynamic. They can and do change and change inrelation to one another too. Throughout their description andanalysis of con®gurations of self, Mearns and Thorne emphasisetheir protective nature. In other words, con®gurations of self arehelpful ways of interfacing with the world having differentfunctions and abilities. In more extreme cases, particular con-®gurations may even be about survival. Warner's (2005: 94)concept of dissociated process involving the existence of `parts'with `a variety of opposing strategies for responding to emo-tional pain' offers an illustration of this.

However they arise and for whatever reason, normally, it isnot that individuals comprise a multiplicity of selves that isdeleterious or in anyway indicative of a need for therapy butpsychological distress may arise when the relationship betweencon®gurations is con¯ictual or disharmonious.

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28Empathy is seen as multi-faceted and complex butit is important to remember that empathicunderstanding is what is essential to effectivetherapy

Almost from the outset of person-centred therapy there havebeen efforts to deconstruct and understand the empathic pro-cess. Recently, these have included `reconsiderations' by Shlien(1997), Bozarth (1997) and Barrett-Lennard (1997), an analysisas to how empathy `cures' (Warner 1996: 127±143), a descrip-tion of `®ve kinds of empathy' (Neville 1996: 439±453), anedited volume concerned with the history, theory and practice ofempathy (Haugh and Merry 2001) and a recapitulation andupdating of the classic client-centred view (Freire 2007). Theintention behind each of these works and others addressingempathy is to explore and explain the concept, to make what itis and/or how it operates clearer.

There have also been attempts to deal with misconceptionsabout empathy. For example, in his iconoclastic manner, Shlien(1997: 67) writes that in his opinion `empathy has been over-rated, underexamined and carelessly though enthusiasticallyconceived' and (p. 79) that empathy `is not much of a theory,explains hardly anything, tells us nothing of the mechanisms'.Shlien is not attacking one of the bedrock six conditions but hischapter is an attempt to re-establish that condition ®ve requiresthat the therapist experiences empathic understanding of theclient's internal frame of reference. This, he (p. 73) considers tobe different from empathy as such. Rather it is a particular kindof understanding `distinct from the types of understanding thatcome from external frames, such as diagnostic, or judgemental,or suspicious interrogation'. It is empathic understanding that(p. 67) `promotes healing from within'. Empathy, he arguesthroughout, is nothing special, animals of all kinds can do it,whereas empathic understanding and the communication of it

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requires effort to acquire and attention of the highest order.This is an important correction. In person-centred therapy, it isnot enough to `feel' the client's pain, emotional distress or joywhatever form that feeling takes. It is on the therapist's under-standing of the client's process and the perception of thatunderstanding by the client that the effectiveness of therapydepends. In other words, although empathy may be a visceral,somatic or emotional experience, at least a degree of cognitiveprocessing is required to turn it into empathic understanding.Shlien (1997: 67) values sympathy because it is a type of com-mitment and writes `[e]mpathy alone, without sympathy, andeven more, without understanding, may be harmful'. Anotherway of understanding this may be that it is only when theexperience of another is understood rather than simply echoedor resonated with can it be accepted.

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29Although the basic hypothesis does not call for it,the communication to and/or perception of thetherapist's congruence by the client has recentlyreceived attention

Wyatt (2001a) has edited a volume of writing and researchdealing with congruence and in her introduction to it she (p. vii)reports that from the 1950s when Rogers ®rst used the term, itreceived little further attention until the late 1980s. One of theways in which it has been thought and written about since thenis in terms of how it may be communicated. While the classicalclient-centred position is that congruence is rarely, if ever,directly communicated in words but rather, as Cornelius-White(2007: 174) explains, via body language which is the product ofinternal congruence, some writers have become concerned withthe appropriateness and nature of `congruent responses' and(Wyatt 2001b: 79±95) `the multifaceted nature of congruence'.

Although it is being which is important about congruence,some person-centred theorists have explored how it operates andits facets. For example, Lietaer (1993: 18), writing from thepoint of view of an experiential therapist, is of the opinion that`genuineness' has two facets, an inner one he calls `congruence'which is about `being' and the availability of experience toawareness (and thus close to the original formulation of Rogers)and an outer facet he names `transparency' which `refers to theexplicit communication by the therapist of his conscious percep-tions, attitudes and feelings'. This communication may be verbalor non-verbal. Making it clear that the separation is in someways arti®cial, Lietaer goes on to explore the differencesbetween these two aspects and in Lietaer (2001a: 36±54) revisitshis ideas. In discussing transparency, he (pp. 42±47) emphasisesthe importance of the `personal presence' of the therapist andexplains the place of `self-disclosure' in the therapeutic encoun-ter. By the former he means that, far from being the blank

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screen reputed to be required of an analytic therapist, the ther-apist `shines through' as a real, recognisable and present person.The second element of transparency, self-disclosure, he sees ascontributing to person-centred therapy moving away from theclassical tradition to a more interactional form of therapy ofwhich a dialogue between therapist and client is a legitimatepart. While such a dialogic form to person-centred therapy maycontribute to (for example) `working at relational depth' (Point38), self-disclosure is something for the therapist to approachwith caution and perhaps to do rarely if at all. Lietaer (p. 47)himself quali®es his ideas stating that it is enormously importantthat `self-disclosing responses [are] embedded in a fundamentalattitude of openness: openness towards oneself (congruence) andopenness towards the experiencing self of the client (uncondi-tional positive regard)'.

Coming from a more `classical' perspective, Tudor andWorrall (1994: 198) identify four components of congruence.These they call:

· self-awareness

· self-awareness in action

· communication

· appropriateness.

The ®rst two elements share much with congruence as it isdescribed by Lietaer but they argue that congruent communica-tion involves more than transparency. In their view, `apparency'`which has a more active, relational, transitive quality' is animportant aspect of congruence. Being apparent is to do with theappropriate communication of the therapist's experience. Just ascognitive processing is an important part of empathic under-standing (Point 20) so therapists need to (p. 199) `think clearly'in order to discriminate between appropriate and inappropriatecongruent responses. For Tudor and Worrall (p. 201), it is morerelevant to focus on `communicating our experiencing thanon disclosing our experience'. So, congruent responses shouldnormally focus on the communication of the here-and-nowexperience of the therapist rather than the sharing of some aspectof personal history. While this is closer to the classic client-

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centred position and can be related to the position of (forexample) Mearns and Thorne (2007: 139±142) who (p. 142)suggest that appropriate congruent responses are those `that arerelevant to [the] client and that are relatively persistent orstriking' (original emphases), the subdivision of congruence isseen as unnecessary and unhelpful by some (see Point 18).

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30Although it remains under-researched,unconditional positive regard has beenreconsidered and re-evaluated

In Wilkins (2003: 75), I report on the relative lack of researchinto the nature and function of unconditional positive regard(UPR). Watson and Sheckley (2001: 185) also comment on thepaucity of research into UPR attributing it to `a number offactors, including the dif®culty of de®ning the construct, poorresearch tools, and an increased interest in the working alliance'.However, there are a number of `re-conceptualisations' andreconsiderations of the notion. These include explorations froma classic client-centred position and from the point of view ofexperiential psychotherapy and even philosophical and religiousexpositions (see, for example, Bozarth and Wilkins 2001).

From a client-centred perspective Bozarth (1998: 83±88)reprises UPR and (p. 83, p. 88) describes it as `the core curativecondition in Rogers' theory' and Freire (2001: 145) reaches theconclusion that not only is UPR `the primary therapeutichealing agent' but that it is `the distinctive feature of client-centered therapy'. From a similar viewpoint, I (Wilkins 2000:23±36) `reconsider' UPR and also reach the conclusion (pp. 33±34) that, in terms of theory and my experience as therapist andclient, the communication of UPR is the active facilitator ofconstructive change. Behind this view lies the recognition that asthe client perceives the unconditional positive regard of acongruent therapist experiencing empathic understanding, theclient's positive self-regard increases. UPR is the factor thatfrees the client from conditions of worth (see Point 17). Writingfrom his position as a leading exponent of experientialpsychotherapy, Lietaer (1984: 41±58) discusses UPR as (p. 41)a `controversial basic attitude in client-centered therapy' andsees it as potentially in con¯ict with congruence. He also (p. 41)considers that `while unconditionality is not impossible, it is

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improbable'. Re-visiting UPR, Lietaer (2001b: 88) describes it as`a multi-dimensional concept' and (pp. 93±98) considers whatlimits UPR or renders it a dif®cult attitude to hold towardsanother. The dimensions of UPR Lietaer (2001b: 88±89) recog-nises are:

· positive regard which is the affective attitude of the therapisttoward the client

· non-directivity as the attitude of non-manipulation of theclient

· unconditionality or constancy in accepting the client.

In accord with other experiential therapists (for exampleIberg 2001: 109±125; Hendricks 2001: 126±144), Lietaer under-stands UPR in terms of therapist behaviour as much as a basictherapeutic attitude. While accepting that there is `general com-patibility' between the classical and experiential positions withregard to respecting the client's self-direction, Bozarth (2007:185) considers that the two approaches involve substantiallydifferent views of UPR and that this has implications forpractice.

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31Person-centred therapy is rooted in a philosophicaland ethical tradition: the work of Peter Schmid

Peter Schmid has been described as `the philosopher of theperson-centred approach'. While he is not alone in seeking tounderstand the philosophical traditions behind person-centredtherapy and the implications these have for practice, it is truethat his work on the anthropological and epistemologicalfoundations of it have made a signi®cant impact. Of particularconcern to Schmid, drawing on the work of the philosophersEmmanuel Levinas, Martin Buber and many others, are theconcept of human beings as essentially relational, the process ofencounter and the dialogical nature of person-centred therapy.

In one of his ®rst works published in English, Schmid (1998b:38±52) explains the importance of the concept of the person and(p. 39) why the paradigm shift from an objective view of humanbeings (what is a human being?) he sees as underpinning muchof psychology and psychotherapy to a subjective view (who areyou?), which characterises the person-centred approach, is trulyradical. Treating someone as an object leads in the direction ofdiagnosis, treatment and cure; attempting to discover whosomeone is involves the process of encounter. It is clear that forSchmid `encounter' is different from `relationship'. In my viewand in my interpretation of Schmid, it is in encounter that eachof us may discover and change ourselves through interactionand dialogue with the Other (see below).

An exploration of Western philosophical thought andreasoned argument lead Schmid (1998b: p. 45) to declare `thetwo most important principles of the person-centred image ofthe human being'. These are that `we live through experience,and we live in relationships' (original emphasis). In Schmid(1998a: 74±90) dealing with `the art of encounter' and stressingthe relational nature of the person, he (p. 81) writes that, from aperson-centred perspective, `each encounter involves meeting

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reality and being touched by the essence of the opposite' (originalemphasis). What Schmid is drawing attention to is encounter asa process of engagement involving acknowledgement, the mean-ing of which (to do the sort of thing Schmid himself does sowell) implies not only recognition of the Other (p. 81) but alsoresponding to and greeting the Other (dialogue). In this way, theOther cannot be seen as an anonymous stranger but becomesa(nother) person; someone real with whom there is at oncecommunion and from whom there is separation. This considera-tion leads Schmid (p. 82) to link encounter with Rogers' notionof `presence' (Kirschenbaum and Henderson 1990a: 137) and`tenderness' (Thorne 1991: 73±81) (Point 25) and it clearlyrelates to the concept of `relational depth' (Point 38). Schmid(1998a: 82) writes:

In the encounter philosophical perspective, presence is theauthentic attitude to be, to fully live in the presence:unconditionally accepting the Other, empathically becom-ing involved in his or her presence, without any priorintention, that is with openness and a wonder towardsexperience.

Revisiting his characterisation of the person-centredapproach, Schmid (2003: 110) lists three distinguishing qualities:

1. Client and therapist spring from a fundamental `We'.2. The client comes ®rst.3. The therapist is present.

Schmid (p. 110) considers that `we exist only as part of a``We'', and that (p. 111):

This We includes our history and our culture. It is not anundifferentiated mass, nor is it an accumulation of `Mes';it includes commonality and difference, valuing bothequally. Only common esteem for diversity constitutes andaccepts a We.

Schmid (2003: 111, 2007: 38±39) is clear that essential to theunderstanding and acceptance of `We' is the recognition and

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acceptance of another person as `Other'. That is `that the Otherreally ``stands counter'', because he or she is essentially differentfrom me'. Schmid (2007: 39) writes that to stand counter `meansto give room to each other and to express respect'. It is only therecognition of standing counter to others that allows encounter.Of encounter, Schmid (2002b: 201) writes:

To encounter a human being means to give them spaceand freedom to develop themselves according to their ownpossibilities, to become, and to be fully the person he orshe is able to become. On the one hand this is opposed toany use as a means to a particular end or any `intention'and on the other hand it is also opposed to interactionbased on role or function.

So, from a person-centred perspective there is no valuing ofsameness or difference but respectful acceptance of the Other inhis or her own terms. Moreover, the We implies a connected-ness, an interrelatedness that, in my view (Wilkins 2006: 12)`goes far beyond the self, even beyond the organism'. All thislinks to the importance of the non-directive attitude (see Point4) and, for example, leads Schmid (2007: 42±43) and Wilkins(2006: 12±13) to see person-centred therapy as centring onethics.

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32Although diagnosis has no place in person-centredpractice, assessment may be an ethical obligation

`Assessment' has long been a contentious issue in the context ofperson-centred therapy. This is largely because assessment isequated or con¯ated with diagnosis and the latter is believed tobe an inappropriate adoption from the medical model implyingthat there is an underlying problem (disease) which, if it can beidenti®ed, can be `treated' and a cure effected. This is completelyat odds with classic client-centred therapy because it puts theproblem before the person (see, for example, Point 5 dealingwith the non-directive principle, Point 9 on the actualisingtendency, Point 10 and the nineteen propositions and Schmid'snotion of encounter in Point 31).

Although Rogers (1951: 221±223) does refer to `the client-centered rationale for diagnosis', this rationale clearly puts theclient and the client's experience at the heart of the process.Furthermore, Rogers (pp. 223±225) immediately follows hisrationale with `certain objections to psychological diagnosis'. AsMearns (2004: 88±101) explains at length (p. 88), `problem-centered is not person-centered' and (p. 90) although two clientsmay have the same or similar `problem' (for example, alcohol-ism), because how they have symbolised their pasts, their waysof experiencing in the present and their visions for the future aredifferent then they are different and their needs from therapyand the therapist are different. Another objection to diagnosisor medicalised categorisation is exempli®ed by Sanders (see,for example, 2006a: 32±39, 2007b: 112±128) who argues that,because it is based on a biological, disease model, the concept ofmental illness is inappropriate and oppressive. Sanders (2007b:119) considers `distress' more relevant than `disease' and seesdistress as arising from psychological and social causes ratherthan biological causes. Sanders (pp. 120±122) goes on to presentarguments with respect to psychodiagnosis, stating (p. 122) that

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resistance to it `can be justi®ed in terms of philosophy, theoryand effectiveness'.

The above views re¯ect some of those published in a sym-posium on psychodiagnosis published in 1989. These areexplored in Wilkins (2005a: 135±138) and (p. 138) summarisedas representing three main views:

1. Psychodiagnosis is irrelevant to person-centred therapy andmay actually be harmful.

2. Although there are problems with psychodiagnosis,assessment and diagnosis are realities in the world ofpsychotherapy and it may be that person-centred therapistsmust take this into account.

3. If assessment focuses on the client and the client's self-knowledge then not only is it compatible with person-centred theory but it is also an advantage in the practice ofperson-centred therapy.

The ®rst two positions may be represented as `purist' and`pragmatic' respectively and they are concerned with diagnosis.The third is different: it is concerned with assessment. In crudeand simple terms, diagnosis is a process of `labelling' a person ashaving a particular (kind of ) problem usually de®ned accordingto a number of criteria arising from theory while assessment is a(mutual) process by which a decision is made as to the likeli-hood that therapist and client can and will build an effectivetherapeutic relationship. Assessment may take place over time.Assessment is not inimical to person-centred theory and prac-tice. Indeed the necessary and suf®cient conditions and the sevenstages of process can be seen as contributing to a person-centredscheme for assessment (see Wilkins 2005a: 141±143). Such ascheme sets aside the notion of the therapist as expert, able toreach a de®nitive conclusion as to the nature of the client'sdif®culties and rather concentrates on the likelihood of estab-lishing a relationship in which the six necessary and suf®cientconditions will be met. It also highlights the potential limitationsof the therapist. Person-centred therapists are ethically obligedto ask themselves if a potential client stands in need of therapy

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and if they can offer an effective relationship to that client. Thecriteria in Wilkins (2005a: 141±142) provide a system formaking such a judgement (see also Point 59).

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33Person-centred theory includes ways ofunderstanding psychopathology. These differfrom the predominant `medical model'

For the most part, in the West the treatment of people experi-encing mental and/or emotional distress has been dominated bypractitioners who adhere to the medical model whether they aremedically trained or not. That is to say that a way of thinkingabout and responding to physical ailments has been appliedwholesale to disorders of thought and feeling. However, theapplicability of a model which goes something like (̀symptoms)±diagnosis±treatment±cure±(lack of symptoms)' has, at least froma person-centred point of view, not been proved. A secondin¯uence on understanding psychopathology has been psycho-analysis. It is from this source that some of the familiar termsassociated with psychological distress arise ± for example,`borderline' and `narcissism'. Historically, both these ways ofthinking about people have been opposed by person-centredpractitioners although more recently there has been some movetowards developing a common or inclusive language especiallyby person-centred practitioners who work in medical settings.This rejection by person-centred practitioners has been criticisedlargely on the basis that person-centred theory lacks a model ofchild development and a model of psychological distress. This iseasy to refute (see Wilkins 2003: 99±107, 2005b: 43±50). Fromthe outset there has been a model of child development as partof person-centred theory (see Rogers 1959: 222) and a linking ofthis to the development of distress (Rogers 1959: 224±230). Thishas subsequently been re®ned and developed by (for example)Biermann-Ratjen (1996: 13±14). There are in fact four majorcontemporary positions with respect to mental ill-health withinthe person-centred tradition. These are those based on:

1. (psychological) contact (see Point 34)2. incongruence (see Point 35)

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3. styles of processing (see Point 36)4. issues of power (see Point 37).

While they share a great deal, each of these approaches tounderstanding emotional and mental distress has been devel-oped primarily from a particular theoretical proposition orphilosophical attitude.

1. Understanding or working with mental distress in thecontext of `contact' derives from the ®rst of the necessaryand suf®cient conditions where it is required that client andtherapist are in (psychological) contact. The underpinningquestion is what to do if this is not so and there is anassumption that the absence of contact is in itself distressing.

2. The notion that it is incongruence which gives rise to mentaland emotional distress is a straightforward reading ofthe second of Rogers' six conditions. It is incongruenceexpressed as anxiety or vulnerability that leads a client totherapy. This incongruence can be anywhere on a spectrumfrom mild unease to acute or chronic suffering of the mostdisturbing kind.

3. Models in which `dif®cult' process is the basis for distressderive from Rogers' (1967: 27) description of life as `a¯owing, changing process in which nothing is ®xed' and therecognition that sometimes this process may be interrupted,distorted, stagnant or in some other way deviate from theideal.

4. That psychological distress relates to issues of power ratherthan to intrinsic, intra-personal and interpersonal dynamicsis based on the assumption that its causes are social and/or environmental. Perhaps this draws on person-centredphilosophy as much or more than its theory of personality. Itrelates to the non-directive principle and the attitude to theexercise of power (Points 5 and 6). The foundation of thisunderstanding of distress is that `madness' is socially de®nedand that social and political circumstances at the very leastcontribute to mental ill-health and are possibly causal.

Each of these four approaches to understanding psycho-pathology is expanded on in the following four `Points'.

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34Pre-therapy and contact work constitute animportant, person-centred way of working with`contact impairment' and extreme mental andemotional distress

With respect to psychological contact and mental distress andperson-centred therapy, the work of Garry Prouty is of pre-eminence (Points 15 and 68). Prouty asked the fundamentalquestion `What happens if the ®rst of the necessary and suf®cientconditions is not met?' This led to the development of a person-centred system of thought and practice embracing clients with(for example) profound learning dif®culties or schizophrenia.This became known as pre-therapy (see Prouty 2002a and b)which (2002b: 55) is described as `a theory of psychologicalcontact . . . rooted in Rogers' conception of psychological contactas the ®rst condition of a therapeutic relationship'. According toKrietemeyer and Prouty (2003: 152) pre-therapy theory `wasdeveloped in the context of treating mentally retarded or psy-chotic populations'. This is because, in Prouty's experience, suchpeople are `contact-impaired' and have dif®culty forminginterpersonal connections. Pre-therapy theory led to the develop-ment of a set of practices by which psychological contact could beestablished (see case studies presented by Van Werde 1994: 125±128 and Krietemeyer and Prouty 2003: 154±160) and for whichProuty (2001: 595±596) summarises the research evidence.

Pre-therapy is a deeply respectful way of working with peoplebefore psychological therapy as it is usually understood can takeplace. So, in its original form and intent at least, it is not acomplete therapy but a preparation for therapy. The primaryaim of pre-therapy is to restore the (psychological) contactwhich, because it is a pre-requisite for forming a reciprocalrelationship, was named by Rogers as the ®rst essential forconstructive personality change. Pre-therapy is under-pinned bycontact theory of which the elements are as follows.

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1. Contact functions ± the client's process. An assumption isthat people who are not contact impaired have the abilityfor:

· `reality contact' or an awareness of people, things,places and events they encounter

· `affective contact' or awareness of their feelings andemotions

· `communicative contact' or the ability to symboliseand represent their experience of their environmentto themselves and others through the medium oflanguage.

2. Contact re¯ections ± the therapist's responses. Essentially,these are what the therapist or contact worker does to (re-)establish contact with the client. Contact re¯ections are of®ve types. These are (after Sanders 2007d: 31 and VanWerde and Prouty 2007: 240):

· Situational re¯ections to re¯ect aspects of the sharedenvironment (people, places, happenings and things) inorder to facilitate reality contact. For example, `You aresitting on the ¯oor. The ¯oor is red.'

· Facial re¯ections which describe in words or mimic thefacial expressions of the client. This facilitates affectivecontact. For example, `You have tears in your eyes.'

· Body re¯ections which re¯ect verbally or by imitationthe body language, movement and postures of the clientwhich may help to establish reality contact or affectivecontact. For example, holding an arm erect when theclient does.

· Word-for-word re¯ections which involve repeating backwhat the client says word for word, however bizarre orirrational. This develops communicative contact.

· Re-iterative re¯ections which entails repeating anyprevious re¯ections to which there was a response ±in other words, if it works, do it again.

3. Contact behaviours ± the client's behaviours as they give anindication of the extent to which clients can express them-selves or make contact with another. One respect in whichthese are important is as a measure of change followingpre-therapy.

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Contact theory is expanded on in Van Werde and Prouty(2007: 238±243) and Sanders (2007d: 24±31).

Sanders (2007c: 18) states that pre-therapy methods `may beused to help restore, strengthen or sustain contact' with people:

· in a state of severe psychotic withdrawal, catatonia orregression

· suffering from dissociative states

· with learning disabilities which impair communication andcontact, from mild to severe and enduring

· suffering from dementia

· suffering from terminal or degenerative illness which impairscommunication or contact, including those, for example,whose palliative care causes drowsiness due to pain-killingdrugs

· with temporary contact impairment due to an organiccondition

· suffering from a brain injury or damage.

The practice of pre-therapy is dealt with in Point 68.

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35Client incongruence, which can be understood ascaused in various ways, is a source of mental andemotional distress

An important person-centred approach to understandingpsychopathology hinges on the second of the necessary andsuf®cient conditions ± that is that incongruence is central tomental/emotional distress. In his exploration of the linksbetween incongruence and mental health, Tengland (2001:169) sees incongruence as contributing to ill health `since it oftenreduces the person's ability to reach vital goals'. This is becausewhen we experience something that con¯icts with how we seeourselves and we cannot make the outer reality ®t with our selfimage we tend to feel tense, anxious, confused or frightened. Tophrase it more formally, when a person has a poor self-conceptwhich is out of touch with the organism, disturbance results andin extreme cases this manifests as distress or even `madness'.This can be framed in terms of conditions of worth (Point 12)which is the classic client-centred view. However, within thebroader person-centred family, some theorists have argued thatincongruence can arise from causes other than conditions ofworth (for example, genetic or other biological causes, lifeevents such as abuse early in life or post-traumatic stress dis-order) and there have been attempts to develop models ofdistress based on understanding incongruence per se.

For Speierer (1996: 300) client-centred therapy is the treat-ment of incongruence. His contention is that incongruence is theroot of emotional distress and that (p. 229) it has three maincauses. These are:

· the acquisition of conditions of worth and/or con¯ictbetween societal and organismic values

· bio-neuropsychological limitations ± either genetic or as aresult of injury or trauma

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· life-changing events of such intensity as to cause (forexample) intrusive ¯ashbacks.

Speierer's theory constitutes a divergence from classic client-centred therapy because he suggests that different `disorders'arise from different types of incongruence and so (p. 307)different therapeutic strategies can be offered according to thenature of the disorder and the needs of the client. This Speierercalls the `differential incongruence model' (see Speierer 1996,1998). However, this can be seen as in direct con¯ict with theclassical client-centred perception of psychodiagnosis aspotentially harmful to clients and de®nitely of unproven bene®t(Point 32).

Biermann-Ratjen (1998) also writes about incongruence andpsychopathology. She devotes sections to `post-traumatic dis-tress disorder', `psychogenic illness' and `neurosis' as manifesta-tions of incongruence. She relates incongruence to (child)development, indicating that it is the stage at which develop-ment is interrupted that determines the nature of distress.

Warner (2007a: 154±167) reviews person-centred theory andpractice with respect to client incongruence and psychopath-ology exploring reformulations of the concept of incongruence,person-centred models of psychopathology and research intoclient incongruence. She (p. 164) reaches the conclusion thatperson-centred therapists are particularly well-placed to workwith clients diagnosed with severe disorders and that the`person-centred approach in work with clients of all levels ofseverity of symptoms' should be proactively promoted.

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36The client's style of processing may result inmental and emotional distress

Emotional and mental distress may be understood in terms ofstyles of processing. That is, in some individuals and for avariety of reasons, rather than the ¯uid form described as desir-able, process is `dif®cult' for the client, the therapist or both.For example, Warner (2001: 182±183) describes three kinds of`dif®cult' process. These are:

· Fragile process. Individuals with a fragile style of processingtend to experience core issues at very low or very high levelsof intensity and have dif®culty holding onto their ownexperience. They are often diagnosed as borderline ornarcissistic. Because of the fragile connection with their ownexperience, they often have dif®culty accepting the point ofview of another person without feeling overwhelmed or thattheir experience has been annihilated. Warner (2007a: 160)indicates that fragile processing is likely to have arisen froma lack of empathic care-giving at crucial stages in earlychildhood or `around newer edges of their experience thathave not previously been received by themselves or others'.

· Dissociated process. Clients experiencing a dissociatedprocess go through periods when they quite convincinglyexperience themselves as having `selves' that are not inte-grated with each other. That is as having multiple selves,one or more of whom may or may not be aware of theexistence of some or all of the others for some or all of thetime.

Sometimes they experience a fragmentation or disunity ofself that can be (literally) maddening to them and appear`crazy' to others. People with dissociated process mayappear to function well enough for years without beingaware of their various `parts' by keeping busy but leading

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restricted lives. However, it is likely that past experienceswill return disturbingly and disruptingly at times of crisis.This type of processing has been identi®ed with `multiplepersonality disorder' and `dissociative identity disorder' andalmost always results from severe early childhood trauma.

· Psychotic process. Clients experiencing a psychotic form ofprocessing have impaired contact with themselves, othersand the world. They have dif®culty in formulating and/orcommunicating their experience in a way which makescohesive sense and have equal dif®culty making sense oftheir environment. People with a psychotic form of pro-cessing may hear voices and/or experience hallucinations ordelusions which are alienating. The label `schizophrenic' isone of many which may be attached to people experiencingpsychotic processing.

In her various papers, Warner describes the possible originsof these styles of processing and effective ways of working witheach group of clients in a person-centred way.

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37The causes of mental and emotional distress areenvironmental, social and to do with power andpowerlessness. The medicalisation of distress isan error

Amongst person-centred thinkers, there is a widespread andincreasing view that the causes of emotional and mental distressare not intrinsic, interpersonal and a response to relationshipswith signi®cant others but that their origin is social and/orenvironmental. Also, there is an assumption that `madness' issocially de®ned and that social and political circumstances at thevery least contribute to mental distress and are possibly (or evenlikely to be) causal. There is also a belief that the imbalance andabuse of power relate to mental ill-health and that it is only ifpower in all its aspects is openly addressed can therapy besuccessful. For example, Proctor (2002: 3) is clear that `there ismuch evidence to associate the likelihood of suffering frompsychological distress with the individual's position in societywith respect to structural power'. She (pp. 3±4) shows howwomen are more likely than men to be diagnosed with a rangeof disorders and that working class people are as a whole over-represented in the mental health services. Similarly, Sanders(2006a: 33) states that there is growing evidence that psycho-logical distress has social, not biological, causes. He goes as faras to say that there is no such thing as mental illness and (pp.33±35) makes a strong, evidenced argument against what hecalls `biological psychiatry', that is psychiatry based on adiagnosis±treatment±cure model for speci®c `disorders' such asschizophrenia and depression.

What is being argued by Proctor, Sanders and many others isthat medicalised psychiatric systems are essentially systems ofcontrol and power. It follows that if distress ¯ows from anexperience of inequality and power and an encounter with psy-chiatric services is disempowering, then (biological) psychiatry

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may be making people worse rather than better. Not only that,but the whole idea of treating speci®c `illnesses' with medicine orby other physical means is based on a false premise (i.e. thebiological/medical model of distress) for which, according toSanders (2006a: 32), there is `hardly a jot of evidence'. This isnot a new position nor is it con®ned to person-centred therapy.Essentially, the antipsychiatry movement of the mid twentiethcentury and currently critical and positive psychologies makethe same arguments. For example, Read et al. (2004: 3) (aclinical psychologist, a psychiatrist and professor of psychiatryand a professor of experimental clinical psychology respectively)consider that the notion that mental illness is an illness in thesame way as a physical disease is not supported by research.They also say that adherence to the medical model leads toignoring or even actively discouraging any discussion orexploration of what is going on in the lives, surroundings andsocieties of people experiencing distress. Of course, in manyways it is insuf®cient to criticise one model of distress andhelping without proposing another and that is just what person-centred therapists are seeking to do.

For example, one way of correcting the potentially oppressivepower imbalance in therapy is its demysti®cation. A way inwhich this may be done is through the therapist's willingness tobe known. Also, a person-centred model to address power issuescould involve working at `relational depth' (Point 38) but itwould also have to take account of inequalities of structuralpower both within and without the therapy relationship.

Sanders and Tudor (2001: 148) see person-centred therapy asoffering a radical view of psychology and psychotherapy and acritical contribution to contemporary concerns about the mentalhealth system. Throughout their chapter, with respect to work-ing with mental and emotional distress, they are very clear thatto consider individuals separately from the social and politicalmilieus in which they live is mistaken. In a later work, Sanders(2007e: 188±191) advocates and describes a person-centredsocial model of distress. This he (p. 190) writes is `multidis-ciplinary as it embraces the material, social, psychological,biological and spiritual aspects of being human'.

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38For some, an extension to person-centred workingis embraced in the concept of `relational depth'

`Relational depth' is a term coined by Mearns (1996) and it isconsidered at length in Mearns and Cooper (2005). What isbeing talked about is a degree of psychological contact betweenclient and therapist which is qualitatively different from theordinary. It is about high-quality encounter of the kinddescribed by Rogers (1986: 137) as involving `presence' andby Thorne (1991: 73±81) as to do with `tenderness' (Point 25)but which Mearns (1994: 7±8) sees as something more prosaicbut no less profound. In a nutshell, the deep personal self-knowledge of the therapist and a willingness to engage with theclient wholly and without arti®ce (and a similar willingness onthe part of the client to be `real') brings about a level of contactwhich is transformative. Relational depth has at least someequivalence with intimacy (in the sense of mutual engagementand openness). Mearns and Cooper (2005: xii) offer thefollowing `working de®nition' of relational depth:

A state of profound contact and engagement between twopeople, in which each person is fully real with the Other,and able to understand and value the Other's experiencesat a high level.

And (p. 36) they characterise the therapist's experience ofmeeting at relational depth thus:

A feeling of profound contact and engagement with aclient, in which one simultaneously experiences high andconsistent levels of empathy and acceptance towards thatOther, and relates to them in a highly transparent way. Inthis relationship, the client is experienced as acknowl-edging one's empathy, acceptance and congruence ± either

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implicitly or explicitly ± and is experienced as fullycongruent in that moment.

In other words, relational depth is conditions three, four, ®veand six at high level and in concert with the addition of someclient qualities and what might be thought of as elements ofmutuality. In this notion of relational depth, `depth' refers tocloseness to personal reality and `truth', a fullness of subjectivelived experience, not to contact with some hidden inner core.Also, what is `deep' is not superior to, merely different from,other ways of being in relationship.

In practice, the conceptions behind working at relationaldepth are different from classic client-centred therapy in at leastas much as the emphasis is no longer on a non-directive attitudenor on facilitating emotional change but on the dialoguebetween client and therapist. It is `relationship-centred therapy'rather than client-centred therapy because the agency of change(while still primarily the actualising tendency) is the co-createdspace between and within the dyad of therapist and client.Arguably, this is nothing new but this stance has previouslybeen implicit rather than explicitly stated and explored in termsof theory and practice. Besides Mearns and Cooper, otherprominent exponents of a dialogical approach to client-centredtherapy include Peter Schmid (Point 31) and Barrett-Lennard(2005). A justi®cation for focusing on and emphasising therelationship in therapy is that research evidence points to thefact that, besides whatever clients bring and/or do themselves,most of the variance in the outcome of therapy can be attributedto the quality of the relationship per se. An explanation for thismay be that much emotional and mental distress is caused bythe absence of or dif®culty in achieving and maintaining closepersonal contact ± that is an existential loneliness ± and thatrelational depth achieved in therapy (or anywhere else for thatmatter) begins to change this. It is postulated that the way thishealing happens is that the sense of connectedness resultingfrom contact at relational depth allows the client to movebeyond the feeling of being totally alone to a feeling of beingrecognised, received, perceived and understood by at least oneother. This is transformative; a relief in itself but also giving rise

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to the hope that such deep human contact is possible outside thetherapy hour and with others. Not only that, but contact atrelational depth, because it is redolent with acceptance andempathic understanding, allows the client to move towardsfundamental issues to do with their very existence and whichmay have previously been denied to awareness.

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Section 4CRITICISMS OF

PERSON-CENTREDTHERAPY ± AND

REBUTTALS

39The theory and practice of person-centred therapyhas been subject to a great deal of criticism. Thiscriticism is often based in misunderstanding

Criticism of person-centred therapy usually comes from anignorance of theory and the way it is implemented. For example,there appears to be a belief that being `person-centred' involveslittle more than being `nice' to people, lending a sympathetic earbut to little effect. It is quite common to hear therapists of otherorientations say that while attentive, accepting listening mightbe helpful in the initial stages of a therapeutic relationship (ifindeed it is helpful at all) the serious work happens when expertknowledge and technique are brought into play. In other wordswhile there is (sometimes grudging) acceptance that the sixconditions are necessary they are not deemed to be suf®cient.

More charitably, there is a view that while person-centredtherapy `works' for the worried well or to help people in acute(but relatively trivial) distress anyone who is more seriouslydisturbed, `mentally ill' or who has deep-rooted problems needsthe stronger medicine of another approach. Given the researchevidence for the ef®cacy of person-centred therapy and therespect accorded to Rogers, why this view is held is dif®cult tounderstand. One view is that there is something about person-centred therapy which is intrinsically threatening to therapists ofother orientation and that this leads to wilful ignorance orcontemptuous dismissal (see, for example, Mearns and Thorne2000: ix±x).

It may also be that person-centred theorists, researchers andpractitioners bear a responsibility for failing to promote theapproach by being too insular and precious, preaching prin-cipally to the converted. Certainly, it appears that the person-centred resistance to conventional hierarchical organisations hasdone the approach no favours. For example, the experience ofthe (few) person-centred therapists who attended the ®rst World

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CRITICISMS AND REBUTTALS

Congress for Psychotherapy in Vienna in 1996 was that person-centred therapy was easily dismissed by therapists of otherorientations because it was not represented by a properly con-stituted international professional body. Modalities practised byfar fewer people and often on the fringes of approaches topsychotherapy were accorded more respect because they wererepresented in that way. Partly in reaction to this, the WorldAssociation for Person-Centered and Experiential Psychothera-pies was formed.

For some, the view of person-centred therapy as relativelytrivial leads the belief that something must be added to it for itto be effective. However, there is no need for this. There isample evidence for the ef®cacy of person-centred therapy andmost of the common criticisms are easily rebutted. The pre-ceding sections, and works under the imprimatur of leadingpublishers including the publications of PCCS Books andPerson-Centered and Experiential Therapies, the leading inter-national journal for the approach, will help you formulate yourown rebuttals. To help you along, this section comprises some ofthe most common criticisms made of person-centred therapyand how they can be answered.

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40It is untrue that person-centred theory holds thatthere is an ideal endpoint to human developmentand this has implications for therapy

Person-centred therapy has often been criticised for implicitlyincorporating the notion of human beings as in some wayinherently `good' and that, given the right conditions, they willdevelop constructively to achieve some ideal state. Central tothis criticism is the fundamental principle of person-centredtheory, the actualising tendency (Point 9), the acceptance ofwhich is a de®ning characteristic of the person-centred therapies.It is assumed that the actualising tendency leads to an idealendpoint to growth which may be a state of `self-actualisation'or a fully functioning person and which is the pinnacle of theindividual achievement of potential. Such is the evidence of theinhumanity of human beings to other human beings and so clearis it that many people are not functioning optimally that thebelief in the constructive, positive nature of humanity is unreal-istic if not delusional. However, in terms of person-centredtheory, when it is used at all, the term self-actualisation refers toa concept different from that of Maslow in that it is not a peakstate resulting from the satisfaction of a hierarchy of needs.

In terms of person-centred theory, self-actualisation is aprocess, not a state. Moreover, it applies only to that part of theperson delineated as the `self' which is a subsystem of the wholeperson (or the organism). This subsystem is also called the self-concept which is, as the term suggests, the way people see and/orconstruct themselves. Self-actualisation is not a goal of eithertherapy or normal, healthy living and it does not necessarilyresult in optimal functioning because it is about maintaining theself-concept. Furthermore, the process of self-actualisation maycon¯ict with the actualising tendency. For example, the need ofthe self for positive regard or af®rmation from others may bemore compelling than experiences which are of positive value in

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actualising the organism (see Rogers 1959: 224). That is to say itis possible, because of conditions of worth, for a person torespond to and internalise the values of others as part of the self-concept thus setting up an uncomfortable tension between theconstructive directionality of the actualising tendency and needsimposed by the social environment.

Arguments as to the nature of the `fully functioning person'are essentially similar, for while this too may be taken asindicating a tenet of person-centred theory that there is someideal human state, it does not. In de®ning the `good life' (that isbeing fully functioning) Rogers (1967: 186) wrote `it is not, inmy estimation, a state of virtue, or contentment, or nirvana,or happiness. It is not a condition in which the individual isadjusted, or ful®lled, or actualized'. Like self-actualisation, thenotion of the fully functioning person refers to a directionaldevelopment, not a state of being. Being full functioning ischaracterised by an openness to experience, increasingly existen-tial living (that is living in the present with awareness of eachmoment) and an increasing trust in the organism. The emphasisis clearly on a process of `becoming'.

So, person-centred theory neither states nor implies that thereis an ideal state which is to be the objective of therapy and/orpersonal growth. Moreover, as Merry (2000: 348) points out,because `the theory of actualization is a natural science theory,not a moral theory', no values are implied.

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41It is untrue that the model of the person advancedin person-centred theory is inadequate to explainpsychopathology and leads to an unprofessionaldisregard for assessment

The person-centred approach has been criticised as lacking atheory of personality and, in particular, of child developmentand thus as having an inadequate view of how mental andemotional distress may arise. This is often more focused and thecriticism becomes one of the absence of an explanation for`psychoses' and `neuroses' as they are de®ned and understood inthe medical model and, to some extent, in psychoanalysis. It isclaimed that from this lack of clarity about the origins of dis-tress there arises a disregard for assessment and this amounts toprofessional irresponsibility. Leaving aside the evident logical¯aw of criticising one theory because it does not give rise to thesame conclusions as another, is this charge true and does itmatter one way or the other?

Firstly, there is in fact a well-developed person-centred modelof the person (see Rogers 1951: 483±522; Rogers 1959: 221±223and Point 8). On the face of it, there is little about the humanorganism that this statement of theory does not explain. It con-siders both `healthy' and `dysfunctional' development and showshow therapeutic change can occur. Additionally, Biermann-Ratjen (1996: 13), drawing on Rogers' six conditions, offers alist of the necessary conditions for self-development in earlychildhood (Point 24).

Similarly, others have pursued the understanding of thecauses of mental distress. This has been particularly evident in,for example, the exploration of the roots of incongruence andthe links of these to mental ill health (Point 35) and in Warner'sconcept of dif®cult process (Point 36). Furthermore, Joseph andWorsley (2005) and Worsley and Joseph (2007) provide a com-prehensive account of person-centred theory and practice with

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respect to emotional and mental distress. As well as considera-tions of person-centred theory with respect to psychopathologyand research, these books include (for example) explorations ofperson-centred practice with people experiencing:

· psychotic functioning

· antisocial personality disorder

· post-traumatic distress

· maternal depression

· the legacy of childhood abuse

· `special needs'

· autism and Asperger's syndrome

· eating disorders

· long-term depression.

With respect to assessment, if that is (erroneously) under-stood to result in diagnosis, there may be a charge to answer.Clearly and axiomatically there is no place for diagnosis inclassic client-centred therapy (Point 32). The perceived problemof diagnosis is that it labels and ®xes the client ± the fear is thattherapy becomes problem-driven rather than client-centred.From another perspective, diagnosis can be seen as helpfulbecause it allows the development of a mutual understandingbetween a variety of healthcare professionals and because itfacilitates the therapist's understanding of the client's process.Arguably, combining these two attitudes to diagnosis plays apart in person-centred practice with people experiencing mentaldistress. For example, Warner's concept of dif®cult clientprocess allows both correspondence to psychiatric ideas and thechallenging of them.

Looked at another way, assessment is an essential part of theprocess of person-centred therapy. Indeed, Wilkins and Gill(2003: 184) have shown that, even though they do not describe itas such, when meeting a client for the ®rst time, person-centredtherapists do indeed conduct a process that could legitimately becalled `assessment' although its aim is not diagnosis. It is anethical and professional obligation for the person-centred ther-apist to ascertain the likelihood of being able to offer thepotential client the therapist conditions or at the very least to

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make a sincere attempt to do so. To this end, Wilkins (2005a:140±143) suggests criteria for person-centred assessment draw-ing on the necessary and suf®cient conditions and the sevenstages of process (Point 32).

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42It is untrue that person-centred theory includesan unduly optimistic view of human nature asfundamentally `good' and that this leads to a naõÈvedisregard for destructive drives and an avoidanceof challenge and confrontation in the therapeuticendeavour

There is a widely held view that person-centred theory holdsthat people are `essentially good'. This presumed assumption iscriticised in the light of the observed behaviour of people. Forexample, how can the perpetrators of the Nazi Holocaust, theKilling Fields of Cambodia, ethnic cleansing in too manycon¯icts to name be fundamentally good? In Kirschenbaum andHenderson (1990b: 239±255) there is a debate between Rogersand Rollo May which addresses this. While Rogers (pp. 237±238) acknowledges the vast amount of destructive, cruel andmalevolent behaviour to be encountered in the world, he doesnot ®nd that people are inherently evil. However, this is not thesame as stating that people are innately good.

The concept of the inherent goodness of people plays no partin the classic statements of person-centred theory. Furthermore,in `A note on the nature of man' (see Kirschenbaum andHenderson 1990a: 401±408), Rogers (p. 403) considers `whatman is not', stating:

I do not discover man to be well characterised in his basicnature by such terms as fundamentally hostile, antisocial,destructive, evil.I do not discover man to be, in his basic nature, completelywithout a nature, a tabula rasa on which anything may bewritten, nor malleable putty which can be shaped into anyform.I do not discover man to be essentially a perfect being,sadly warped and corrupted by society.

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In my experience I have discovered man to have charac-teristics which seem inherent in his species, and the termswhich have at different times seemed to me descriptive ofthese characteristics are such as positive, forward-moving,constructive, realistic, trustworthy.

So, while Rogers is clearly stating that people are not intrin-sically evil, he is not con®rming that people are `good'. Rogers'statement was not meant to imply moral judgement but was theresult of empirical observation and not a declaration of desir-able or admirable qualities. Arguments about `inherent good-ness' are spurious ± it is neither stated nor implied. Primarily,Rogers is making a statement about the biological and psycho-logical nature of people: we are constructive and tend to grow,to move towards the achievement of potential. However, forethical reasons, person-centred theory does hold that people areof worth but even this does not imply `goodness'. Being con-structive, trustworthy and of worth does not amount to inherentand innate saintliness!

Nothing in person-centred theory leads its practitioners toconclude that feelings such as envy, murderous rage, bitternessand hatred are to be avoided. These are well within the reper-toire of normal human emotions and are encountered and metin the context of therapy and in ourselves. However, that some-one is feeling murderous, spiteful or sadistic does not alter thatthey are of worth. Sometimes such feelings are directed towardsthe therapist and, when that happens, they are met, acknowl-edged and worked with. Quite why when so many person-centred writers have referred so often to the expression of`negative' emotions the myth persists that we deny and avoidsuch normal ways of being mysti®es me.

In unconditional positive regard (or perhaps via a fusion ofthe three therapist-provided conditions) person-centred thera-pists have a powerful tool for aiding clients to contact andexpress powerful, negative and shameful feelings. When reson-ating with their clients' frames of reference they are able toconvey to them something like: `I know that you feel murderous,I can even feel it within me ± this does not frighten me nor doesit change my sense of you as a person of worth.' This usually

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happens beyond words but is all the more powerful for that.Theory and experience lead me to the knowledge that this canlead to an even deeper connection with destructive impulses,negative and shameful emotions, bitterness and the like. It iswhen this connection is deeply felt and openly expressed thatchange of some kind is likely to occur.

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43Rogers' (1957/1959) statement of the necessaryand sufficient conditions has been challenged.While many accept the necessity of these, thesufficiency is doubted

Although person-centred theory has never asserted that the so-called `core conditions' of empathy, unconditional positiveregard and congruence are necessary and suf®cient conditionsfor constructive personality change (the hypothesis demands allsix conditions, Point 13), research into and criticism of thehypothesis of the necessary and suf®cient conditions usuallyconcentrates on them.

Wilkins (2003: 67±69) reviews the research evidence for thehypothesis showing that, while there is evidence for the primacyof the relationship in the therapeutic endeavour (which isimplicit in Rogers' statements), the basic hypothesis remainsunproved (but in spite of efforts to do so, neither has it beendisproved). This is at least partly because efforts to investigatethe hypothesis as a whole are rare if indeed they exist at all.Most research concentrates on the therapist-provided condi-tions, usually singly, sometimes in combination. Bozarth (1998:165±173) reviews the ®ndings from research into therapistattitudes and argues that they demonstrate the effectiveness ofRogers' conditions.

The proposition that Rogers' conditions are both necessaryand suf®cient is often dismissed by therapists of other orienta-tions and even `modi®ed' by some therapists who consider them-selves to be in the wider person-centred family of approaches.The principal argument is that while the `core conditions' arenecessary or at least helpful in the forming of a therapeuticrelationship they are not suf®cient. Something else is needed.Notions of what the `something else' is vary with the orientationof the critic but it always rests on techniques and expertiseavailable to them but apparently eschewed by person-centred

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practitioners. There are even arguments that the therapist-pro-vided conditions may be counter-therapeutic (for example,empathy may encourage a client to wallow in self-pity ratherthan to change). Often, while broad agreement with person-centred theory is indicated, there are suggested re®nements andadditions. For example, Dryden (1990: 17±18) notes that whilerational-emotive behaviour therapists agree with the need for thetherapist-provided conditions (acceptance and genuineness inparticular) he doubts the value of `warmth' because (p. 18) it mayreinforce the client's need for love and approval and the `lowfrustration tolerance that many clients have'. This re¯ects areal philosophical and theoretical difference between the twoapproaches. In terms of person-centred theory, it is uncondi-tional positive regard (for which `warmth' is one of Rogers'synonyms) that decreases conditions of worth (Points 12 and 19)and increases self-regard. This results in an increasing internal-isation of the locus of evaluation and therefore a decreasing needfor the `approval' of others. Because such differences are rootedin different, unproved theoretical constructs (usually to do withthe nature of people), arguing about them can be fruitless.However, it is acceptable to reject attacks based solely on adifferent belief and certainly to refuse to be diminished by them(but remember this works the other way round too).

While there is widespread agreement in the wider person-centred community that the six conditions are necessary andsuf®cient, this does not mean that person-centred practitionersare unthinking about them. There are constantly being `recon-sidered' (for example, congruence by Tudor and Worrall 1994,empathy by Bohart and Greenberg 1997 and unconditionalpositive regard by Wilkins 2000), reviewed and readdressed (forexample in the series Rogers' Therapeutic Conditions edited byGill Wyatt for PCCS Books). Currently, it seems that researchinto the effectiveness of psychotherapy indicates that (apartfrom what the client brings and does) the major `change factor'is the relationship between therapist and client. Arguably, that isexactly the weight of the hypothesis of the necessary and suf®-cient conditions.

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44Person-centred therapy is seen as arising from andbound to a particular culture milieu and this limitsits relevance and applicability

Human beings are each products of a complexity of culturalin¯uences. Who we are, how we manifest in the world stemsfrom when and where we were born, our ethnicity, faith, gender,class, sexual orientation and so on. Rogers and his early col-leagues and collaborators were, for the most part, well-educated,middle-class, white American men. It is widely held that thetheories and practices they developed re¯ect who and how theywere. That is to say that person-centred therapy is essentially theproduct of a mid-twentieth century, white, North American,male perspective. Perhaps (for example) it is true that a culturalemphasis on rugged individualism did contribute to the devel-opment of humanistic psychology and thus person-centredthought. However, if this was the sole in¯uence, then the actual-ising tendency and other theoretical precepts are artefacts of aparticular time, place and culture and their relevance to anyother time, place and culture is at least questionable. This in turnwould mean that the applicability of person-centred therapy islimited because it fails to take note of variations in culture.Needless to say, person-centred practitioners do not accept thiscriticism wholesale. For some, person-centred theory, because itis organismic, natural and universal (Point 11), is independent ofculture and there is appreciation from outside the approachof the anti-intellectual, non-racist, non-sexist qualities inherentin person-centred therapy. However, for other person-centredpractitioners, although this is true, culture is something to beconsciously taken into account in both theory and practice.

Whatever the position individual practitioners take, it isprobably mistaken to assume that any theory can belong whollyto one time and place. The philosophical roots of the person-centred approach have been traced back to Ancient Greece and

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to have been in¯uenced by a variety of Eastern and Westernspiritual traditions (see Wilkins 2003: 56±57 and Schmid 2007).So, person-centred theory arose from something broader thanthe perspective of mid twentieth century USA but what aboutcultural diversity and person-centred practice?

`Cultural awareness' has been an issue for person-centredpractitioners from the earliest of days. Rogers (1951: 437)believed it to be important that therapists had at least someknowledge of their clients' cultural setting and that it wasimportant to actively learn about `cultural in¯uences very differ-ent from those which have molded [the counsellor]'. The issue ofcultural differences has featured in person-centred writing eversince. For example, Holdstock (1993) pointed out that theconcept of `self ' and `I' differed between cultures and that thishad implications for the practice of person-centred therapy andthere have been more recent attempts to address (for example)issues of gender and ethnicity.

One of the major concerns of person-centred practitionerswith reference to difference is that of power. For example, menand women, black and white, poor and wealthy are different intheir daily experience of power and oppression and this plays apart in psychological development. A major criticism is thatsuch differences are not allowed for in person-centred theory.With respect to gender, some notable person-centred writers ofcritiques and theoretical modi®cations include Wolter-Gustaf-son (1999) who considers Rogers' theory of human developmentwith reference to feminist and postmodern ideas and Natiello(1999) who shows how conditions of worth lead to gendersplitting and how gender typing challenges congruence. In addi-tion there is a major work edited by Proctor and Napier (2004)concerned with intersections between feminism and the person-centred approach. Similarly, attention has been given to issuesof race and ethnicity by person-centred theorists and prac-titioners. Of particular note in this respect is Moodley et al.(2004: 85±174) presenting the views of a number of people onrace and culture in person-centred counselling and Proctor et al.(2006: 143±231) where the contributors address socio-politicalissues and the therapy relationship. All the above and a numberof other writers are raising awareness of the shortcomings of

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person-centred practice in the absence of cultural awareness.This is the major concern of Lago (2007: 251±265) who (p. 255)considers the tensions and criticisms in relation to difference anddiversity within the person-centred approach and (pp. 261±262)makes recommendations `for person-centred therapists workingacross difference and diversity'.

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45In ignoring `transference' person-centred therapyis seen as naõÈve and seriously lacking

An area in which person-centred theory is seen to be lacking iswith respect to the phenomenon of `transference' and other`unconscious' processes (Point 22). This view is characterised bythe assumption that person-centred practitioners seek to `avoid'transference issues by being congruent and non-directive and thusignore an important process to the detriment of their clients.In this analysis, person-centred therapists are seen as encour-aging, through their actions and approach, positive transference(being supportive and `parental' in the best sense of the word)but as denying the client expression of `negative' transferencefeelings. This prevents real, in-depth therapy. The `discourage-ment of negative transference' argument seems to be rooted in theassumption that the attitudes of person-centred therapistsamount to a bland `niceness'. However, in context, confrontationand challenge may be part of the process of therapy. Person-centred therapy depends (amongst other things) on the expressionof real feelings in the moment and this can and sometimes doesinclude anger at the therapist.

However, it is a misconception that person-centred practi-tioners do not believe in transference and certainly do not take itseriously enough. It is true that some person-centred theorists aredismissive of transference but this is more to do with notions ofits importance than of its existence. In person-centred terms,either transference may (sometimes) be part of an interaction butit would be counter-therapeutic to work with it (because to do sowould avoid the `here and now' interactions and attribute thedynamic almost solely to the client's process) or it is a psycho-analytic theoretical construct with no reality. While Rogers (inKirschenbaum and Henderson 1990a: 129±130) acknowledgedthat in the therapeutic encounter there could arise emotions

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having little or nothing to do with the therapist's behaviour thesewere of no practical relevance.

Other person-centred theorists have expressed stronger views.Most notably, Shlien (1984: 153±181) proposed a `countertheoryof transference' which he intended to be instrumental indeveloping an alternative theory of the unconscious. Shlien (p.153) was of the view that `transference is a ®ction, invented andmaintained by the therapist to protect himself from the conse-quences of his own behaviour'. More recently, Mearns andCooper (2005: 53) expressed the opinion that transference phe-nomena occur only in comparatively super®cial levels of rela-tionship and disappear altogether when working at relationaldepth (Point 38). They (p. 159) go further and claim that con-centrating on transference phenomena actively blocks connect-ing at relational depth. This neatly reverses the familiar claim ofpsychodynamic therapists and puts working with transferencein the position of being counter-therapeutic. Of course thereare person-centred therapists who take different views aboutthe existence and importance of transference phenomena. Forexample Lietaer (1993: 35) takes the view that while transferencedoes exist it is how it is worked with in person-centred therapythat is different. He points out that transference phenomenadissolve of their own accord as a result of a good workingrelationship and that person-centred therapy does not `provide apriority in principle [original emphasis] to working with aproblem in the here-and-now relationship'.

It is also true that transference is a theoretical construct usedby some people to describe a process they observe and to whichthey attribute signi®cance. It is a concept, not a veri®ed processand, if it occurs at all, there are different explanations for it.These include person-centred explanations. It is possible thatperson-centred practitioners observe the same processes as ther-apists of other orientations but name and understand themdifferently. For example, in Wilkins (1997a: 38) I point out thatsome of the many processes described as `countertransference'may, in terms of person-centred theory, very well be described asempathy.

As yet, there is no more proof for one theoretical positionthan another. To argue against one theory as if another were

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proven is illogical and spurious. Additionally, it isn't thatperson-centred practitioners are ignorant of transference phe-nomena but that there is an alternative explanation for themand different ideas about the relevance of transference topractice.

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46The non-directive attitude is a fiction and anirresponsible denial of power

The principle of non-directivity is the bedrock of person-centredtherapy (Point 5). However, this is sometimes criticised as adenial of the inevitable greater power of the therapist in thetherapeutic relationship and/or as a practical impossibility. Inthe ®rst place, it is argued that because therapists are investedwith knowledge and expertise and the client has neither, it is theformer who has control of the session. Thus there is an inevit-able imbalance of power. Indeed, because the second of Rogers'conditions requires that the client is at least to some extentvulnerable and anxious and this is likely to provoke and invokefeelings of powerlessness and a sense of a lack of control,person-centred theory may even seem to con®rm this inevit-ability. In these circumstances, whether therapists wish it or not,at least some clients are likely to follow what they perceive to bedirections from them. So, the argument goes, for person-centredtherapists to pretend they are non-directive is to deny reality andleads to an avoidance of the issue of the power imbalance in thetherapeutic relationship. Also, it is argued that therapists haveskills, knowledge and experience that they are professionally andethically obliged to employ to the client's advantage. This issomething person-centred practitioners are assumed to avoidand in so doing deprive and disadvantage their clients. All this isrooted in a misapprehension as to what in person-centred theoryis meant by non-directivity.

In one of Rogers' earliest works (Counseling and Psycho-therapy, 1942), he wrote a chapter entitled `The directive versusthe nondirective approach' (see Kirschenbaum and Henderson1990a: 77±87). In essence, the difference between these two posi-tions relates to who chooses the client's goals. In person-centredtherapy, a non-directive stance relates ®rst and foremost toclients' right to choose their own life goals even if these con¯ict

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with the view of the therapist. The belief is that clients haveinsight into themselves and their problems and are best placed tomake the right choices at the right time. This is about trusting theactualising tendency (Point 9). However, according to Kirschen-baum and Henderson (1990a: 62), Rogers did come to fear that anon-directive approach had come to emphasise particulartherapist techniques at the expense of therapists' attitudestoward the client. From this it can be inferred that non-directivityis less to do with particular therapist behaviours (such as con-®ning responses to `re¯ection') and everything to do with thetherapist's recognition of the client as an autonomous personwith a unique personal wisdom. The clients are the experts ontheir own lives and ways of being in the world.

Arising from all this, there seems to be a misassumption thatperson-centred practitioners are relatively passive, respondingonly to direct input of some kind from their clients ± speci®callyby merely re¯ecting the client's words. This in turn leads to thebelief that anyone can practise person-centred therapy. How-ever, it has been clear from the earliest days that person-centredpractice does require and depend on considerable knowledgeand expertise at least in the sense of adherence to a form ofpractice rooted in a belief in the actualising tendency and atwhich the necessary and suf®cient conditions lie at the heart.With respect to expertise, the issue is about power, mystique andtheir misuse.

The non-directive attitude remains at the heart of classicalclient-centred therapy. In this and related forms of practice,clients formulate their own goals and therapists are companionson the journey, not leaders. Person-centred therapists cannothave goals for their clients, cannot presume to know what out-comes are desirable for them. It is by tracking clients' subjectiveexperiences (empathically, acceptingly and congruently) thatperson-centred therapy `works'. What matters most is not whatis said or done by the therapist but what the client experiences,i.e. it is an essential precept that the ef®cacy of person-centredtherapy depends on clients perceiving themselves as not beingdirected to a particular course of action, belief or code ofconduct. Within the broad spectrum of person-centred practice,there are different ways of achieving this aim.

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47The concern for power in the therapeuticrelationship shown by person-centred therapists ismisconceived and misdirected

As indicated in Points 5, 6 and 37, the issue of power has longbeen considered as important in the practice of person-centredtherapy. At the very heart of the approach lies the therapist'seschewal of the direction and domination of the client. However,this appears to con¯ict with what is generally agreed to be aninherent imbalance in the power dynamic in which the therapisthas knowledge and expertise and the client is vulnerable andanxious. Also effective person-centred therapy depends on ther-apists being fully present as powerful people. However, ratherthan denying their power in a relationship person-centredtherapists are required to be acutely aware of it and to exercise itin a constructive, in¯uential way. It is also hoped that as thetherapeutic relationship develops, as the result of increasedreciprocal trust, there is a move towards the sharing of poweror, more correctly, the establishment of a co-operative andcollaborative endeavour in which therapist and client are equalalthough they have different aims, focus on different things andfunction differently. That is to say, in the person-centred rela-tionship `equality' is not about being the same but being of thesame worth.

For at least some outside the approach this belief in thedesirability and achievability of equality within the therapeuticrelationship solely through reliance on the necessary and suf®-cient conditions is a naõÈve (and potentially dangerous) myth. Thisview may be summed up as `therapists enter into relationshipswith clients determined to change them. This is powerfullymanipulative. To deny this is hypocritical'. However, as alreadypointed out, person-centred therapy does not involve therapistsrelinquishing their power. To do so would be incongruent andtherefore clearly counter-therapeutic. Moreover, it is a theoretical

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precept backed by empirical observation that when, in theabsence of direction, clients are met congruently with empathicunderstanding and unconditional positive regard they do changeand this change involves an increased sense of their own power,an internalisation of their loci of evaluation.

There is a problem here. Clearly, by offering clients thetherapist conditions person-centred therapists are seeking toin¯uence them even if not to direct them. This is about beingpowerful even if the direction and endpoint of change are not anissue for the therapist. This relates to what Proctor (2002:87±97) calls `role power'. However, while recognising the inher-ent power imbalance in the roles of therapist and client, she(p. 87) points out that, through the non-directive attitude,person-centred therapists seek to avoid client disempowerment.This is an important distinction. It is possible and desirable toexperience personal power without exercising authoritarianpower ( power over). It is this refusal to disempower the other, totake responsibility for the course and direction of the thera-peutic encounter that allows the emergence of `power-from-within' (see Proctor 2002: 90), however weakly experienced upto that point.

Perhaps part of the problem with respect to power is thedifferent ways in which this can be understood. In our prevailingculture we tend to think of power in terms of authority, controland supremacy. In this understanding, power is about gettingyour own way almost regardless of the cost to others. There areother ways of conceiving of power. Bozarth (1998: 21) arguesthat, from a person-centred perspective, `power' is closer to itsLatin roots ± posse is `to be able'. He is of the opinion that inthis reading to be powerful is to be all you are capable of being.Writers in¯uenced to at least some extent by feminist principleshave also offered elegant analyses of power and its manifesta-tions (see, for example, Marshall 1984; Natiello 1990; Proctor2002). Essentially, the views expressed by such authors are thatnot only is there authoritarian power over others, there is per-sonal power (power from within) and collaborative power. Thelatter is joint enterprise, openness with respect to information,responsiveness to the needs of all, mutual respect, co-operationrather than competition and personal empowerment. It is these

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notions of collaborative power and power as a force movingpeople towards what they can be that are the heart of person-centred therapy.

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48Person-centred therapy is a palliative for theworried well but lacks the depth and rigour to dealwith people who are `ill '

A popular view of person-centred therapy is that it is mild andinoffensive, great for people who want and need little more thana sympathetic ear but, in reality, anodyne and weak so of little orno use to anyone with real mental distress. People with mildneuroses and acute but everyday problems may gain somethingfrom the opportunity to just talk to someone who will listen in anon-judgemental way but person-centred therapists lack theknowledge and skills to deal with deep-rooted psychologicalproblems. Paradoxically, another view held by (for example)Kovel (1976: 116) is that person-centred therapy is adequatewhen working with people who are so deeply disturbed anddysfunctional as to be `unsuitable' for psychotherapy (groundwhich, via pre-therapy and contact work, person-centred therapyhas proudly claimed for its own ± Point 34). What both theseviews amount to is the assumption that person-centred therapy isa palliative but that it is ineffective with people experiencingdeep-rooted emotional distress. Even though there is an increas-ing recognition that person-centred therapists do work withpeople who may be called mentally ill this is seen as a recentdevelopment and the old myths persist. In reality, at least fromthe days of the Wisconsin project in the 1960s which involvedinvestigating the ef®cacy of person-centred therapy with peoplediagnosed as `schizophrenic' (see Barrett-Lennard 1998: 267±270), there has been evidence of person-centred practice withpeople who may be described as `severely disturbed'.

In part, questions about the ef®cacy of person-centred therapywith people experiencing extreme mental and/or emotional dis-tress go back to the sterile argument about the difference between`counselling' and psychotherapy (see Wilkins 2003: 100±104).For the most part, because it is the client who determines the

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nature, duration and `depth' of the therapeutic relationship,person-centred therapy admits of no such difference. This doesnot mean that person-centred therapists do not do what othersmay call `psychotherapy'. Even a fairly cursory glance at theperson-centred literature will demonstrate this. There is a body ofwork addressing a person-centred take on psychopathology(Point 33) and person-centred therapists have published accountsof their work with people who are (amongst other things) contactimpaired (Point 34), experiencing dif®cult process (Point 36),diagnosed as `borderline', `psychotic', having a `personality dis-order' and so on (see Lambers 1994: 105±120). More recently,Joseph and Worsley (2005) and Worsley and Joseph (2007) haveproduced two edited volumes addressing the theory and practiceand research evidence for person-centred practice with peopleexperiencing a variety of `psychopathological' ways of being inthe world.

While, in the English-speaking world, evidence for the applic-ability of person-centred therapy to working with people experi-encing extremes of emotional and mental distress does seemto have been in short supply from the 1960s until the end ofthe twentieth century, there is suf®cient published work todemonstrate that person-centred practitioners do not con®netheir work to the `worried well'. Alongside developing practicehas been developing theory. It is now clear that person-centredtherapy is at least as effective with `psychopathological' states asany other approach.

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49Person-centred practice comprises solely`reflection' and this is a technique of little effect

At least super®cially, the practice of classic client-centredtherapy can appear to be little more than parroting the client'swords. Sometimes this referred to as `re¯ecting'. However, this isin some ways an unfortunate term. Although, when faced with atherapist who represents what they have said, this may be likehaving a mirror held up to them the better that they canunderstand what they said this is not the intention of person-centred therapists. Rogers (in Kirschenbaum and Henderson1990a: 127±128) was clear that when he con®ned his responsesto the frame of reference of the client he was not trying to`re¯ect feelings' but ascertaining that he had heard and correctlyunderstood the client's communication. In such `re¯ective'responses therapists are asking the implicit question `Have Iunderstood you? Is this what you are experiencing?' Moreover,when such responses are made in an accepting way there is animplicit assertion from the frame of reference of the therapistwhich is something like `I understand the feelings you areexperiencing, the events you are describing and something ofhow it is to be you in this moment and this knowledge does notalter my perception of you as a person of worth.' Of course,person-centred therapists respond not only to expressions offeeling but to expressions of other kinds including thoughts,bodily sensations, fantasies, memories and so on.

Exactly what person-centred therapists are doing when they`re¯ect' is actually quite sophisticated and far from trivial.Indeed Rogers (in Kirschenbaum and Henderson 1990a: 127)quotes Shlien as saying that, in the right hands, re¯ection is `aninstrument of artistic virtuosity'. Re¯ection is at the heart ofperson-centred practice because it is about being non-directive(Point 5) and communicating the therapist conditions. If, whenre¯ecting, the therapist's intention is to hold a mirror up to the

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client so that they may see themselves (with the notion thatsomething will happen as a result) then what is going on hasmoved away from attempting to understand the client's experi-ence and to communicate this with empathy and unconditionalpositive regard and moved into responding from the therapist'sframe of reference. In some way and on some level `mirroring'responses are the results of the therapist taking the decision thatthe client should see/hear something of what the therapistbelieves them to have expressed. This is in effect `doing' some-thing to clients rather than accompanying them on their jour-neys and so moves away from their perceptual worlds. However,if the intention is to check therapists' perceptions of what isbeing experienced and to offer empathy and unconditionalpositive regard then this is the non-directive attitude in action.

Person-centred therapists are not con®ned to re¯ecting onlythe words of the client. An aim in the therapeutic encounter is tounderstand and respond to the whole of the client's experience.Quite a lot of what we perceive of communication is aboutsomething other than the words spoken per se. Non-verbalcommunication and empathic sensing may also tell something ofthe client's way of being in the moment. This too can be`re¯ected'. Again, the aim of therapists is to check their percep-tions of unvoiced feelings, scary thoughts and the like. However,it is important that such responses do relate to the client'sexperience and are not the result of some interpretation on thepart of the therapist.

In person-centred therapy there can be no delving into the`unconscious'. Even if the therapist perceived unconsciousmaterial unavailable to the client (which is probably impossiblefrom a classical client-centred point of view), because it wouldnot be recognised or owned and more importantly because itwould be directive, it would be mistaken for the therapist tooffer what amounts to an interpretation. However, there is anotion of the `edge of awareness' (see Rogers 1966: 160 andMearns and Thorne 2007: 78±82). Brie¯y, this concept involvesthe assumption that there are things (thoughts, feelings,sensations, intuitions) just below the threshold of awareness.Sometimes, these can be perceived or empathically sensed by thetherapist and when they are re¯ected the client experience is

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instant recognition: `Yes ± that's it!' Responding to `the pool ofimplicit meanings just at the edge of the client's awareness'(Rogers 1966: 160) is contentious and certainly requires caution.However, it is clear that working with `edge of awareness'material by making `re¯ections' is part of the person-centredtradition.

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50Because of its obsession with `non-directivity' thepractice of person-centred therapy results inharmfully sloppy boundaries

Person-centred therapists have been accused of an apparentprofessional and ethical laxness because of an assumed disregardfor boundaries inherent in person-centred theory. To a largeextent, this is the result of a misunderstanding of just who isperson-centred and a confusion of the behaviour of individualswith what person-centred practice actually involves (see Wilkins2003: 121±122). In reality, how person-centred practitionersoperate with respect to boundaries is, for the most part, nodifferent to therapists of other orientations. However, it is truethat, from a theoretical perspective at least, because of the con-cern with power (Points 5, 6 and 37), the stance of person-centred therapy with respect to `boundaries' is different fromsome others. This is about the non-directive attitude and thestance of person-centred therapists as `non-expert' with respectto the client's process.

A lot of structural boundaries in therapy are a matter ofconvention and/or imposed by the therapist (for example, theduration and frequency of sessions, the length of contracts,where and when meetings take place). However, there is nothingin person-centred theory that delimits where, how often andunder what conditions `therapy' takes place. Given the centralityof the client's experience to person-centred therapy and the non-directive attitude of its practitioners, it would seem that person-centred theory indicates the desirability of ¯exibility with respectto at least some boundaries. Because of the history of thedevelopment of counselling and psychotherapy, a lot of whathas come to be accepted as desirable or even mandatory aboutboundaries is rooted in psychodynamic theory and practice (seeWilkins 2003: 124±125). Person-centred theory is based onentirely different premises and to judge it on the basis of other

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models of the person and nature of therapy is mistaken andunfair. Nevertheless the person-centred therapist has rights andpreferences and ethical obligations, any or all of which must betaken into account in the setting and operation of structuralboundaries (see Wilkins 2003: 128). It may be that, for sometherapists, working with some clients, some of the time it isappropriate to move beyond the conventions of meeting for anhour, once a week in the therapist's room but this is somethingto be carefully considered and preferably discussed in super-vision and/or with colleagues beforehand.

Primarily, it is with respect to `power' and client autonomythat person-centred therapy may differ most from otherapproaches. Because clients are deemed to be the best expertson their own lives and driven by their actualising tendencies inthe direction of positive ful®lment of their potential, the person-centred therapist cannot ethically take responsibility for theclient. To take such responsibility would be to impose the will ofthe therapist and to deny the client the right to exercise (or failto exercise) personal power. That is, it would be directive.However well-intentioned the direction, by de®nition, it wouldbe counter-therapeutic and, arguably, unethical. This has impli-cations with respect to (for example) who ends therapy, how itends and what are the responsibilities of therapists towardsformer clients. Conclusions with respect to such issues may verywell be different from those held in other approaches. Essen-tially, from a person-centred perspective, within a given ethicalframework, what is important about boundaries is that they arefunctional, allowing a justi®able ¯exible response to particularclients rather than structural ± that is boundaries as a set ofpredetermined behaviours (see Mearns and Thorne 2000: 48).

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Section 5PERSON-CENTRED

PRACTICE

Subsection 5.1The foundations of

person-centredpractice

51Responsible person-centred practice requires astrong theoretical foundation and particularattitudes and personal qualities

Beginning and continuing person-centred practice involves morethan acquiring theoretical knowledge and practical skills. Incommon with approaches there are many things to consider anddo before proceeding to the meat of the therapeutic encounter.

Of course, there is a need for appropriate training and thisshould include the acquisition of practical skills and a thoroughgrounding in person-centred theory as set out by Rogers, hiscolleagues and successors (Sections 2 and 3, Point 53). However,there is more to being a person-centred practitioner than this.Person-centred practitioners tend to talk of `being person-centred' as if it is not only a way of doing therapy but of being inthe world. While, arguably, it is possible to be a client-centredtherapist without being a `person-centred person' (that is carryingthe values and attitudes of the person-centred approach intoendeavours and encounters other than therapy and perhaps to thewhole of life) person-centred practice does involve embracing aphilosophy (at least in the lay sense of the word). Something ofthis philosophy is discussed in Point 4. What ¯ows from thisphilosophical stance is a deep respect for people as autonomous,intrinsically healthy beings, a commitment to the non-directiveprinciple (Point 5) and a willingness to eschew `power over'(Points 6 and 37). Effective person-centred training will probablyaddress all of these things.

Even for the experienced person-centred practitioner theseattitudes remain fundamental to day-to-day practice and are atits core. Although preparation for practice is an issue in anyapproach to therapy, person-centred theory and practice empha-sise some different things and most things differently. Thissubsection is about the groundwork person-centred therapistsmust do.

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PERSON-CENTRED PRACTICE

52Person-centred practice takes place in manycontexts and the terms `counselling' and`psychotherapy' apply to some of these but areoften interchangeable

Person-centred principles have been and are applied to many®elds of human endeavour. They are, after all, about a way ofbeing in relationship and this has an important part in (forexample) education, social, political and cultural change, workwith families and children and even research but most famouslyit is known as a way of doing counselling and psychotherapy.However the principles are applied, the theory and practicedescribed as relevant to therapy are likely to be of importance.

The term `counselling' has many different meanings in differ-ent cultures. Even in the UK there is not complete agreement asto what the term means. All of this leads to different assump-tions as to what a counsellor actually does. `Counselling' mayeven include the giving of advice or even a disciplinary function.Neither is there agreement as to the exact meaning of the term`psychotherapy'. With respect to person-centred therapy, thesituation is different again for, in terms of theory, there is nodifference between counselling and psychotherapy. That is, theyare not (for example) distinguished by notions of the degree of`depth' or duration. Person-centred practice is about therapistsresponding to clients and the client's subjective experiencewhatever it may be in the same way and with the same intentwhether they are being told about acute mild anxiety or the gut-wrenching, chronic pain of horrendous early abuse. In otherwords, regardless of what the client brings to the therapysession, the therapist relies upon the body of theoreticalknowledge set forth in the earlier part of this book and else-where and responds congruently with empathic understandingand unconditional positive regard. At least from a person-centred perspective, perceived differences between counselling

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and psychotherapy are cultural, historical and political and stemfrom vested interests.

Ultimately, disagreements as to the differences betweencounselling and psychotherapy are sterile because they rest ondifferent de®nitions. That is there is a basic assumption that`psychotherapy and counselling are the same (or different)because I believe them to be'. This leads to fruitless, circulararguments. However, within the person-centred world the twoterms are used in such a way as to imply that they are differentin some ways. For example, the lead international organisationfor the approach is the World Association for Person-Centeredand Experiential Psychotherapy and Counseling and some train-ing organisations allow people who complete training in person-centred counselling to go on to do a further period of trainingto qualify as person-centred psychotherapists. There is noagreement as to what the difference might be and, rather thanuse either term, many person-centred practitioners refer to whatthey do simply as `therapy'. It is the practice of a person-centredway of working and in particular person-centred therapy withwhich this section of the book is concerned. However the prac-tice is described, the same principles apply.

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53The first step towards person-centred practice is athorough grounding in person-centred theory

One of the great and potentially dangerous myths about person-centred practice is that it is in some way `theory free' and thattherefore almost anyone can do it on the basis of very littleknowledge. The belief is that person-centred therapy is easy tolearn ± it is just a matter of being friendly and understanding.Actually there is a big difference between being a person-centredtherapist and acquiring a set of skills derived (often somewhatloosely) from the thought and practice of Carl Rogers. Prac-tising in a person-centred way requires a great deal more than apassing acquaintance with the so-called core conditions. While itis true that during the therapeutic encounter the focus of thetherapist must be on the client's current experience rather thantheoretical interpretation this can only be done effectively andsafely when the therapist has a real understanding of person-centred theory. What is needed is a thorough grounding in allaspects of person-centred theory, a real understanding of thepracticalities of relating to clients, a deep commitment to anethical stance which includes respect for the client as a self-determining person, attention to the self-development of thepractitioner probably including extensive experience in a peergroup and many hours of supervised practice. The best way ofachieving this is to attend a training course acknowledged asperson-centred by the person-centred community. Courseswhich include `person-centred counselling' as a core model donot necessarily offer a full training in person-centred therapy.Effective practice as a person-centred therapist should includenot only knowledge of the necessary and suf®cient conditionsbut also (for example) of the person-centred model of the personand the need for positive self-regard, the roots of and reasonsfor the non-directive attitude, an understanding of and belief inthe actualising tendency and appreciation of how conditions of

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worth arise and how they affect development. A good place tostart with all this is to read the classic works of Rogers (forexample, 1951, 1957, 1959) and also the re-presentations of thisbasic theory by (for example) Mearns and Thorne (2000 and2007), Merry (2002) and Sanders (2006b).

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54Person-centred practitioners work with clients, notpatients

Although it might seem inconsequential and common to manyapproaches to therapy, the fact that person-centred practitionersrefer to the people they work with as clients rather than patientsis signi®cant. The term `client' was originally used by Rogers in1940 and he intended it to indicate a therapeutic relationship ofa different kind to that common up to that time. Although it isnow often taken for granted, the notion of working with `clients'embodies much of the person-centred attitude and stancetowards people. It is about seeing them as autonomous and self-determining. Additionally, whereas `patients' are `sick' and aredependent on medical practitioners for a cure, person-centredtheory does not allow that people who seek the help of a ther-apist are in need of diagnosis and expert guidance. Rather thereis the explicit knowledge that each of us contains within us theseeds of our own growth and healing. We may need a com-panion but never someone to take over and decide what iswrong and how to put it right. It is not the expertise in terms ofskills, techniques and interpretations of the therapist which arehelpful but the ability to embody the attitudes of congruence,empathic understanding and unconditional positive regard. Inits time, this was a subversive, revolutionary move away fromthe prevailing medical/psychiatric model and, in many ways, itremains such.

What this attitude means for practice is highly signi®cant. Itis axiomatic that the client's process is trustworthy and that allindividuals are to be respected. Conveying this from the outsetand throughout the relationship is a primary responsibility ofthe person-centred therapist. This means thinking about howclients are met and greeted, how the terms of a contract(including fees) are presented and (if possible and relevant)negotiated, the layout of the room in which the therapeutic

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encounter will take place and so on. Each of these things (andothers) contributes to the client's sense of being respected,valued and trusted. Although there are some obvious things (forexample avoidance of furniture and the arrangement offurniture that conveys differences in status ± no little chair forthe client facing a big chair behind a big desk for the therapist!),it is impossible to be prescriptive about these things because notwo therapists are alike and our settings and circumstances vary.What is important is that, within whatever constraints there maybe, therapists ®nd ways of warmly and congruently indicating totheir clients the collaborative and non-directive nature of thetherapeutic relationship.

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55An objective of person-centred practice is to offera healing relationship. This comprises severalingredients including the six necessary andsufficient conditions

In a way, it goes without saying that person-centred therapy is ahelping relationship, the objective of which is to offer the clientopportunities for healing and growth ± this is the aim of coun-selling and psychotherapy as a whole. However, person-centredtheory has a particular take on how this can be done in practice.The necessary and suf®cient conditions resulted from the empiri-cal observation of what actually does promote `constructivepersonality change'. Basically, this amounts to an understandingthat it is the quality of relationship that matters, not expertknowledge and the application of technique. There is a great dealof support for the conclusion that what clients ®nd helpful is acaring, respectful, understanding relationship in which they canexamine and analyse their thoughts and feelings withouthindrance or interference (see, for example, Howe 1993; Proctor2002: 89±90). The ®rst task of the person-centred practitioner isto offer a relationship of this quality. The foundation stone forthis is the therapist's attitude and commitment to the non-directive attitude and a belief in the client's actualising tendencyand (therefore) trustworthy process. From this attitude andbelief stems the desire and ability to implement the six necessaryand suf®cient conditions (not just the so-called `core con-ditions'). This is because, although the therapist-provided condi-tions of congruence in the relationship, empathic understandingand unconditional positive regard are vital, it is only in thecontext of the contact between client and therapist, the anxietyand vulnerability of the client and the client's reception andperception of the therapist's respect and understanding that theyare effective. To lose sight of any one or more of the necessaryand suf®cient conditions is to risk losing an understanding of

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what is happening in the relationship as a whole and the needsand perceptions of its participants. Instead, concentrating onlyon the core conditions is equivalent to paying attention only tothe behaviour, feelings and intentions of the therapist. Thequestions become Àm I congruent/empathic/accepting' ratherthan Àre my client and I in contact?', `Does my client needtherapy and is what I can provide likely to be useful (i.e. is myclient not only incongruent in our relationship but vulnerableand/or anxious)?' and Ìs my client perceiving empathy andunconditional positive regard from me?' Concentration on thetherapist-provided conditions changes what is going on from arelationship to something the therapist does to the client.

Another danger of relying solely on being congruent in therelationship and providing empathy and UPR is that these aretransformed from relational qualities which are part of acomplex collaborative and co-created relationship to therapist-provided skills ± something `done to' the client rather than away of being in relation to the client. This is detrimental to thehealing relationship because that is about not just the therapistbut what both client and therapist bring to the relationship andhow they collaborate to co-create it. Also, it may in any case bea mistake to think of the therapist-provided conditions as threedistinct entities. Although in his classic statements of thenecessary and suf®cient conditions Rogers chose to identify andcharacterise three therapist-provided elements, it is likely thatthis was to allow for the description of what many believe to bein reality one thing (Point 14). Certainly, when it comes to thephenomenon of `presence' (Point 25) and working at relationaldepth (Point 38), separating these conditions seems to beirrelevant and possibly to interfere with the healing relationship.

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56Because person-centred therapy relies on how thetherapist is rather than what the therapist knows,there is professional obligation on person-centredtherapists to attend to their own growth anddevelopment

The importance of a thorough grounding in theory to thesuccessful practice of person-centred therapy has already beenindicated (Point 53) but this alone is not suf®cient to ensure thattherapists can offer an effective relationship. Because person-centred therapy emphasises the importance of not only the`person' of the client but also the person of the therapist, there isa professional obligation on the latter to attend to personalgrowth and development. Just as an athlete keeps in andimproves physical condition by exercise and training so, for thegood of their clients and their own health, person-centredtherapists are strongly advised to attend to their psychologicaland emotional well-being. However, whereas an athlete keeps intrim to avoid loss of muscle tone and strength, the objective ofthe person-centred therapist's attention to psychological well-being is, for example, to avoid `burnout' (see Mearns 1994: 29±33) and a subsequent decrease in effectiveness and quite possiblyillness.

Of course, this is not unique to person-centred therapy butwhereas some other approaches include de®nite ideas as to theplace of personal therapy in training and in continuing pro-fessional development (CPD) in principle person-centredapproaches are not prescriptive about this. However, it is likelythat programmes of person-centred training will include someform of personal development as well as professional training.This may serve as grounding for further development in thecourse of practice. The aim of personal development is to enabletherapists to increase their ability to work effectively with clientsin ways that are safe for both parties and to incrementally

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increase this effectiveness. It is about dealing with blind spots andlimits to unconditional positive self-regard so that it is possible toencounter the pain of clients empathically and with uncondi-tional positive regard. It is also about maintaining the energy andenthusiasm that effective person-centred therapy demands.

Working intensively with clients can be stressful and it iscertainly demanding of the personal resources of the therapist.This stress can be ameliorated through supervision and thesupport of colleagues but effective working necessitates positiveand proactive steps on the part of the person-centred therapistto engage in rest and recreation. This is because the symptomsof burnout include a decreasing ability to be congruent sincethere is an increasing need on the part of the practitioner toprotect and preserve those parts of the self-structure that areexperienced as under almost intolerable pressure. The need to becongruent in the relationship is one of the six necessary andsuf®cient conditions, all of which are needed for constructivepersonality change to occur. Without congruence on the part ofthe therapist then the prospect of therapeutic change is limited.Also, when under such stress, the therapist is likely to becomemore problem-focused than client-centred (because the formerseems more tractable and/or less demanding of the personalresources of the therapist) and more rigid with respect to con-tracting boundaries. This involves signi®cant loss of the abilityto empathise with the client and will almost certainly be experi-enced as lacking unconditional positive regard. These things alsoamount to a signi®cant move away from a non-directive attitudetowards directivity. Again, there is a con¯ict with the demandsof person-centred theory. There may even be a tendency tobecome increasingly self-deceptive with respect to the ef®cacyand depth of client work. Mearns (1994: 31) writes about thepossibility of person-centred therapists reacting to burnout bybecoming over-involved with their clients, presenting themselvesas powerful or even omnipotent agents of change rather than asfacilitators of the client's own change process. This is, onceagain, a move towards a directive, `expert' stance involvingdecreased empathy (because it is about the therapist's frame ofreference) and unconditional positive regard (because it involvesenvisaging and imposing the therapist's `solution'). The possi-

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bility of burnout is a matter for supervision but its preventionand `cure' is about attention to personal development.

Just as because it is based on client need and the client'spersonal process of change, it is impossible and undesirable to beprescriptive about ways in which the personal and professionalgrowth of person-centred therapists should be done. Each of ushas different qualitative and quantitative development needs atdifferent times. Personal therapy of some kind is a traditionalresource for therapists because it includes the maintenance ofpsychological, emotional and spiritual well-being, increasingunderstanding of human nature and personal growth. Otherways of doing this include spiritual or meditative practice, sys-tematic re¯ection on personal experience (for example throughdream-work or journal keeping), reading creative or imaginativeliterature and creative approaches to relaxation (see Wilkins1997b: 123±142).

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Subsection 5.2The initial processes

of person-centredtherapy

57In person-centred therapy, getting started with anew client is an involved and involving process

Although in the eyes of some, person-centred therapists are seenas `casual' or even cavalier in their attitudes to practice, parti-cularly with respect to contracts and boundaries, beginningtherapy with a new client in fact requires that the therapist con-siders a number of issues and carries out a number of processesconcerned with these very things. This includes an assessmentprocess (although many person-centred practitioners neither callit such nor think of it in that way ± Point 32), `contracting', thatis agreeing with the client the terms and conditions of therapyhowever ¯exible these may be, and also considering and beingexplicit about the boundaries to be imposed by the therapist and/or by the institution or service under the auspices of whichtherapy will be offered. All of these involve a careful considera-tion of ethical and professional issues and they are addressed inthe following Points. It is in the nature of person-centred therapythat exactly what is done and how it is done will vary for eachclient/therapist relationship. Person-centred therapy is about theencounter of two individuals, a meeting of persons, and so eachbeginning is idiosyncratic and not about working methodicallythrough a checklist. However, there are professional and some-times institutional obligations to be sure that the client is clearabout what is likely to happen and what the limitations of theoffer of therapy are.

However it is done, the process of `initiating' therapy is notsome stand-alone element, a separate thing to be done ®rst andsomething different from therapy proper. A ®rst meeting with aclient may be described as an assessment meeting or a contractingsession (and this may very well be a necessary aspect of it) but it isvital to realise that the therapy relationship begins at the momentof ®rst contact (which may even be before a face-to-face meet-ing). Therefore, the therapist must be available to the client as a

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respectful, full and present person even if there are administrativetasks to perform. Whatever else happens, it is essential that theclient's needs are not overridden by the therapist's need to get thepaper work in order and to tick all the necessary boxes. Even inthis process, person-centred therapists should pay attention totheir clients and respond with unconditional positive regard andempathic understanding. First-time clients and even ones with agood understanding of the therapeutic process tend to be uneasyand anxious at the ®rst meeting with a therapist. If the therapistis over-concerned with gathering or passing information it islikely that the client will be deterred (because some of the client'smore subtle or tentative expressions of need are missed) and/orthat they will miss something the therapist thinks is important.In these early stages, just as in an established therapeutic rela-tionship, the therapist's primary responsibility is to enter theexperienced world of clients in such a way as to meet them withgenuineness, warmth and understanding.

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58Contracting and structure in person-centred therapy

As Tolan (2003: 129) notes, all relationships have rules and, ofcourse, this includes the relationship between therapist and clientin person-centred therapy. These rules include those to do withboundaries of time, space and allowable behaviour (from eitherparty and between them), the issue of con®dentiality and perhapshow and by whom payment will be made. These rules are aboutsafeguarding the client and the therapist and perhaps aboutmeeting the needs of the institution or organisation under theauspices of which therapy takes place. It only takes a moment torealise that at the outset, most of these rules are likely to beknown by the therapist but not by the client. One of the initialtasks of therapy is to make them explicit and to agree how theywill operate.

Imposing rules and conditions from the frame of reference ofthe therapist can seem like a contradiction of the principleof non-directivity and the autonomy of the client. However,although the terms `person-centred' and especially `client-centred' seem to imply an emphasis on the rights and desiresof the client, this does not mean that this is to be achieved at theexpense of the rights of the therapist. It is the relationship whichis the agent for change and this involves two people. A healingrelationship will only be created when the needs of both partiesare met. One of the duties of person-centred therapists is toensure their continued well-being so that they are able to beavailable as congruent, empathic and accepting people to alltheir clients. This means that they must structure their sessionsin such a way as to preserve and protect themselves while stillbeing fully available to their clients. This is one of the thingsboundaries are for. That said, there is room for ¯exibility inperson-centred therapy and rules are not necessarily rigidlyimposed once and for all. Person-centred therapy is a process ofnegotiation and re-negotiation. It is the co-creation of a healing

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relationship. However, it is the task of the therapist to lay downthe ground on which this co-creation can proceed.

From the moment of ®rst contact with a client, it is incum-bent on person-centred therapists to make an explicit statementof the `rules' which will govern the relationship. This includesobvious things like where and when meetings will occur andfor how long, payment, what to do about cancellations and soon. This is what Tolan (2003: 130) calls the `business contract'but she also draws attention to another aspect of contracting,the `therapeutic contract'. By addressing the needs and expec-tations of the client and the role of the therapist, this involvesthe beginnings of the equalisation of power deemed desirablein person-centred therapy. In the beginning stages of therapy,the therapist has a lot more knowledge about what is likelyto happen and how it may happen than does the client. Knowl-edge is power. One way of ameliorating this imbalance is to`demystify' the process of therapy by explaining something ofwhat will happen including the responsibilities of the therapist.

Because (by de®nition) clients are vulnerable or anxious theyare unlikely to take in every aspect of what they are told aboutthe contract they are embarking on in a `contracting session' soit is good practice to have at least the essential points in theform of an information sheet. This sheet can be given to theclient before the ®rst meeting, during it or at the end but when-ever this happens the client can be encouraged to read it and toask questions about its contents. The person-centred therapist'sjob is then to respond to the things that the client asks about butnot necessarily to go into detail about what is not questioned.However, these may be raised later and should, of course, beaddressed then.

However it is done and whatsoever its content, the contract-ing session is not something which stands outside therapyproper ± it does not occur before establishing a therapeuticrelationship, it is part of the process of doing this. Therefore,even the `business' aspects of contract setting are conducted inaccord with the necessary and suf®cient conditions. It is verylikely that even in this process clients will be communicatingsomething of their needs and/or ways of being ± this is to beresponded to appropriately.

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59Assessment in person-centred practice

Alongside the contracting process, the initial stages of theperson-centred therapeutic relationship will involve some sort ofassessment process. The theoretical arguments for and againstassessment and diagnosis in the context of person-centredtherapy were made earlier (Point 32). While diagnosis is seen asunnecessary, unhelpful and even potentially harmful to thecourse of person-centred therapy, assessment of the client isviewed similarly. However, in practice many, if not most, person-centred practitioners do make an assessment of the likelihoodthat they will be able to offer a relationship including Rogers' sixconditions to the particular client, at the particular time, in theparticular place even if they call it something else. This is some-thing other than diagnosis and the emphasis is on the (potential)relationship not the client. Under the right circumstances, theclient will make constructive personality changes. Any limitationto this prospect is more likely to lie with the therapist and, in away, part of person-centred assessment is the gauging of thetherapist's ability by the therapist.

One way of assessing the likelihood of successful person-centred therapy is for the responsible therapist to ask a series ofquestions based on the necessary and suf®cient conditions.Thus:

1. Are my potential client and I capable of establishing andmaintaining contact?

2. Is my potential client in need of and able to make use oftherapy? That is to say, is my potential client in a state ofincongruence and vulnerable and/or anxious?

3. Can I be congruent in the relationship with my potentialclient?

4. Can I experience unconditional positive regard for thispotential client?

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5. Can I experience an empathic understanding of the poten-tial client's internal frame of reference?

6. Will my potential client perceive at least to a minimal degreemy unconditional positive regard and empathy?

If the answer to one or more of these questions is `no' thenthe necessity for the six conditions has not been met and, byde®nition, therapeutic change will not occur. Under thesecircumstances it is incumbent on the person-centred practitionerto address the short-coming, perhaps in supervision or, if theunlikelihood of offering an appropriately effective relationshippersists, to decline the contract. This is assessment.

An additional aid to assessment lies in the seven stages ofprocess (Point 17). These indicate a client's likely way of beingand so what is appropriate from the therapist. Although there isa great deal of variation and individual difference in clients'processes and no one is ever wholly at one stage or another,nevertheless knowing something about the client's stage ofprocess can help the therapist make appropriate ethical andprofessional decisions.

The stages of process imply that there are qualitative differ-ences and differences of intent required of the therapist dealingwith clients at different stages. For example, people in stages 1and 2 are unlikely to willingly enter therapy or, if they do, areunlikely to stay. People in stage 3 are likely to commit to acounselling contract but perhaps without fully understandingthe implications. Such clients need to be fully accepted as theyare if they are to progress to subsequent stages. It is probablethat empathic responses con®ned to the client's apparent andcurrent experiencing are likely to be most effective. People instages 4 and 5 constitute the bulk of clients. They have someinsight and an agenda for change. Here, responding to edge ofawareness material (Point 22) and working at relational depth(Point 38) become possible and `presence' (Point 25) mayspontaneously occur. Stage 6 is highly crucial. It is at this stagethat irreversible constructive personality change is most likelyto occur. The full repertoire of the person-centred practitioneris appropriate to this stage. By stage 7, the journey is more orless over ± or at least it can now take place without the

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companionship of a therapist. Reaching a judgement aboutthese things is assessment and requires appropriate action.

Together, the necessary and suf®cient conditions and theseven stages of process provide an appropriate practicalassessment scheme for person-centred therapy. They provide aguide to:

· deciding the likelihood of establishing a successful thera-peutic endeavour

· monitoring the process of therapy

· the nature of appropriate therapist responses and ways ofbeing (although this is less important).

While it is important to remember that these are guidelinesand that every relationship is unique requiring unique responses,they are essential to sound person-centred practice.

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60Establishing trust

Person-centred therapy is predicated on trust. Firstly there is theaxiomatic basic trust in the person as of worth and propelled bythe actualising tendency to achieve potential. In other words,clients are to be trusted ± given the right climate, they will dowhat they need to do as and when they need to do it. The primerequirement of person-centred therapists is to establish this trustin the potential of others. It is to this end (and others) thattraining in the approach and attention to personal growth aredirected (Points 53 and 56). The belief that the necessary andsuf®cient conditions are precisely that is fundamental to person-centred therapy. From this follows a trust in the process oftherapy. Sometimes this is expressed glibly as `trust the process'but this shouldn't be taken to imply a laissez-faire attitude isgood enough. As Tudor and Merry (2002: 145) point out, it is alsonecessary to `process the trust'. Trusting the process is about fullengagement with and an understanding of what is happening andabout being actively facilitative. However, it is a given that, forperson-centred therapy to work, person-centred therapists musttrust their clients, the process and themselves. But it is also truethat the client must be equally trusting of the same elements. Itis unlikely that clients will have a realistic trust in the therapistand the process of therapy when they ®rst present and certainlynot in their organismic experiencing (otherwise they wouldn'tneed therapy). Therefore `establishing trust' is something to beaddressed in the early stages of the therapeutic relationship.

Trust is important in the therapeutic relationship because itallows greater openness and less defensiveness. Trust is theprecursor to change. However, trust cannot be engendered inthe client by the therapist at will. To use a clicheÂ, trust must beearned and the way that person-centred therapists do this is tobe trustworthy. Trustworthiness is a product of the therapistconditions of congruence (`I am as I appear'), unconditional

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positive regard (`I see and accept you as you are') and empathicunderstanding (`I accurately sense how it is to be you'). Giventhese attitudes, clients will come to realise that the therapist doesnot intend to manipulate them into doing something and thatacceptance is not conditional. Clarity about the nature of the`business contract' (Point 58) underpinning the therapeuticrelationship is also part of the process of becoming trustworthy.Stating the boundaries of therapy and holding to them is abouttrust. Explaining the likely process of therapy and the role ofboth therapist and client (the therapeutic contract) deals withsome of the uncertainty and fears the client may have. This toohelps with trustworthiness. Any attempt to address the initialpower imbalance between therapist and client will also help.This involves openness and honesty on the part of the therapist.However, for the client to recognise the trustworthiness ofthe therapist may be a slow process. After all, for many clientstrust is a big issue. They may have learnt that to trust others isdangerous and to have incorporated this into their self concept.One way to facilitate the establishment of trust is to uncon-ditionally accept the client's lack of trust.

To re-iterate, the establishment of trust is most likely to occurin response to the therapist's genuine acceptance, warmth andunderstanding. It is likely to be gradual and to increase as theexperience of being accepted for whom and what they arebecomes more apparent to the client. In response to this, theclient will allow more experience into awareness and, as this toois accepted, so the trust will be yet deeper.

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Subsection 5.3The basic attitudes

underpinning person-centred practice

61Non-directivity in practice

Although much of what has been discussed in the previoussection and much of what will come later is either implicitly orexplicitly concerned with implementing a non-directive attitudein the practice of person-centred therapy, this is such anessential principle it is worth saying something speci®c about it.The theoretical position with respect to the non-directive atti-tude is examined in Point 5. What is important to remember isthat being non-directive is to do with accepting clients as apeople of worth and the `experts' on themselves and their waysof being in the world. However, this is not a mere philosophicalstance but a practical position involving ethical implementation.It is also something about which myths and misunderstandingshave arisen both outside and within the person-centredapproach.

Firstly, being `non-directive' is not about being passive,merely parroting the client's words for fear of de¯ecting themfrom their subjective experience of the world. Being non-directive involves actively communicating an understanding ofthe client's lived experience. Consider the following clientstatement:

I really hate myself. I am thinking of ending it all. Don't youthink that would be best?

The simplistic, misguided `non-directive' response may besomething like:

You hate yourself and are thinking of killing yourself andyou wonder if I think that would be for the best.

However, a response more in line with the non-directiveattitude would be:

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You are really struggling at the moment and feel really badabout yourself. Things are so awful that you can see nofuture and are wondering if you'd be better off dead.

Depending on what else had been expressed (tone of voice,posture, gesture, facial expression etc.) a non-directive approachcould include reference to emotions expressed other than inwords:

You are really struggling at the moment and feel really badabout yourself. When you told me that, I could see tears inyour eyes and there was a catch in your voice. Things are soawful that you can see no future and you are wondering ifyou'd be better off dead.

In the latter response, nothing has been introduced from thetherapist's frame of reference. Although there is what might be areference to the client's emotional state it is either in the form ofan observation (tears, a catch in the voice) or as a re-framing ofthe client's own words. It is possible to go further than this andto respond to the feelings expressed by the client by actuallynaming them but not going beyond them or to do so to aminimal extent:

You are really struggling at the moment and you are feelinghurt and in pain. You're so desperate and desolate that youwonder if you'd be better off dead.

This can be an effective way of doing therapy but it still isn'tquite what is meant by `being non-directive'.

Ideally, and, to be honest, not always practically, being non-directive involves the therapist in actively experiencing andresponding to the experienced world of the client. It really is thewalking in someone else's shoes sometimes used as a metaphorfor the person-centred counselling process. It is about being withand within the client's experience rather than observing it. Thisinvolves high-quality attention to the entire client and leaves noroom for analysis, diagnosis and the like from the therapist. It is

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about implementing the therapist-provided conditions in theirentirety and in concert.

Finally, as Brodley (2006: 46) pointed out, being non-directive in person-centred therapy is not about behaving in aset way but it is an attitude. While being non-directive does notpermit all forms of behaviour (speci®cally those to do withimposing the therapist's frame of reference on the client) it doesallow many and various responses to the client depending uponthe client's expressed experience (whether or not that expressionis in words).

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62Clients are the experts on themselves and areactive agents in their own growth and healing

Research evidence indicates that, in the process of therapeuticchange, much of what happens is as a result of the client'scontribution (see, for example, Bohart 2004; Bohart and Tallman1999). This can be in the form of the client/therapist relationshipand/or what are sometimes called `extratherapeutic variables'which include such things as the client's resources. That is to say,as well as responding to the therapist's congruently expressedunconditional positive regard and empathy, clients are somehowactively contributing to their process of constructive personalitychange. In effect, therapy is a collaborative effort and notsomething the therapist does to or for the client. Indeed, it mayeven be that the client is doing most of the active work.

How this seems to work is that clients are good at makingpositive use of nearly everything that happens in a therapysession. They do this, for example, by looking beyond thesuper®cial things that are said or done and respond to the moreconsistent and stable attitudes and values of the therapist andthey make positive use of whatever they can. They do this intheir own way, regardless of what the therapist may haveintended. For example, as a counselling student, I witnessed agroup therapist react very angrily and (apparently) unaccept-ingly towards a client. He shouted at her, called her a wimp andwas generally rather aggressive and confrontational. However,in the course of the diatribe he said `Has it ever occurred to youthat just because your mother was mad it doesn't mean youare?' While I expected the client to be damaged by the processand to feel unheard, she seemed positively buoyed up and evenglowed. What I suspect happened is that she didn't `hear' all theconfrontational, attacking stuff but she did hear the deeplyaccepting statement of her worth and sanity. She made con-structive use of the bit of the interaction that served her purpose.

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As Sanders (2006b: 92) points out, that clients can make useof poor responses is not an excuse for poor practice. The point isthat clients do not simply passively receive what the therapistputs before them but are active agents in its receipt and pro-cessing. Clients recover, grow, heal even when they don't seemto be doing what psychotherapeutic theory says they should. Inevery way, the client is in charge. The implication for practice isthat, yes, it is necessary to be non-directive and to communicatethe therapist-provided conditions but most importantly thetherapist's job is to trust the client to run the change process intheir own way and not to obstruct or hinder them in that.However, this does work better in a climate in which the sixnecessary and suf®cient conditions are present.

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63The person-centred therapist's job is to followwherever the client leads, putting aside theoreticalunderstanding and any other `expert' knowledge

Although it follows from the whole concept of the non-directiveattitude, it is worth emphasising that, whatever experience andknowledge person-centred therapists bring to the practice, theirjob is to immerse themselves in the client's experience and torespond to that and only that. Theory and knowledge informpractice and they can be helpful in preparing therapists andsustaining them but they must not get in the way of paying high-quality attention to what the client is saying and experiencing.When as therapists we `know' something about what our clientis going through, has experienced and is likely to experience wecan become distracted from what they are actually telling usand/or experiencing in our presence. This runs counter to whatperson-centred theory tells us is likely to be helpful. What ishelpful is to track the client's experience as closely as possibleand to trust that, if you do this, the clients will do what theyneed to do. Perhaps the best way to illustrate this is by a story.

When I was training as a therapist I had a client from WestAfrica. In our ®rst session she told me a story of multiple loss.She had recently miscarried, a close relative had died and shewas far from her family and culture. I was mentally rubbing myhands. This was about loss and grieving. I knew about the griefprocess ± I had read the books and attended the lectures. All myclient had to do was to tell me her story as a way of facilitatingher progress through the stages of grief and she would be ®ne.

My client came to the second session and I expectantly waitedfor her to tell me about her losses. She didn't. After a few briefwords, her head went down and nothing more was said. I knewabout silence, silence is good. After half an hour I was less sureof this. Surely my client wasn't making use of her time with me?Shouldn't she be experiencing and processing her grief? I gently

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informed her that we were halfway through the session. Shelooked up and smiled sadly but said nothing. Her head wentdown once more. With ®ve minutes to go, I spoke again. Stillnothing but a sad smile. At the end of the session, we madeanother appointment. OK, I thought, surely next time we willget to the meat of what she needs to do.

The next and subsequent sessions passed in exactly the sameway. I began to question my abilities as a therapist. I must bedoing something wrong because this wasn't going at all the waythe books said it would. This was con®rmed for me in our tenthsession at the end of which my client said that she wouldn't becoming any more. She had exams and she thought she shouldapply herself to them. I thought she was letting me down gentlyfor clearly I hadn't helped her grieve.

About a month after our last session, my client came to ®ndme bearing a gift. She told me how wonderful I had been andthat she had passed her exams with ¯ying colours. This was alldue to me. I was a bit taken aback but I thought about ourprocess together. Of course, I have no idea what actually hap-pened for my client (and it doesn't really matter exactly whatwas helpful) but the way I have explained it to myself is that shewas using the time we spent together to return to her homelandin her imagination and that I was somehow a companion onthat journey. To her, there was something important about thetime to re¯ect and the companionship.

Whatever the truth of the matter is, I learned a great dealabout the power of paying attention, staying with the client'sactual process and experience (rather than seeking to push in thedirection of one that would be `good' for the client) and theimportance of letting go of my knowledge.

Of course theory is important as is an understanding of howclients might react to life events but it is more important to putthe client before the knowledge.

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Subsection 5.4The necessary and

suf®cient conditionsin practice

64The necessary and sufficient conditions are all ittakes for successful therapy

It is axiomatic that the necessary and suf®cient conditions forconstructive personality change are precisely that. Therefore,certainly from at least the classical client-centred position, allthat is required of person-centred therapists is to ensure contactand, once it has been established, to hold the three therapistconditions in such a way as to allow their clients to perceiveempathic understanding and unconditional positive regard. Theprimary way in which this is done is by `checking perceptions'.The implicit question behind a majority of therapist responses is`This is what I think you mean/how you feel/what you areexperiencing . . . have I got that right?' However, questions assuch are not amongst the primary tools of person-centredtherapists so they are more likely to check and communicatetheir understanding by conveying their sense of what has beensaid or their impression as to what the client is currentlyexperiencing. `You are sad' is probably a more effective responsethan Ì think you are telling me that you are sad. Am I right?'On the other hand, in person-centred terms, both are better thanÀre you sad?' and certainly than `How do you feel about that?'.Crudely, this is the `technique' of re¯ection. Often there is moreconcern with re¯ecting feelings than re¯ecting anything else butwhat the client is thinking is also of importance and deserves toreceive a response. Certainly, even when the client is talkingabout past events, the primary focus of the therapist is oncurrent experiencing ± in the ®rst instance that of the client butalso (for a variety of reasons including monitoring congruence)their own. This does not mean that person-centred therapistsignore historical accounts of either the `When I was a kid . . .' orÒn my way here . . .' kind and all things between but rather justas the client is telling the story from the perspective of thepresent, so the therapist responds to it in and from the present

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ideally picking up on just what the client is experiencing withrespect to the story being told.

In reality, the process of person-centred therapy and theresponse of the person-centred therapist are a lot more sophis-ticated than simply `re¯ecting' the client's experiencing. For astart, because person-centred therapy is always about theparticular individuals and the particular relationship how this isdone varies from relationship to relationship and, as the clientmoves through the seven stages of process (Point 17), over time.Responses of different kinds may be required to accord with thetherapist's different reactions to the client's material. Althoughmany person-centred therapists would see empathic responses asthe primary tool in person-centred therapy, there may be timeswhen, perhaps in order to maintain or regain congruence, aresponse of a different kind is necessary. This section is abouthow the necessary and suf®cient conditions are implementedand just how sophisticated this can be.

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65Contact in practice

The ®rst of the necessary and suf®cient conditions is that thetherapist and the client are in (psychological) contact. This isde®ned as each making at least a minimal impression on theexperiential ®eld of the other. For most of us, most of the time,this can be taken as a given. We almost always know when we arein the presence of another person and are taking at least somenote of who, how and what they are, what they are doing andhow all this impinges on us. We are also likely to have someawareness of how we are affecting the other person. However,this does not mean that, in person-centred practice, contact canbe assumed and neglected ± it is something to be deliberatelycultivated and the acknowledgement of the client by the therapistis fundamental to successful therapy. Also, there are differentdegrees of contact and the depth of contact will in¯uence or guidethe manner in which the therapist responds to the client.

In the normal course of events, there is an immediate mutu-ality to contact. It involves recognition and acknowledgementby each of the other. Coming into contact is entering a rela-tionship. It is through contacting others that we are able toperceive ourselves as meaningfully present, the acknowledge-ment of another con®rms our actuality. This is one of thereasons why contact is fundamental to effective therapy.

In the normal course of events, contact between individualsoccurs via a variety of channels. Everything we do or say is acommunication and communication involves contact. The waywe dress, how we sit or stand, our facial expressions and ges-tures, our scent as well as what we say contribute to contact.Even in our words there are a number of things that in¯uencecontact. Tone of voice, accent, para-verbal expression (`ummm',`ahhhh' and so on) and the pace of our speech all contribute tothe seemingly simple but actually complex process of contact. Atleast to some extent, the practice of person-centred therapy

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involves the therapist in paying attention to each of these things± and probably others. However, to add to the complicatednature of contact, it is important that it is congruent. It is amistake to (for example) speak in a soft, mild tone in theinterests of `contact' if this does not accord with the therapist'sinner state or to `dress down' (or dress up) in order to `®t in'when this is too different from the therapist's normal way ofbeing. So, the way each of us contacts others and is available tobe contacted is personal. Contact is best assured by being trueto one's nature. Also, how contact is ensured and conveyed willvary from relationship to relationship and with time in anyparticular relationship. Thus, there are no de®nitive rules abouthow to contact another other than that it involves acknowl-edging their presence and being opened to being contacted bythem. In person-centred therapy, it involves the development ofshared meaning and the co-creation of a working relationship.However, there can be obstacles to initiating and/or maintainingcontact and the effectiveness of therapy may relate to its depth.

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66The therapist's availability for contact

It is a fact of human nature that most of us, at times, are limitedin our availability for contact and our willingness to receiveanother. Sometimes this is because we have burdens of our ownthat responding to the needs of another would seem to increaseso it is easier, even on the face of it necessary, to screen othersout, for example, when we are tired or ill or immersed in ourown psychological or emotional processes. Sometimes it is aboutbeing unaccepting of another's way of being, deciding that theyare mad, bad or sad and that we want nothing to do with them.We may (for example) block contact or at least limit its depthwhen we are confronted by behaviour of which we disapprove,when the person before us provokes fear or connects us with ourprejudices or when we are afraid that being seen will lead us tobeing rejected. All of these things limit availability for whatCameron (in Tolan 2003: 87±92) calls `basic contact'.

While it is probably true that the client almost always makesat least a minimal impression on the experiential ®eld of thetherapist, it is also true that there are times when we are liableto bring such attitudes with us into the therapy room. This bringsperson-centred therapists a responsibility to monitor their avail-ability for contact and, when it is or may become limited, toaddress whatever might block it. This is about attending to well-being through, for example, ensuring suf®cient rest and recrea-tion, continual attention to personal and professional growthand, perhaps above all, getting good supervision.

As well as things that may interfere with or limit basiccontact, there are things that may interrupt the process. These(after Cameron, p. 92) include:

· distracting thoughts about things outside the session (`Whatshall I have for tea?')

· concern about being a good enough therapist (`Was that agood response?')

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· or, conversely, self-congratulation (`Wow ± I was reallyempathic just then!')

· feeling shocked (`You did what!')

· identi®cation (`When that happened to me . . .')

· feeling attracted to the client (Ì really fancy you ± I wish wecould . . .')

· interpreting/analysing the client (Àlthough you haven't saidso, that sounds to me like you have been abused')

· irritation or annoyance (`You're whining again and I'mgetting pissed off').

Such interruptions to the ongoing ¯ow of contact are anormal part of relating to others. However, the role of person-centred therapist brings with it a responsibility to monitor andaddress such things. Mostly this is about catching the distractingthought or feeling and getting back on track there and then.This may involve a congruent response ± that is an open owningof the distraction ± `When you told me that I was shocked' orÌ'm very sorry but I drifted off into my own thoughts then'because it is likely that the client noticed something was amiss.Alternatively, particularly if there is a pattern to the failure tomaintain contact then noting what occurs, when it occurs andwhat happens as a result and addressing this in supervision orpersonal therapy is probably the way forward.

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67The client's availability for contact

By de®nition, clients for person-centred therapy are incon-gruent, being vulnerable or anxious. This may very well limittheir ability for sustained contact ± certainly contact at depth(but note that the basic hypothesis does not require `depth' ofcontact and there are differences of opinion about the quality ofcontact). In some cases, the potential client may be in a state orhave a way of being that prevents meaningful contact. This iswhere pre-therapy and contact work come into their own. Theseare dealt with separately (Points 34 and 68). Clients who havethe capacity for contact but for whom it is (temporarily) dif®cultcan be facilitated in the direction of deeper and more sustainedcontact.

A client's availability for contact may be limited or impededby the nature of their current experiencing. Anger, fear or asense of being swamped by events can all result in a tendency towithdraw and act in a guarded fashion. Likewise, a client underthe in¯uence of alcohol or one or more other drugs (prescribedor otherwise) may be distant or remote, appearing to be cut offfrom experiencing their current environment, giving the ther-apist the impression that they are not quite in the world (or atleast the same world as the therapist). For some maintainingdistance from others or limiting contact is a response to con-ditions of worth. Allowing other people close is dangerous,perceived as threatening. And just as therapists may be limitedin their availability for contact by physical and emotionalailments, so it is with clients. Exhaustion ± even everyday tired-ness, virus infections, ill-health, worry about a third party andemotional disturbances of many kinds (for example, depression,anxiety, panic or the numbness brought about by bereavementor trauma) ± may also inhibit contact. In each and any of thesecases, it is up to the person-centred therapist to act in such away as to enhance the contact.

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Often, communicating the close attention the therapist ispaying to the client will at least begin to deepen contact.Responding empathically in such a way as to recognise the lackof contact may be helpful ± a response such as `You seemdistracted and caught up in your thoughts' may very well helpthe client come back into contact. Sometimes a process com-ment may be helpful: `When we talk about . . . I lose my sense ofyou and what is going on for you' may help the client contactthe reality of loneliness and isolation. However, it is reallyimportant to realise that a silent, withdrawn client is notnecessarily a client out of contact. For example, in the course ofmy training, I had a client who, week after week, apart from afew words at the beginning of the session and `goodbye' at theend spent the whole session in silence, scarcely even respondingto my reminders of the passing of time (`We are halfwaythrough our time now', `We have ®ve minutes'). She decided tohalt her time with me because she had forthcoming exams. Ithought she was letting me down gently. Clearly, I had been nouse to her. After the exam period, my client came to ®nd me ±she told me that I had been wonderful, I was the reason shemade it to and through her exams (she passed with ¯yingcolours) and that she couldn't thank me enough for my efforts.Whatever else was going on for my client, it is clear that she wasaware of my presence (I made at least a minimal impression onher experiential ®eld) and that it was important to her.

The story above indicates some of the dif®culty of assessingthe client's availability for and degree of contact. It is a judge-ment call, one that perhaps improves with experience but whicheven experienced therapists can get wrong. Ultimately, it is forthe client to judge if there is a suf®cient degree of contact.Nevertheless, when the therapist is in doubt about mutualcontact, it is important to respond to that sense (empathically,congruently, with a process comment). It should not be ignoredbut responses should be tentative, gentle and encouraging, nevercompelling the client to contact of kind they do not desire orneed. If the client really is out of contact, it may be worthwhilemaking simple contact re¯ections (Points 34 and 65) but thisshould not be confused with `doing pre-therapy'.

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68Contacting the `unavailable' client ± contactimpairment and pre-therapy or contact work

Although there are acute causes to the limitation of the abilityfor contact, these can be worked with in the `normal' person-centred way (Point 64). However, there are clients for whomtheir unavailability for contact is a chronic condition. Suchclients may include those with severe learning dif®culties, seriousmental disturbance or both. For such clients pre-therapy or`contact work' may be suitable therapeutic strategies (Point 34).However, although pre-therapy can sound deceptively simple itis actually dif®cult to do well.

Apart from that it is more dif®cult to do than it seems,perhaps the ®rst thing to realise about pre-therapy is thatalthough its founder, Garry Prouty, referred to his way ofworking with clients as a series of `techniques' this does notmean that they can be applied in a detached, mechanistic way.Pre-therapy is a person-centred way of working and, as such, itsef®cacy is predicated on the assumption that it is in the thera-peutic relationship that constructive change occurs. Responsi-bilities of the pre-therapy practitioner additional to thoseincumbent on any person-centred therapist and in addition tousing techniques are given by Sanders (2007c: 21±22).

The practitioner:

· assumes full responsibility for contacting the client

· validates the client's experience (including, for example,psychotic experience)

· values the importance of the client's expressions

· recognises that e.g. hallucinations and delusions are mean-ingful

· acknowledges the client's self-autonomy process towardsmeaningful experience

· contributes to the client's healing process.

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In essence, the objective of pre-therapy is to encourage clientstowards contact with self, the world and others. Therapists andcontact workers do this by offering contact. This is a slow, re-iterative process requiring discipline and patience. In contactwork, everything the client does is important and so it isnecessary to pay close attention to expressions of all kinds (forexample, grimaces, tugging at clothing, kicking the furniture,smiling, staring), posture (for example, slouching, self-hugging,crossing and uncrossing legs), words (no matter how randomand unconnected they appear to be) and para-language (forexample, grunts, humming, screams, clicking noises) and somuch more. The worker's task is to respond to what the clientdoes by making contact re¯ections (see Point 34).

Sanders (2007d: 30) points out that pre-therapy work properis very demanding of the practitioner for the (slightly adapted)following reasons:

· It is a special sort of communication for special circum-stances.

· It can be embarrassing or awkward to use contactre¯ections at ®rst.

· It requires time and patience, since it can sometimes take along time to produce noticeable results.

· People already quali®ed as helping professionals will almostcertainly have problems in scaling down their responses tothe minimalist, concrete responses necessary for successfulcontact work.

· Some of the time spent doing contact work can be in silence,or at a slow tempo to match the lived experience of theclient which may add to the awkwardness for people unusedto silent or slow-paced attention-giving (although, para-doxically, sometimes the client's behaviour can be extremelyrapid).

· When helpers get involved in the process with their clientthey can forget to keep it very simple and absolutely basic inthe heat of the moment.

It is beyond the scope of this book to give a full account ofdoing pre-therapy. Sanders (2007f ) provides an excellent

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introduction but, for anyone wishing to use pre-therapy in theirwork, there is no substitute for good training.

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69Dealing with client incongruence

One of the most important things to remember when faced withan incongruent client is that is how they are supposed to be. Toput it another way, it is a sense of their incongruence (manifest-ing as vulnerability and/or anxiety) that brings clients to therapyor, as Sanders (2006b: 43) puts it, `the client needs help, andknows it'. This is in accord with the second of the necessary andsuf®cient conditions and recognising and accepting clientincongruence is a fundamental task of person-centred therapy.

Incongruence results from a gulf between the perceived selfand the actual experience of the total organism and, in fact,person-centred therapy is about increasing (or bringing about)harmony between self and experience, the inner world and theouter such that they are in accord and situations evaluated andchoices made in line with a personal valuing system rather thanan introjected one. Introjected value systems give rise to con-ditions of worth and these are seen as a principal cause ofincongruence (Point 12).

Incongruence and conditions of worth can take many forms.They may impede or limit the client's ability to make psycho-logical contact and likewise the ability to perceive communica-tion from others in an undistorted way. Points 65 and 68 dealwith the enhancement or repair of contact and these can be seenas ways of addressing client incongruence.

A way of viewing incongruence is to see it as arising from alack of (or insuf®cient) unconditional positive regard. Condi-tions of worth result from conditional positive regard from asigni®cant other. Because conditions of worth disturb a person'sinternal evaluating process it prevents movement towards thestate of being `fully functioning'. This, by de®nition, results inincongruence. Thus the `corrective' for incongruence is theconsistent perception of unconditional positive regard from asigni®cant other. In the context of person-centred therapy, it is

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the role of the therapist to provide this unconditional positiveregard. In a nutshell, the unconditional positive regard of thetherapist facilitates the unconditional positive self-regard of theclient who is thus no longer incongruent. So, unconditionalpositive regard is seen by at least some person-centred therapistsas the curative factor in therapy (see, for example Bozarth 1998:83 and Wilkins 2000: 33±34). When it is experienced from oneperson to another it overturns conditions of worth and pro-motes congruence.

To summarise, person-centred therapists deal with clientincongruence not (usually) by confronting it or challenging itbut by unconditionally accepting clients as they are in a climateof their own congruence and empathic understanding. This iswhat the next few Points are about.

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70Being congruent or integrated in the relationshipas a therapist

The third of the necessary and suf®cient conditions requires theperson in the role of the therapist to be congruent or integratedin the relationship. The ®rst thing to understand about this is it isnot a requirement to be some sort of permanently perfect being.Person-centred therapists are not expected and certainly notobliged to be completely congruent in all their dealings, all thetime. Rogers (1959: 215) was very clear about that, going so faras to say that if it were indeed so there would be no therapy(because it would demand an impossible level of perfection).Person-centred theory and practice recognise that therapists arelimited in their ability to be congruent. Indeed, it may even bethat part of being congruent is the acknowledgement to one'sself of all the imperfections and ¯aws that make us human andthe acceptance of these. Whatever may be the case, the con-gruence required of person-centred therapists to be effective intheir role is, strictly speaking, limited to that role.

The second important thing about being congruent is that it isprecisely that ± it is about being totally yourself and fully presentwithout facËade and not necessarily (and certainly not usually)doing something. In person-centred theory, congruence is de®nedin terms of the distinction between self and experience not interms of therapist behaviour. Brodley (2001: 59) emphasises therelational nature of congruence, stating that it is about therelation between the contents of experience and the symbolsrepresenting the contents but it is not the contents per se. Torestate and reframe that, being congruent in the relationship doesnot call for action but an openness to experience (internal andexternal) is required. This includes an open and honest accept-ance of the things that con¯ict with being a `good' therapist suchas fear of the client, fear of failing the client, becoming absorbedin one's own thoughts, losing concentration and so on.

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In terms of classical person-centred theory, the thirdimportant thing about congruence is that there is no require-ment that it is communicated to or perceived by the client.However, the therapist's congruence probably `works' because itresults in the client's perception of the therapist as someone whois authentic and thus to be trusted. An authentic therapist is onewhose unconditional positive regard and empathic understand-ing can be received and believed. Certainly, because it throwsdoubt on those same therapist attitudes, it is assumed that theperceived incongruence of the therapist, albeit as a vague,uncomfortable feeling rather than as a conscious thought, iscounter-productive. This is because when, for example, thetherapist is irritated with the client but unaware of it or sup-pressing it then this directly contradicts attempts to conveyunconditional positive regard and empathic understanding.Such contradictory messages, however subtly received, confuseclients and tend to make them distrustful. Even so, momentarylapses in concentration or judgement that (almost inevitably)occur in the practice of person-centred therapy, if accuratelysymbolised in awareness, can be recognised and owned bythe therapist and, if necessary or advisable, admitted to theclient and so are unlikely to be disruptive of the therapeuticprocess. Indeed in most cases such ¯eeting distractions, pre-occupations or failures in unconditional positive regard are notperceived by others. They remain a part of the private innerprocesses of the therapist. As long as they are not distorted ordenied it is probable that no great harm results. Such lapses arepart of being a fallible human being; however, especially if thereis a pattern to them, it is well worth re¯ecting on them andtaking them to supervision or addressing them in personaltherapy.

Although `modelling' is not an objective of person-centredtherapy, it may very well be that the therapist's consistent con-gruence is an encouragement to clients to develop their own.Perhaps more importantly, the congruence of the therapistoffers the client the genuine reaction of another person who canbe trusted and who honours the client's value system rather thanimposing their own. This is extraordinarily powerful; at itsfullest, it is the meeting of the deepest, most real, most vibrant

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and vital self of the therapist with the client ± it is encounter inthe truest sense and it is of great potency in the client's quest fortransformation.

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71Developing and enhancing therapist congruence

In many ways, because it is about being rather than doing andtherefore the `skills' element to be learned and practised is mini-mal or non-existent, developing congruence appears to be dif®-cult particularly to therapists in the early stages of their career.Indeed, becoming acquainted with the ¯ow of internal experienceand how that matches outward expression is a demanding task.However, because congruence is about the relation betweenexperience and its symbolisation it is really a matter of self-awareness and self-acceptance. Developing congruence is aboutlearning to acknowledge all your internal responses withoutdistorting or denying them ± in the context of the practice ofperson-centred therapy perhaps especially those you have inresponse to your client regardless of whether or not they ®t yourpreconception as to what it means to be a good therapist. So, it isat least partly about learning to listen for and become aware of allthe thoughts and feelings you have in relationship with a client.As Tolan (2003: 45) points out, the second thing is to learn whenand how to communicate that awareness to your client.

For a person-centred therapist, being self-aware means thatall thoughts, feelings, sensations and intuitions are available toconsciousness. For most of us, developing self-awareness is anever-ending task. In this context, self-awareness means thattherapists' feelings are available to their consciousness. How-ever, being congruent is not about turning your gaze inward andconcentrating on your own experience for that would defeat thevery object of person-centred therapy. Rather, it is abouttrusting yourself and being enough at ease with yourself to allowthe free-¯owing of your experience while you concentrate on thelived experience of another. This is something which can bedeveloped and enhanced.

Perhaps it is stating the obvious to point out that the degreeto which we can be self-aware and therefore congruent is limited

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by our self-acceptance, our ability to offer unconditional posi-tive self-regard. So, the ®rst way to develop congruence is to payattention to our own personal development. Personal develop-ment can be understood as attending to personal needs in sucha way as to increase the ability to be with clients in a safe wayand which incrementally improves effectiveness. It is aboutdealing with blind spots and resistance so that the therapist isbetter able to accompany the client on what may be a painfuland challenging journey without blocking them because theyseek to enter areas that are frightening or painful for thetherapist. For person-centred therapists as for therapists ofmany other stripes a recognised way of doing this is to engage inpersonal therapy. This can be of the `normal' one-to-one onehour a week kind but alternatives such as group therapy oroccasional residential sessions may do just as well. It is a ques-tion of preference, availability and cost. As well as personaltherapy, supervision, debate and discussion with colleagues,re¯ective writing or journal keeping, reading and some form ofmeditation or spiritual practice may severally or together serveto aid the enhancement of congruence.

Personal development is helpful in increasing the capacity tobe congruent; however, even for those with an enhanced capa-city to be congruent in the therapeutic relationship there areadvantages to taking deliberate steps to lay aside petty distrac-tions, clearing the mind of the issues of the day (what to havefor dinner, personal relationships and so on). Leijssen (2001:151±155) recommends `clearing a space' and describes an exer-cise to achieve this. By `clearing a space' she means payingattention to your own world in such a way as to allow your ownconcerns to fade into the background thus preparing yourselffor contact with clients.

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72Making congruent responses

At least for some therapists who identify with the classicalclient-centred approach to therapy, for therapists to makeresponses from their own frames of reference should be rare ifit happens at all. This is because anything but an empathic,`checking perceptions' response may de¯ect clients from theirown processes. That is any response other than one that is inaccord with the client's frame of reference and current experi-ence is directive and therefore contrary to one of the principlesof person-centred practice. However, there are other thoughtsabout this and it may be that, on occasions, therapists' willing-ness to express themselves about their reaction to the client'sexperience is helpful to their clients.

There are several ways in which this may be so. Firstly, aresponse from the therapist's frame of reference (as long as it isabout or enhancing of the relationship) can be experienced as`humanising' the therapist and thus contributing to a sense of thetherapeutic endeavour as a collaborative enterprise. A personalresponse can help dispel the mystique surrounding therapy andgo some way towards the equalisation of power. Secondly, if thetherapist has feelings towards the client other than unconditionalpositive regard, particularly if these are distracting and/orpersistent, it may be helpful to openly own them. This is becausefeelings such as irritation or boredom may in any case havealready been picked up by the client and masking them may beexperienced as incongruent and unaccepting and because some-times naming the therapist's feeling is what clears it. However, thenotion of responding `congruently' should not be taken as licencefor self-disclosure other than of the most limited and relevantkind. When they are appropriate, congruent responses aregenuinely felt reactions to the client's current experience and onlythat. Also, note that congruence per se is different from whatTolan (2003: 54) calls `authentic communication' (that is making

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congruent responses) and that this in turn is different from self-disclosure or a `willingness to be known' on the part of thetherapist. Congruence is about being integrated in the therapeuticrelationship; authentic communication is about the facilitativeexpression of the therapist's response to the client's current livedexperience while self-disclosure is about therapists communicat-ing their own experience from their own frames of reference. Thelatter may have a function in the therapeutic relationship (`Whenthat happened to me . . .' may be helpful in terms of willingness tobe known) but, because the therapist's self-disclosure is a de¯ec-tion from the client's process, it should be approached withcaution. However, if the initiative comes in the form of questionsfrom the client (`How old are you?', Àre you married?') then it isprobably best to answer brie¯y and honestly. But this has nothingto do with being congruent.

In their discussion of congruence, Mearns and Thorne (2007:130±133) describe three ways in which a therapist may `resonate'with a client's experience. Firstly, there is self-resonance which isthe reverberation of the therapist's own thoughts and feelingstriggered by the client's account but not related to it in any otherway. Secondly, there is empathic resonance as `concordant' ±the depiction as accurately as possible of the client's expressedexperience (also called àccurate empathy') and as `complemen-tary' which is when, as a response to an empathic sensing, thetherapist adds something to the client's expressed experienceperhaps delving into èdge of awareness' material (see Point 22).Thirdly, there is personal resonance in which the therapist(p. 131) ìncludes her own responses, as a reasonable person, tothe client's experiencing'. When making a personally resonantresponse, therapists are communicating their side of the rela-tionship. It is a sharing of the therapist's personal, feelingreaction to the client's material in a way that is relevant to theclient's process and consistent with a non-directive attitude.Mearns and Thorne (p. 131) are of the opinion that suchresponses encourage the client to move into relational depth(Point 38).

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73Being yourself, psychologically mature andpractising according to your personal style: themultifaceted nature of therapist congruence

Wyatt (2001b: 79±95) argues that congruence is complex anddescribes the therapist's congruence as `multi-faceted'. In herview (pp. 84±85) the therapist's congruence comprises threecore elements, each having implications for practice. Theseelements are:

· Being myself: Each of us has a unique way of being in theworld and a task of person-centred practice is to bring thisuniqueness into the therapeutic relationship rather than tohide behind a professional facËade.

· Psychological maturity: Being integrated in the therapeuticrelationship depends upon self-awareness (knowing andowning strengths and weaknesses, recognising that there isalmost certainly more to discover), an ability for auton-omous action while remaining a relational being and anability to appreciate the person in the client role as equallyautonomous and unique. In terms of person-centred theory,congruence relies on a ¯exible enough self-structure to allowmost experiencing to be accurately symbolised in awareness± that is denial and distortion are at minimal levels. Or,more simply, your degree of psychological maturity accordswith the extent of your openness to experience.

· Personal style of the therapist: Because each of us is uniquewith our own way of being in the world, we are different inwhat we do and how we do it. This means that even thoughthey share core theoretical beliefs and a commitment tonon-directive practice, each person-centred practitioner willbe different in the ways that they offer the therapist con-ditions and in their responses to clients. So, there is no`right' way to do person-centred therapy except, within the

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framework of person-centred theory, to allow the naturaldevelopment of a personal style. The way you practise in aperson-centred way will be different from the way the nextperson does it. What is important is that there is harmonybetween how you are in the therapeutic relationship (whichis at least subtly different from what you do ± it is how youdo things that result from your personal style) and theperson-centred approach.

Wyatt (2001b: 85±93) goes on to describe the `facets' of thetherapist's congruence. Brie¯y, these are:

· Being open to moment to moment experiencing: The congruenttherapist has a ¯uid enough self-concept to accuratelysymbolise most experience into awareness including experi-ences arising from the therapist's way of being, the client'sway of being and the relationship between them. There areother sources, for example, experiences also result fromsensory impressions of the environment. Openness toexperience allows the therapist to make judgements aboutits potential signi®cance to the client and the therapeuticrelationship. For example, some experiences may revealunconditional positive regard for and/or empathic under-standing of the client while some may result in uncomfortablefeelings or a sense of vulnerability. The latter indicate thatincongruence has been triggered and this will probably needto be addressed in the session, in supervision, in personaltherapy or in some combination thereof.

· How to be with our incongruities: At times every therapist isincongruent with a client. Such incongruence may be theresult of a lack of awareness of feelings or the resistanceto communicating feelings of which the therapist is awareeven if they are relevant to the client and the relationship.Whatever its nature, the therapist's incongruence relates tounresolved personal issues. These can be dealt with inpersonal therapy. However, with respect to dealing withincongruity in the ongoing therapeutic relationship, Wyatt(p. 87) writes of the importance of `communicating . . .incongruency congruently'. This is to be done openly and

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honestly but with sensitivity towards the client and theclient's process.

· Genuine empathic understanding and unconditional positiveregard: The therapist's congruence ensures that empathyand unconditional positive regard will be perceived of asgenuine. They are received in this way only when clientsknow that the therapists are genuinely interested in themand their experiences.

· The therapist's behaviour: How the therapist behaviourstoward the client directly in¯uence the client's perception(not least of the therapist-provided necessary and suf®cientconditions). Practising in accordance with a developed per-sonal style and in a non-defensive way is at the heart of thetherapist's congruence.

· Limits and concerns regarding the therapist's expression:Wyatt (pp. 91±92) asks `what is appropriate therapist self-expression?' and note that although it is impossible todelineate or codify them, there are always limits. Sometherapist behaviour is inappropriate. The therapist's self-expression is returned to in Point 74.

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74The therapist's self-expression and self-disclosurein person-centred therapy

The issue of the degree to which person-centred therapists mayexpress and disclose themselves in the person-centred relation-ship is contentious. However, there is general agreement thatself-expression, self-disclosure and a `willingness to be known'are different from congruence. What is certain is that, evenunder the (misunderstood) label of `being congruent', there is nolicence to `tell it how it is' and the excuse `I felt it so I said it'runs directly contradictory to person-centred practice. There isnothing in the necessary and suf®cient conditions to indicate thedesirability of the therapist responding to the client from thetherapist's frame of reference and in classical client-centredtherapy this would be done only exceptionally if at all. Also, aninvestigation by Barrett-Lennard (1998: 265) of the effect on thetherapist's willingness to be known on the progress and successof therapy indicated no correlation ± but it did show theimportance of empathic understanding. Nevertheless, the issueof the therapist's self-disclosure to the client is constantlyrevisited and many take the view that, at times and in limitedways, this may be a useful thing to do. Just what to do and whento do it is debatable and there are no commonly agreed guide-lines. Even Rogers himself can be considered inconsistent withrespect to his views in this matter. Perhaps when and how tomake responses from one's own frame of reference is somethingthat arises from our personal style and it is for each of us tomake up our minds about this facet of practice. To help, thereare some key points.

Self-disclosure and self-expression are most likely to behelpful to the client and the therapeutic relationship when:

· they are relevant to the client and the client's currentexperiencing

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· they are a response to the client's experience

· a reaction to the client is persistent and particularly striking.

From a classical client-centred position, Brodley (1999: 13±22) gives reasons why (p. 13) `client-centered therapists mayspeak to their clients from their own frame of reference'. Inbrief, these include:

· In response to questions and requests from the client ± toanswer openly and honestly helps dispel mystique; however,therapists are entitled to privacy and it is sometimes OK tosay `I'm sorry but I don't want to tell you that because . . .'

· When it seems that the client wishes to ask a question but doesnot directly voice it.

· To make an empathic observation ± that is to express aperception of an aspect of the client's communication oremotional expression. Brodley (p. 15) distinguishes such aresponse from empathic understanding because it is rootedin the therapist's experience of the client rather than theclient's current experience.

· To correct for loss of acceptance or empathy or incongruence.

· To offer insights and ideas ± but only very occasionally andwhen it is clear that the insight relates to an issue the clientis currently exploring and trying to understand and whenthere is explicit permission from the client. It is also wise toask the client if the timing of the offer is appropriate.

· In an emotionally compelling circumstance ± this refers to theimpulsive emission of a personal emotional reaction fromthe therapist's frame of reference to the client's expressedexperience. This is hazardous because the therapist'sreaction may not accord with that of the client.

So, although person-centred therapists do sometimes makeresponses from their own frames of reference, this is somethingbest done rarely and only with the intention to aid the client'stherapeutic process. Even then, the principles of person-centredtheory must be borne in mind. In general, if you have any doubtthat a response from your own frame of reference will behelpful, don't make it.

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75Developing your unconditional positive self-regard

The extent to which any of us can offer another unconditionalpositive regard relies directly on our ability to accept ourselves.Even though most of us embark upon training in person-centredtherapy thinking of ourselves as accepting people, because ofthis, unconditional positive regard is the hardest of the thera-peutic attitudes to develop. It cannot be effectively faked andtolerance (the ability to patiently endure or allow something) isno substitute. What we need to be effective in the role of person-centred therapist is positive self-regard.

According to Bozarth (1998: 84), it is unconditional positiveself-regard that reuni®es the self with the actualising tendency.One consequence of this is that there is a weakening of andloosening of the defences of distortion and denial and an ameli-oration of conditions of worth. In the context of the therapeuticrelationship, because the defensive reactions of the therapist tothe client's material are counter-therapeutic, it is necessary forperson-centred therapists (and therapists of other kinds) to haveunconditional positive self-regard; that is to prize, respect andfeel warmth towards themselves. Unconditional positive regardfor another comes from an understanding that everyone has areason for what they do and how they are and the recognitionthat each of us is prompted by our actualising tendency to makethe best possible choice given the circumstances as we experiencethem. It follows that unconditional positive self-regard meansholding this attitude towards ourselves. Paradoxically, this mayinclude an acceptance that we will sometimes fail to do so.

Successful person-centred therapy depends upon approachingclients without prejudice, with respect for whom and what theyare and with recognition that they are self-determining persons.However, we each have values and opinions and few of us arewithout pain and shame so this can be very dif®cult. Because thetherapist's unconditional positive self-regard is fundamental to a

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successful therapeutic relationship, it is imperative that person-centred therapists take positive, constructive steps to developand maintain such an attitude towards themselves. Perhapsthe ®rst thing each of us needs to accept is that our ability tooffer unconditional positive regard to others is limited andvariable. The second is to discover these limits and what it isthat causes us to vary in our ability to extend the attitudetowards others (tiredness, personal dif®culties, mood are eachamong several possibilities). Having discovered your limitations,seek to expand them (while working within them in the interim);having recognised the reasons for any variations in your ability,address them ± perhaps through increased self-care. How to doall this is a matter of choice and opportunity. Personal therapyis a well-known and time-honoured route; joining a personalgrowth/self-development group may be helpful (not leastbecause it will expose you to not only the foibles of others butbecause you will also learn something of how others see yours)but it might be that meditation or some other contemplativepractice serves as well. Perhaps it matters less what you do aslong as you do something to increase your self-acceptance, self-prizing and self-warmth.

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76Developing unconditional positive regard

In the previous point, the deep connection between uncondi-tional positive regard for others and unconditional positive self-regard was explained and examined. In a way, to separate thedevelopment of one from the other is arti®cial; they are inextric-ably linked. However, given that work continues on the latter,there are some things that can be done to promote the former.

Firstly, it may help to re-examine and re-evaluate attitudes topractice and to clients. Rigid adherence to the conventions ofpractice and to the `categorisation' of clients is often uncon-ducive to unconditional positive regard. Certainly, it is worthcritically appraising existing conventions of practice and devel-oping a credulous attitude towards clients and the ways in whichwe behave towards them. Boundaries of all kinds are there tofacilitate effective, safe working and not to dictate the courseand shape of therapy regardless of the needs of the client and thetherapist. While honouring issues of safety and ef®cacy, it is amistake to let the tail wag the dog.

It is also worth monitoring attitudes towards clients. Forexample, any notion of the client as attention-seeking or mani-pulative seems to have little to do with unconditional positiveregard. If someone is attention-seeking doesn't that bespeak adeep need to be attended to? Similarly, when a client is late foror misses an appointment, however irritating this may be, does itmerit a punitive response or the paying of attention to theimplied message or obscurely expressed need? It isn't that inperson-centred practice the communication of unconditionalpositive regard demands a permissive, laissez-faire, `anythinggoes' attitude towards clients (far from it) but it may be that theuncritical acceptance of and rigid adherence to the structuresand conventions of therapy sometimes runs counter to it.

Secondly, it is important to ®nd ways of seeing the world asthe client experiences it. I once had the task of working with a

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client who, at least seemingly, had very different attitudes andbeliefs from my own at that time. He had a deep admiration forthe military way of being and a love of the trappings of war. Healso expressed deeply misogynistic and racist views. This was areal challenge to my liberal attitudes. However, I knew that tobe effective as his therapist I had to genuinely accept him andhis way of being in the world. It wouldn't do for this to be fakedand any limitation of my attitude would limit the success oftherapy. As I listened and responded to him, I began to thinkabout what life-experiences could have led him to such extremeviews. The tale he told was of being brutalised as a child and`robbed' of his home and possessions as a consequence of amessy and bitter divorce. Also, between sessions, I read abouthow prejudice may arise. Almost without noticing, I slippedfrom being challenged and repulsed by my client's views to anappreciation of him as a person of worth in spite of them. Asthis happened there was a softening ± in him, in us and in me ±and we moved to a relationship characterised by companionshipand humour.

It wasn't that he changed from his authoritarian position or Ifrom my liberal, Guardian-reading views but nevertheless wewere both changed by the process. I found that I had moved to aposition of deeply embodying the knowledge that unconditionalpositive regard meant the issue of my approval or disapprovalwas irrelevant and immaterial. Each of us is doing the best wecan and what is necessary to our continued existence even if,because of our lived experience and the way we perceive theworld to be, this con¯icts with the values of others. I also had aneven deeper realisation that when my ability to accept anotherjust as he was (even militaristic, racist and misogynist) ischallenged, it is my job to move myself to a position in which Ican genuinely hear, respect, prize and feel warm towards theother. Or, if I cannot do this, to withdraw from the therapeuticcontract (see Point 32 on person-centred assessment).

To summarise, the ability to develop and convey an attitudeof unconditional positive regard depends on a willingness toapproach each person as an individual with unique needs. Thisis not without tensions and, sometimes, these can only beresolved on a case-by-case basis. For example, if your

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unconditional positive regard is limited by ignorance (as wasmine with respect to the origins of prejudice), take steps to learn.If there is something about your client's experience that scaresor disquiets you or arouses your own unresolved issues, take thisto personal therapy or supervision.

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77Unconditional positive regard in practice: payingattention to the whole client

Unconditional positive regard for another involves recognisingand attending to the whole person, hearing everything that is said± and even recognising what is not said. This must be donewithout judgement even if that judgement would be `positive' orin agreement with the client's own estimation or expressed atti-tude. Unconditional positive regard does not (usually) involvethe therapist in taking any position whatsoever with respect tothe client's experience, views, reactions etc. except one of impar-tiality. UPR does not of itself involve therapists in liking clientsbut it does mean the former prizing, respecting and experiencingwarmth towards the latter. There is no need for the therapist toshare the values or beliefs of the client. Indeed, any sense ofrecognition (`She's just like me!') or disagreement (`That's justplain wrong!') may interfere with or inhibit unconditional posi-tive regard ± both positive and negative personal reactions to theclient and the client's attitudes and lived experience have nothingto do with unconditional positive regard which can only be trulyexperienced when these are set aside. To some extent, as dif®cultas it can be, this is obvious. What is far trickier is avoiding whatmight be thought of as responding with unconditional positiveregard to only part of the client's experience.

Tolan (2003: 71) writes about the `partial hearing' of theclient's material. `Partial' has three meanings, existing only inpart (a bit of ), favouring one side in a dispute (being biased) andhaving a liking for. Each of these is relevant to unconditionalpositive regard because each interferes with it. For example,paying more attention to one bit of the client's experience thananother (or others) may result in the client feeling unaccepted forthe whole of who and what they are while favouring one of theclient's views over another does much the same thing. `Liking'your client for some of the ways they are is equally detrimental.

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Clients often express themselves in complex and self-contradictory ways (see Tolan 2003: 71±73 for a good example).Hearing and accepting everything that is said is complicated butnecessary. When the therapist responds to only one of the thingsthe client expresses, even if that seems to be constructive andpositive when others don't, is a failure of UPR and is likely toblock the client's progress. Tolan's example is about the conse-quence of the therapist responding to the abused client's wish toleave her partner while not picking up on the love the womanfeels for her abuser or her fear of having to make a fresh startelsewhere. Although as a concerned person anyone of us mightwant to see an abused woman out of the hands of her abuser, asa person-centred therapist it is an aim to facilitate the client tomake her own choices. This is most likely to happen when theclient feels accepted (and acceptable) in her totality. However,such choices are rarely simple and easily made (if they were whywould the client bring them to therapy?). For example, con-tinuing with Tolan's example, if the abused woman were toleave her partner, she might be risking her status and acceptancein her own social circle or family. In some cultures there mayeven be a strong cultural imperative to stay.

Whatever the case, for the therapist to respond strongly toonly part of what a client has said (whether approvingly or withapparent neutrality) is likely to result in the client feelingunheard and thus only conditionally accepted. In Tolan'sexample the abused woman may feel that if she does what thetherapist appears to sanction (leaving her partner) she will beacceptable but that her tender feelings for him and her fearsabout being alone are not. She will not perceive the therapist'spositive regard as unconditional therefore one of the necessaryand suf®cient conditions will not be met and constructivepersonality change will not occur.

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78Unconditional positive regard in practice: theavoidance of positive reinforcement and partiality

Sometimes, one of the dif®cult things about unconditionalpositive regard is the avoidance of positively reinforcing aspectsand attitudes of the client that seem bene®cial and growth-promoting. While it is important to value and respect the client,this is very different from praising the client or con®rming theclient's thought, feeling or action. The latter involves making ajudgement, is far from impartial and it is directive (because itpoints the client in the direction of a particular way of being/doing). To put it another way, the con®rmation comes from thetherapist's frame of reference and may involve the client insuccumbing to an external locus of evaluation. One of thehealing processes of person-centred therapy is clients' establish-ment of internal loci of evaluation; that is an increased ability totrust their experiences and perceptions and to form judgementsaccordingly rather than to take on board the values andopinions of others in a way that supersedes their own.

Relatedly, the conclusion from theory is that for the therapistto offer unconditional positive regard to the client will effectconstructive personality change. However, for the therapist tohave that as an expectation and certainly as a desire (howeverwell-intentioned) may be counter-therapeutic. Holding anotherin unconditional positive regard involves accepting their rightnot to change. While it is natural for person-centred therapiststo want their clients to change, and perhaps even to form a viewof to what change might lead, for at least some clients changeonly becomes possible when the therapist lets go of the desirefor it.

The relatively straightforward con¯ict with basic person-centred theory is not the only problem when therapists aretempted into praising or reinforcing clients in particular views.By con®rming and approving of some part of the client's

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experience, there is a strong likelihood that the therapist is ineffect rejecting another. Also, it is a simplistic mistake to thinkthat person-centred therapy is always supporting `growth-promoting' aspects of the client. We are all complex creaturesfull of ambiguities and contrary views, some growth-promoting,some less so and we experience support for one of our experi-ences or values as rejection of another or others. Paradoxically,favouring (apparently) growth-promoting aspects of the clientwhile ignoring or down-playing other aspects is likely to becounter-therapeutic because, in effect, the therapist ends upoffering the client a conditional relationship. It is particularlydif®cult for therapists to avoid positive reinforcement when onlypart of a client's experience or way of being in the world hasbeen revealed ± which is most of the time. It is probably bestalways to assume that there is more to the client than meets theeye. Not only that, but the totality of the client's experience is aresult of the prompting of the actualising tendency. Evenapparently harmful aspects have their purpose and stand in needof empathic understanding and unconditional positive regard.For this reason alone it is unwise to praise or show approval ofthe client, the client's actions or intended actions.

It is also wise to avoid the sometimes facile attitude `AlthoughI disapprove of what you do, I accept you as a person of worth'(also occasionally put as `Hate the sin but love the sinner'). It isextremely unlikely that any of us wholly separate what we dofrom who we are ± clients are no exception. Not only that but thebehaviour that seems reprehensible to the therapist may beequally so to the client who may feel a great deal of shame aboutit. For the therapist to express (in words or otherwise) dis-approval of the behaviour (past or present) will be experienced asrejecting and it may very well compel the client to lock awayfeelings of shame. The disapproved-of behaviour becomes a no-go area. The therapist's disapproval may very well be even moreharmful when the client doesn't see anything wrong with whathas been done or said.

This doesn't mean that person-centred therapists have toapprove of or accept (for example) criminal or immoral beha-viour. Rather it is that in person-centred therapy approval anddisapproval are equally irrelevant. In practice, unconditional

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positive regard is precisely that; there are no conditions, nolimitations and, one way or another, the personal values of thetherapist must be set aside.

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79Unconditional positive regard in practice: theavoidance of rescuing the `helpless'

It is common for person-centred therapists to hear their clientsexpress attitudes about themselves that the therapist doesn'tbelieve to be true. For example, a client may say that they are soworthless that they would be better off dead when it is apparentto the therapist that they have the potential for a bright andhappy future. Or someone who has been assaulted may blamethemselves for being in the wrong place at the wrong time,dressed the wrong way and having had too much to drink whenthe therapist knows we should all have the freedom to walkthrough our streets unafraid. Sometimes, there is a strong urgeto contradict the client, pointing out the error in what they say.Because it is fundamentally unaccepting, it isn't helpful to say toa suicidal person something like `But you are so young, with somuch ahead of you.' This holds even if the therapist believes itto be true. Likewise, to say to someone who blames herself forbeing raped that she is not to blame probably isn't helpful. Itmay be that what she is doing is giving voice to her feelings ofshame and that when these are heard and responded to withempathic understanding and unconditional positive regard shewill be able to move on from them to her own recognition of herinnocence and to express her justi®ed anger.

Contradicting a client (for example by pointing out theirstrengths when they are identifying themselves as weak) ordistracting them from their feelings (by, for example, assuringsomeone in tears that they are a strong, capable, coping person)can be seen as an attempt to rescue the client from pain anddistress. Although this may arise from the desire to reassure,comfort and encourage the client it is about the therapist's need,not the client's. It may even be that the therapist is uncom-fortable with or upset by the client's distress. When there is even

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the slightest suspicion of this it is a matter for supervision andpersonal therapy.

Whatever the reason for the attempt to rescue the client, it isa failure to offer unconditional positive regard. For clients, theexperience is that their pain and distress have not been heard; orthey have been brushed aside. This is likely to make them seemshameful and unacceptable (when our feelings are unacceptedwe feel our person is unaccepted and unacceptable). Not toaccept that someone feels they would be better off dead isto reject an important part of that person's experience. Not toaccept that someone blames herself for getting raped is equallyrejecting. What is intended as reassurance actually blocks theclient's expression. Inadvertently and with the best of intentions,by not accepting clients as they see themselves therapists run therisk of creating whole areas of the clients' experiences thatcannot be brought to therapy.

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80Accepting the whole of the client: unconditionalpositive regard and configurations of self

The danger of positive reinforcement may be particularly evi-dent when the client has obvious `con®gurations of self' (Point27). There is often a temptation to respond to one or morecon®gurations at the expense of others especially if some seemmore constructive while others are inhibiting or even destruc-tive. It is important to respond to all aspects of the client and torespect and accept them equally ± even those that Mearns andThorne (2000: 115±116) call `not for growth' con®gurations.The examples they give of not for growth con®gurations includethose that want to retreat from the world and do nothing, thosethat want to return to some previous state and those that haveangry and/or aggressive feelings towards the therapist. Theyacknowledge that to pay attention to not for growth con®gura-tions can be very challenging for the therapist but point out that(p. 115) `the therapist must actively value this part of her clientas well as understanding its nature and existence'. Person-centred therapists are tasked with the responsibility to respondcongruently and with empathic understanding and uncondi-tional positive regard to the totality of the client. As Mearns(1999: 127) points out, it is not only one or even a few ofthe con®gurations comprising a client's self-concept which isimportant but all the con®gurations comprising that client andthe dynamics between them. He states that if any parts aremissed or banned from therapy because they are too dif®cult forthe therapist what results is a conditional and possibly counter-therapeutic relationship. It is important and helpful to remem-ber that all con®gurations of self, however `negative' they mayseem to the therapist, came about because they were useful ±indeed they may even have been about survival and/or protec-tion. Seen in this light, it is usually easy to comprehend thenecessity of extending unconditional positive regard to them all.

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Whether or not the concept of con®gurations of self makessense to you and even if it does and there are no apparentcon®gurations of self in the client with whom you are working,it still remains true that it is vital to accept the whole of yourclient regardless of how contradictory, self-condemning and self-deprecating they may be. To do otherwise is to deny the validityof your client's experience.

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81Developing your empathy

Empathy is the natural, innate ability of human beings to per-ceive the subjective experience of others ± it is usually used torefer to the sensing of the feelings of another but, at leastarguably, it applies to all other aspects of their current beingincluding their thoughts and visceral sensations. That is to saythat how the experience of another is sensed and what form thatsensing takes varies both from time to time and with individuals.In person-centred practice, whatever shape empathy takes ther-apists are aware that what they are sensing relates to theexperience of the other. It is an às if' experience. Therapistsaccurately perceive something of the inner frame of reference ofthe client as if they were the other person but all the timehanging on to the às if' awareness. It is not unusual for me toliterally `feel' empathy; that is to pick up on a physical sensa-tion. For others it is different. For example, one of my super-visees would `see' sometimes very elaborate images and whenshe described these to her clients their experience was of deep,accurate empathic understanding.

I (Wilkins 1997c: 8±9) and others (for example, Baughan andMerry 2001: 233±234) have made a case that empathy is a uni-versal human trait that has evolutionary advantages. Knowingsomething about the experience of others facilitates social livingand thus survival. However, for many of us, our experience of theworld leads us to lose touch with our empathic sense. There arethings we can do to reconnect with and enhance our ability toconnect with the inner experience of another. This is a process ofdiscovery (literally the uncovering of something) not of learninga technique. Indeed, to treat `becoming empathic' as a matter oflearning appropriate responses might very well result in becom-ing less empathic. Increasing the capacity for empathic under-standing is about discovering your own way of connecting withthe experience of others às if' it were your own. You may do this

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as perceiving thoughts, as feeling bodily sensations, as `seeing'images, as having a sense of transpersonal connection, as any orall of these in combination or in some other way altogether. Youmay sometimes get the às if' experience one way, sometimesanother. Discovering your ability for empathic understanding isabout tuning into and trusting these às if' sensations howevervague they may be. As with many things, it is practice that makesfor effectiveness.

Empathy is often spoken of as an art. If it is, in the ®rst placeit is the art of paying close attention to another. Empathicsensing is most likely to arise when you stay with and in yourclient's frame of reference. Needless to say, this isn't as easy as itsounds. We are all distracted at times and there are things wejust don't want to hear. Practice may help us deal with distrac-tion; personal therapy may help us expand our capacity to hear.The second àrt' of empathic understanding is to communicatewhat you have sensed of the experience of another. Thisimproves with time and practice. Initially, it is about respondingto what you have heard by making what are sometimes called`re¯ections of feeling'. With experience, it is possible and likelythat you will `hear' something which has not been said or com-municated directly via some other form of expression. This maybe in some form other than words. Communicating this tenta-tively to your client so that it can be easily accepted, denied oramended is likely to be helpful. If what you are doing is agenuine attempt to understand the experience of your client (asopposed to interpret it, offer some conclusions about it etc.)then even if you are wrong your response is likely to be wellreceived.

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82Communicating your empathic understanding

Empathic understanding involves connecting with and commu-nicating awareness of the client's meaning and experience. It ismuch more than parroting of the client's words and even of`re¯ection of feeling' (although that is sometimes a good place tostart). Each of us has our own way of being empathic. Often thistakes us beyond the client's words or outward expression. Forexample, I was meeting with a young woman client for the ®rsttime. She had a smile on her face and was talking in a bright andbouncy way. As she spoke, telling me how great her life was,I was aware that the ¯esh between my shoulder blades wascreeping and squirming and that I felt physically very uncom-fortable, even slightly nauseous. This physical discomfortseemed linked to emotional distress (although I could not tellof what kind). Although this appeared to have nothing to dowith my client's overtly expressed experience, I was sure thefeeling wasn't mine ± that it was an `as if' experience. So, ratherthan repeat to her what she had said, I told her about myphysical sensations and she burst into tears telling me that washow she felt all the time. Because I had somehow sensed thelevel of her distress, she was able to connect with it in mypresence and to tell me about what lay behind it.

An important thing about this story is that, although myempathy was what has been described as `somatic empathy' or(Cooper 2001: 222±223) `embodied empathy', to communicate itto my client I had to use words. Similarly, for those who`receive' visual images the most usual way of communicatingthem is to describe in words the content of the image. Evenwhen we are responding directly to what a client has said, it isusually best to avoid `parroting' the exact words spoken(because this can be perceived as involving only a super®cialunderstanding of the communicated experience). There is alwaysmuch more to communication than the words spoken. Tone,

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pacing, facial expressions, posture and your own inner experi-ence all add something to the content and meaning of what isbeing expressed. All these enhance the empathic connection.

In responding empathically, using exactly the same words asthe client can seem like a passive, automatic response so it isusually best to translate what the client said into your ownwords because this demonstrates a real effort to understand ±and, more sophisticatedly, allows you to respond to what hasbeen expressed non-verbally. To do this and to communicateempathic understanding as fully as possible it is really helpful tohave an extensive vocabulary ± perhaps especially of words foremotions and emotional states. This is because to communicatewhat you have thought, felt, `seen' or otherwise sensed às if' itwere your own experience as accurately as possible it is helpfulto have as many words as possible at your disposal. It is alsobecause English is a very rich language and has many words forfeelings ± these have nuanced differences (for example, considerwords connected with fear ± worried, scared, frightened, terri-®ed, anxious, panic-stricken all have different meanings) ± usingthe one closest to what your client has communicated (regard-less of which was spoken) is likely to result in a greater sense ofbeing understood. However, sometimes using the same word asthe client is exactly the right thing to do. Sometimes, regardlessof what you might think is an equivalent word or a better wordfor what your client is expressing, the client in effect rejects yourword by re-stating their own. For example, the client says à bitscared', responding to the intensity of feeling you sense (sweat-ing, shaking, quavering voice), you say `terri®ed' but the clientrepeats à bit scared'. This probably means either your clientdoesn't understand you or, more likely, the word they are usinghas particular weight and meaning for them and it is importantthat you `hear' it. In such cases repeating the client's words isthe most helpful thing you can do (even if your client is terri®ed,not merely a bit scared).

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83Facilitating the client's perception of therapistunconditional positive regard and empathy

At ®rst glance, there is not much difference between the ther-apist's attempt to communicate unconditional positive regardand empathic understanding and the client's perception of them.However, the 1959 version of the necessary and suf®cient con-ditions is concerned with the client's perception and this issomething about which person-centred practitioners and theor-eticians have been thinking and writing recently (see, forexample, Wyatt and Sanders 2002). And there are indeed subtledifferences between `communication' and `perception'. Whatthe therapist `communicates' is not necessarily perceived. Forexample, there is a possibility that your empathic sensing will be`right' but denied by the client. To illustrate, as a young man andclient, I was `told' by my therapist that I was angry. In my self-concept, anger was a sub-human emotion, beneath my dignity. Icould not understand why my therapist was suggesting I might beangry. While it didn't irreparably damage our relationship Icertainly went away with a different view of her skills. Of course,she was absolutely right and had accurately communicated herempathic understanding but I didn't realise that for years. Shehad gone beyond my `edge of awareness' into some part of methat I could not/would not admit into awareness. I was unable toperceive my therapist's empathic understanding. So, in effect, inthis case condition six was not met. `However accurate it may be,will my client be able to receive it' is something to bear in mindwhen offering empathic understanding.

The situation with respect to unconditional positive regard issimilar ± but different. As explained in Points 77 to 79, thecommunication of unconditional positive regard is less to dowith what is said and more to do with the therapist's attitude tothe whole of the client. The client's perception of unconditionalpositive regard relies upon the sincerity of this attitude. In a

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way, for most of us, perceiving the unconditional positive regardof another is the greatest challenge for it undermines the core ofthe `self' that has arisen through our experience of the world(and the `self' as distinct from the organism is an adapted andadaptive structure `built' for protection and defence). Withrespect to facilitating the perception of unconditional positiveregard perhaps what is necessary is patience, consistency andgenuineness ± of intent and of acceptance.

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84The therapist-provided conditions as a whole:preparing for and facilitating `presence' and/or`relational depth'

Although there is general agreement that `presence' (Point 25)cannot be brought about on demand and that it is somethingwhich `just happens' when there is a peculiar and particular setof circumstances, paradoxically, some practitioners do thinkthat there are things that may be done to enhance the possibilityof this special state in which both parties are transformed. Forexample, Geller and Greenberg (2002: 77) indicate that it ispossible to prepare for the possibility of `presence' in such a wayas to increase the likelihood that this will happen. They discussstrategies of two types; those that are implemented immediatelyprior to or at the beginning of the session and those which areabout the way of being of the therapist ± what they call `in life'preparation.

The former involves actively `clearing a space' by deliberatelyputting away personal concerns and the letting go of self-concerns and issues. This is sometimes called `bracketing'. Thisallows the therapist to approach the client with an attitudeof openness, interest, acceptance, and in a non-judgementalmanner. The therapist approaches the client with naõÈvety of aspecial kind, a not-knowing combined with an openness toknowing whatsoever there is to know (the client is the expert, any`knowledge' the therapist brings to the interaction is of at bestsecondary importance and the task is to understand the client'ssubjective experience almost as if the therapist was `inside' it).

In life preparation involves a philosophical commitment topresence in the daily life of the therapist. This includes a `com-mitment to personal growth as well as practising presence intheir own lives, with friends, partners, and in everyday encoun-ters'. Daily meditation is also seen as a way of preparing for

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presence as is attending to the personal needs and concerns ofthe therapist on an ongoing basis outside the session.

Geller and Greenberg (2002: 77±80) go on to discuss what thetherapist does when in presence in a session with a client. Theysay that this involves:

· Receptivity ± that is (p. 78) `fully taking into one's being ina palpable and bodily way, the experience of a session'. Thisreceptivity is multi-sensational involving all channels ofperception (kinaesthetic, sensual, physical, emotional andmental). It is a process of àllowing', letting in experienceand allowing it to ¯ow freely through the therapist's self.

· Inwardly attending ± this is about the therapist attending totheir inner ¯ow in response to the received experience. Thisinward attention allows therapists to use themselves asinstruments trusting their spontaneous reactions and torespond to the client by conveying the inward experiencewhich may be in the form of (p. 79) ìmages, visions,intuitions, guiding voices, techniques, emotions or bodilysensations'.

· Extending and contact ± this involves therapists extendingthemselves and their boundaries in such a way as to meetand contact their clients in an ìmmediate' way. Extending(p. 79) ìs the act of emotionally, energetically and verballyreaching outwards to the client, and offering one's internalself, images, insights or personal experience'. Contact (p. 79)ìnvolves directly encountering and meeting the essence ofthe client, whether in shared silence or in verbal expression'.

Although they don't use quite the same language, in theirdiscussion of `facilitating a meeting at relational depth', Mearnsand Cooper (2005: 113±135) suggest very similar strategies andattitudes. They write about the importance of:

· the therapist `letting go' (of aims, lusts, anticipations andtechniques) (pp. 114±118)

· high-quality attention to the whole of the client and theclient's experience (pp. 118±124)

· an openness to being affected by the client (pp. 124±126).

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Arguably, although these strategies are presented as thosefor the facilitation of presence and meeting at relational depth,they are simply those that will enhance any person-centredencounter.

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Section 6PERSON-CENTRED

THEORY ANDPRACTICE WHENWORKING WITH

REACTIONS TO LIFEEVENTS

85Person-centred therapy and the `one size fits all 'approach

Amongst at least classical client-centred therapists there hasbeen a traditional resistance to the idea of describing person-centred ways of working with different client groups. This isbecause, ideally, person-centred therapists should have exactlythe same way of being in response to any client no matter whatbrings them to therapy. That is to say, no matter what theclient's experience is or how they view themselves and the world,the person-centred therapist is charged with responding non-directively and in such a way as to offer the therapist-providedconditions of congruence, unconditional positive regard andempathic understanding. That is to say that person-centredtherapists take their direction from their clients, work at theirclients' pace and in accordance with their clients' ways of being.Nothing more is necessary and, indeed, it is argued that tointroduce more may be counter-therapeutic. It is the quality ofattention that is important not expert, theoretical knowledge ofthe client's situation, life experience or reactions to life events.As Bozarth (1998: 100) puts it, `contamination occurs whentherapists assume they know what is best for clients, what iswrong with clients or in what direction clients should go'. At thevery least such knowledge brings the danger of distraction fromthe client's actual experienced process (see my story in Point 67)and the valuing of the model in the therapist's head over whatthe client is actually experiencing. Also, clients are whole peoplewith a range of emotions, thoughts and reactions. Nobody is(for example) just a user of drugs or alcohol, nobody is just asurvivor of abuse, no one experiences bereavement and onlythat. To put knowledge of such reactions to life events at theforefront of practice or to treat different clients differentlybecause of what has happened to them (rather than because ofwhom they are and their way of being in the world) is a mistake.

WORKING WITH REACTIONS TO LIFE EVENTS

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However, just as a thorough grounding in person-centred theoryis essential to good person-centred practice, so it can be helpfulto have some knowledge of the ways in which person-centredtherapy can be done with people who have certain life experi-ences. This is less to do with how to be with the clients (althoughsuch knowledge may be helpful in aiding therapists to pick upsome of the more subtle signs and communications) and more todo with aiding therapists to deal with their own uncertainties.

However, if held lightly, theory and knowledge of particularlife experiences can help therapists stay with their clients.Having some understanding of what may be happening for aclient allows the therapist to remain congruent and thus moreable to experience unconditional positive regard and expressempathic understanding. It is imperative that knowledge is `heldlightly'. Theory is a general statement about people rather thanstatements about a particular individual and the same is true forknowledge of reactions to life events. Nobody exactly followsthe text book and some may have experiences very far fromthose described.

The next few Points explain and examine how person-centredtherapy is practised with clients who are experiencing reactionsto speci®c life events. This is meant to indicate and exemplifythe applicability of person-centred therapy. To do this, I havesummarised, adapted and added to the work of experiencedpractitioners with particular client groups as this appears in aforthcoming text (Tolan and Wilkins, in press). It is not anexhaustive list and it is most certainly not a set of prescriptionsfor person-centred ways of working. The client and the client'sactual experience always come ®rst.


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86Person-centred theory and loss and bereavement

Many current approaches to loss and bereavement can bedescribed as `stage' or `phase' theories. That is, they describe theexperience of grieving as a psychological process including feel-ings such as numbness, denial, yearning, anger, depression andacceptance. Additionally, they suggest that the `business' of griefand mourning is to ®nd a way of letting go of the lost object orperson in order to be able to move on with existing relation-ships, to move forward toward new relationships and generallyre-engage with life.

Haugh (in press) points out that these stage theories are usefulinsofar as they have helped to `normalise' different reactions togrief in a way that has helped therapists to stay with their clients'processes. However, as with any theoretical knowledge, there is adanger that the idea of a grief process will be taken too literallyand interpreted as being ®xed phases through which a bereavedperson must be helped to pass. This is an error. She goes on tosay that the process is not necessarily linear, it ebbs and ¯ows.Moreover, it is individual. No two clients grieve in exactly thesame way. To put the notion of a grief process before the client'sexperience can be counter-therapeutic because it may involve theloss of unconditional positive regard (the client is doing whatshould be done) and empathic understanding (the therapist doesnot `hear' what does not ®t the model). Similarly, the idea thatgrief is something to be surmounted does not sit easily withperson-centred theory.

In terms of person-centred theory, it is more important tounderstand individual reactions to bereavement and loss than tograsp some global process. In terms of classic client-centredtheory, it is the notion of the self-concept which helps to explainthis (in terms of additions to person-centred theory, con®gura-tions of self also has relevance).


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The self-concept, operating through conditions of worth or asan expression of the organism, may dictate individual reactionsto bereavement. Haugh (in press) gives the example of Andrewwho when faced with bereavement had no tears to shed, eventhough he was feeling distraught and distressed. She says thatthere are two theoretical possibilities here. Firstly, althoughAndrew felt deeply affected by his loss, his lack of tears was hisself-concept in congruence with his organismic experiencing.That is his lack of tears was a psychologically healthy response.On the other hand, if, for example, he had a condition of worthto the effect that `big boys don't cry' although his organismicexperiencing may include expression through tears, his self-concept would deny or distort this expression to awareness. Hemay just feel sick (distortion) or have no feelings of tears at all(denial).

So, what looks like the same reaction in different individualsmay have different roots. This is an important point in relationto cultural differences and bereavement. We should not makethe assumption that the healthy grief reaction known to usthrough our cultural lens ± whatever that lens may be ± will beequally healthy for those from cultures other than our own. Or,to put it another way, our reactions to bereavement areculturally embedded and healthy grief reactions vary substan-tially across cultures.

Finally, Haugh (in press) points out that with respect to aperson-centred understanding of the grieving process andindividual reactions to bereavement, it is wise to be cautiouswhen thinking about what is `healthy'. From a person-centredperspective, a healthy grieving process is the one the client isexperiencing because (by de®nition) a person reacts in thehealthiest way for them at the time. It is not possible to knowparts of their self-concept are being protected by their currentway of being. What is called for is trust in their actualisingtendency and commitment to the knowledge that clients knowbetter than an outsider (for example the therapist) what it is theyneed at any particular time. This is why it is a mistake to thinkin terms of directing a client towards addressing their issues ofloss or to assume that there is a particular process they shouldfollow.


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87Person-centred practice with clients experiencingloss or bereavement

Writing of her practice with bereaved people, Haugh (in press)states that in person-centred terms, the purpose of grieving is toenable a bereaved person to integrate their loss into their lives inwhatever way is right for them. This presents a challenge to allperson-centred practitioners to be open and accepting of allways in which a person responds to their loss and to hold theoryso lightly that no client is ever forced into a theoretical box. Foralthough responses to loss can be generalised to some extent,each person is unique, with a unique past, present and future,with unique con®gurations of self and unique conditions ofworth. In the climate of the necessary and suf®cient conditions,the bereaved client's actualising tendency will prompt them togrowth, healing and resolution as and when these are appro-priate for them. In other words, clients can be trusted to dis-cover those aspects of themselves that are causing anguish andtherapists can trust their movement towards health.

She goes on to say offering unconditional positive regard tosomeone experiencing bereavement means being fully acceptingof whatever, and however, the bereaved person is feeling andthinking, irrespective of whether the loss was two days ago ortwenty years ago and whether it is the death of a parent, childor partner or because the budgie has escaped. This includes thepossibility that the person may not be feeling or thinkinganything in particular in relation to their loss. It can never beassumed that a person will be feeling one way or another withrespect to whatsoever the nature of their loss. It has to besupposed that the way they are responding is the best for themin this moment.

Empathy, as expressed through empathically followingresponses, is the most uncontaminated way of expressing uncon-ditional positive regard. So, working with a bereaved client is ®rst


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and foremost about empathising with them, whatever they areexperiencing, whether that has to do with their loss or not. If theyare expressing extreme distress about their loss, the task is toattend to that expression. Likewise if, in the next moment, theyare working out what to have for dinner attention should bepaid to that exploration. Having a process model of grief in theback of the mind when working with a bereaved client may behelpful ± at least in as much as knowledge of the variety offeelings someone experiencing loss may display can aid uncon-ditional positive regard and, particularly if they are subtly dis-played, promote and facilitate empathic understanding ± but thisis something to let go of in the light of the client's expressedexperience not clung to regardless.

According to the `self-concept' explanation for the process ofgrieving, it is sincerely held person-centred attitudes and adetermined effort to congruently experience unconditionalpositive regard for the client and to express empathic under-standing of their experience that helps them move through theirnecessary process. In such a psychological climate, the clientbegins to feel safer and their self-concept begins to loosenbecause they do not need to protect those aspects of themselvesthat were previously met with conditional positive regard. Thisloosening means that previously denied or distorted material canbe admitted to awareness. As the self-concept becomes more¯exible it becomes more at one with the organismic valuingsystem. In other words, the person becomes less incongruentand more congruent. When working with someone facing loss,this move from incongruence to (more) congruence is facilitatedby a therapist who is able to accept and understand all aspectsof their grief, including those aspects that are not concernedwith their grief. The task is not to facilitate progress through apre-determined process but to respond to the client's particularand personal process whatever that might be. The aim of theperson-centred therapist is not to take away the pain of loss butto be a companion through the darker hours.


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88Person-centred theory and client reactions to beingabused as children

Although it is a common experience for person-centred ther-apists (similarly to therapists of other kinds) to encounter clientswho have been abused as children, there is little in the classicclient-centred literature about child abuse. This is largelybecause, for the most part, person-centred therapy is a way ofbeing with a client regardless of what brings that client totherapy or what emerges in the course of therapy. However,Rogers did put a child's relationship with its carers at the heartof his theory about the development of self, and some of hiswritings are particularly helpful in understanding an abusiveadult±child relationship. He described a deteriorating relation-ship (1959: 237±240), applied his personality theory to familylife (1959: 241), and touched on behaviours which might now beascribed to an abuser (1959: 229). It is only recently that person-centred writers have begun to address abuse. Examples includeHawkins (2005, 2007) and Warner (2000). For the most part,those writing about abuse from a person-centred perspective areaddressing it in terms of the dynamics of power (Point 37),`dif®cult process' (Point 36) and/or con®gurations of self (Point27). However, the experience of childhood abuse can also beframed in terms of the necessary and suf®cient conditions.

In effect, for the abused child, the mutual conditions aredistorted and perverted, the incongruence of the child is extremeand the therapist-provided conditions are reversed and distortedby the abuser. Arguably:

1. An abused child experiences `traumatic contact' (seeCoffeng 2002: 153±154) often including violation of notonly psychological boundaries but also bodily ones. Thiscan result in the child withdrawing from contact and gener-ating one or dissociative states.


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2. Rather than merely feeling vulnerability and anxiety, anabused child experiences terror and fears annihilation. Thesubsequent disjuncture between self-concept and the organ-ism leads to extreme incongruence.

3. The abuser is incongruent in the relationship, distorting,denying or dissociating from the harmfulness of theirphysical, emotional and/or sexual violence and their neglectto care for or supervise the child.

4. The abuser expresses conditional, negative or abusive regardor disregard for and towards the child.

5. The abuser does not experience empathic understandingof the child's internal frame of reference, and/or abusesempathic understanding of the child.

6. The abused child perceives the lack of regard and lack of ordistortion of empathy and incorporates them.

This leads the child to a perception of her or his self as lackingpower and being socially isolated as well as increasing thedisjuncture between self-concept and the organism by theacquisition of conditions of worth. Power (in press) argues thatthis reversal of the therapist-provided conditions by an abusercauses the child to experience a huge psychological and physicalthreat to her/his organism. Indeed abuse is experienced cog-nitively, emotionally and somatically and the abused child istransformed accordingly. This leads to extreme incongruencelikely to include distortion and denial of the abuse and perhaps adissociative process. Certainly, there will be an introjection ofnegative values and conditions of worth. Moreover, the imposedneed for secrecy ampli®es the abused child's feelings of power-lessness and isolation. Abused children may habitually fear theirorganismic responses in case something should slip out.

Abuse can have a profound effect on the child's still-developing self. As with other traumatic life events, abuse canlead to dissociation. The many different feelings and contra-dictory values may need to be `shared out' more safely betweendifferent aspects of self or even, subjectively at least, differentselves. Different aspects have different roles. Highly contra-dictory and extreme feelings may be threatening to the self-concept, but are felt nonetheless, and need to be handled


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somehow: murderous hate towards the abuser; anger towardsthemselves; enjoyment of the contact afforded by abuse. One ormore of these splintered or scattered aspects may be hiddenfrom other people and even from other aspects of self. Indeed,abused children do have to develop different selves in theirvarious environments, for instance to deny their experiences ofabuse from the night before, in order to behave well at school.Practical experience with clients who have experienced abuseand trauma as children has identi®ed extreme incongruence andthe development of plural selves as directly related to earlychildhood dif®culties. Although childhood abuse is not the onlycause of it, this phenomenon has been noted by Mearns andThorne (2000: 101±119) with their concept of `con®gurations ofself' (Point 27) and Warner (1998, 2000) in her theories of`fragile and dissociative process' (Point 36).


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89Person-centred practice is effective with clientsabused as children

First and foremost, as with all clients, the ®rst thing to graspabout doing person-centred therapy with people who have beenabused as children is that it is the client who is at the centre of therelationship, not the abuse. Each person's experience is uniqueand although there may be some common themes in the stories ofpeople abused as children, they will not be uniform or formulaicand not all `expected' threads will be in every story. Power (inpress) points out that, moreover, abused people often have con-tradictory ideas about their abuse. They may be at once outragedby what has happened to them, so deeply self-critical, so that evenwhen they experience their therapist's positive regard, it is hardfor them to shift their deeply held conditions of worth and evenhave some warm (or at least ambivalent) memories of the abusiverelationship and/or abuser. Needless to say, it is the task of theperson-centred therapist to unconditionally accept and empathi-cally understand the client's current experience regardless ofpersonal reactions to and beliefs about the effects of childhoodabuse. This will probably include empathising and respecting thepart of the client that loved, or still loves the abuser. Generally, itwould be a mistake to challenge the perception the client has ofthe abuser whatever that may be.

As Power (in press) asserts, there is no formula for workingwith abuse issues: each child experiences cruel treatment indifferent circumstances at the hands of different people and sofeels its effects uniquely and learns to handle them, as a child andan adult, in their own way. If they come to therapy with a person-centred practitioner they can choose to work with these experi-ences (or not) in their own way, in their own time. Abused peopleare not merely the product of an abusive relationship. Theymay well have other issues and it may be important to them tobe recognised for who and what they are as well as someone who


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has experienced abuse. A therapeutic encounter with an abusedperson will not necessarily have anything to do with the abuse ±at least not in terms of content. Regardless of how `important'the abuse may seem to the therapist it is not for them to set theagenda. As always, the person-centred therapist's task is toextend unconditional positive regard to the client and respondwith empathic understanding regardless of whether or not theclient is addressing the issue of abuse. That said, when workingwith people who have been abused as children, it is helpful tohave some awareness of how life can be for an abused child andhow this can play out in adult life. This includes the possibilitythat the client may dissociate in the course of a session. Warner(2000: 167±169) discusses the importance of recognising when aclient might be dissociating and how to connect with dissociatedparts (Point 36).

Perhaps there are additional issues to be addressed whenworking with an adult abused as a child. Such people may benaturally distrustful of everybody and, on some level, expect allcontact to be abusive. This may be especially true when meetingsomeone perceived to be in a more powerful position (that is thetherapist) in a closed (`secret') one-to-one meeting. Any attemptto convey the therapist-provided conditions may be perceived asa pretence. This calls for patience, consistency and clarity aboutthe terms and conditions of the relationship. There are hugeissues around power and control for abused people, so develop-ing a collaborative process throughout the relationship andparticularly during contracting may be the ®rst opportunity fora client to exercise some personal power in a relationship.

For many clients abused as children, being in therapy is tough.The process of bringing memories of abuse into awareness, andall the hidden feelings surrounding them, can be extremelydif®cult. Some clients bring their experiences of childhood abuseto therapy at the outset; others develop awareness duringtherapy. It is the congruent expression of unconditional positiveregard and responding to the client's story, dif®culties in tellingthe story, ambivalence about the abuse and so on that provides aclimate in which the client can explore the abusive experience andits effects to the extent that is right for them at that time.


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90Post-traumatic stress and responses to criticalincidents may be understood in terms of person-centred theory

We all have a self-concept ± an organised con®guration of per-ceptions of the self which are admitted into our awareness. Putsimply, it is who we think we are and includes an expectation ofhow we will react in predictable situations. It also includes anunderstanding of the environment in which the person lives (the`world concept'). In the normal course of events things happenin life which comfortably ®t within our self-concept or aresuf®ciently close to it for us to make minor adjustments to itwithout dif®culty or anxiety. Turner (in press) notes that ifsigni®cant events are way beyond our expectations we havedif®culty in symbolising them in awareness. A traumatic eventcontains elements that are likely to be so far beyond our pre-vious experience that we initially ®nd it dif®cult to incorporatethe new experience within our self-concept. Such traumaticevents include `critical incidents'.

Turner (in press) de®nes a critical incident as one in whichsomeone was killed or, at the time, there was good reason tothink that someone might be killed. The reaction of thosewitnessing the event is horror. People often react in ways theywould not have predicted before the event. Those whose self-concept predicts that they will function well sometimes end uphiding in the toilet or a cupboard. Conversely, sometimes thosewho would expect themselves to be paralysed and powerless totake action by such an event are not. A person's introjectedimage of self may be incongruent with their organismic self. Thecritical incident highlights this.

Turner goes on to say that responses to trauma and criticalincidents are various but they are susceptible to a person-centredexplanation. For example, it is very common for people whohave witnessed or been directly involved in a critical incident to


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have disrupted sleep and disturbed and disturbing dreams. Inperson-centred terms, dif®culty in sleeping may be understoodas due to excessive brain activity because the mind has not yetassembled a coherent symbolisation of the event. After a day orso the feeling of a `racing mind' diminishes and then the dreamsare likely to start. The mind is continuing the same process, thatof making order out of chaos. From the individual's perspectivethis means explaining the inexplicable and bringing meaning tothe meaningless. Dreams can be seen as the continuation ofun®nished emotional work ± that which is not yet accuratelysymbolised continues to be worked upon. Unfettered by thedemands and rationale of the waking world the mind canexplore a wide range of possibilities in its search for meaningand explanation. The actualising tendency is doing its work:prompting the organism to symbolise experience in awareness asaccurately as possible.

Sometimes the threat to the self-concept following a trau-matic incident is so great that an intolerable incongruence iscreated and some people solve that dif®culty by denial or dis-tortion of awareness. The incongruence causes their mind to`blow a fuse' every time they think about it so the solution theyadopt is not to think about it and thus the normalisation processis frustrated or even stopped. This may result in what is some-times called `post-traumatic stress disorder' or PTSD. It is the`avoidance' of psychologically processing the event and its realmeaning that promotes the development of PTSD. This isbecause the person's reactions to the experienced traumaticevent are so shocking and so far beyond their self- and world-concepts that they are unwilling, or unable, to reconstruct theseto incorporate the new awareness. In effect, this threatens theexisting concept of the `self ' with extinction. Faced with annihi-lation of self, it is not surprising that people ®nd the newawareness dif®cult to embrace. Even those willing to attempt itundertake an extremely dif®cult task.


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91It is possible to offer person-centred therapy topeople who have experienced a critical incident orother traumatic event

Writing of his experience with people who have experienced atraumatic event, Turner (in press) states that, although someperson-centred therapists take the view that in responding to aperson who has experienced a traumatising event all that isrequired is adherence to the necessary and suf®cient conditions,there are other strategies available to those working in a broaderperson-centred framework. One such approach is `psychologicalprocessing'. This involves a structured meeting which gives theclient an opportunity to understand the facts of an event withparticular reference to sensory memories. In addition linksbetween cognitive and emotional memories are observed. Lastly,the client is helped with normalisation by having commonlyoccurring reactions and responses explained to them. Groupsessions are more helpful than individual sessions in the earlystages particularly for a complicated event. A complicated eventis one where a single person's eyewitness account of the event isunlikely to fully explain it because signi®cant physical aspects ofthe episode occurred in more than one place at a time.

In incorporating the reactions to a traumatic event intoawareness, processing it is vital. As well as understanding whatactually happened, the exact sequence of events, who did whatand when, it is necessary for those involved to make sense of it. Inthis process the debriefer (that is the person facilitating thepsychological processing) pays great attention to helping theclient(s) construct a detailed and accurate picture of whathappened. Although for many people their actualising tendencycan be trusted to aid them in recovering from the traumatic effectsof a critical incident, psychological processing seems to acceleratethe process which is then also more complete and robust. Thisassists the process of symbolising what has happened by offering


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the conditions of unconditional positive regard, empathy andgenuineness. Within such an accepting framework, the indivi-dual can be supported in remembering accurately what happenedand begin to incorporate the experience into his or her self-structure. Psychological processing also seems to help clientsprocess earlier traumatic events they have experienced as well asthe current one.

In person-centred therapy with a person who has experienceda traumatic effect, the most important task is for the person tosymbolise the new, and often painful, knowledge which is theconsequence of the event. Until they are able to do this they livein a state of incongruence between the world they want to live inand the self they see living in that world, and reality. They aretrapped between two worlds, one dead, and the other powerlessto be born. Although it may at ®rst seem directive (supplying aclient with information they might not have but which would beuseful for them to know), if it is done sensitively, in a climate ofunconditional positive regard and empathic understanding andwith respect to the client's experience and frame of reference,this is not necessarily so. Even person-centred therapists whouse psychological processing when working with clients whohave been traumatised may choose to explain to the client thatexamining the traumatising event closely may be helpful. Thiswill involve describing and thinking about as many aspects ofthe event as possible. A person-centred way of doing this is tofacilitate (but never pressure or even persuade) the client to enteras fully as they can into this process. This helps clients toconstruct the foundations upon which to build an accuratesymbolisation of the event.

It is vital that the client has a genuine choice in deciding howthey want to tackle the task and it may be that, for some clients,the therapist need only employ the therapist-provided conditionsas the client explores aspects of their experience. However,person-centred therapists who do critical incident work reportthat, for the most part, traumatised people opt to start bytalking about the event itself. They know that they will beoverwhelmed if they expose too much so it is always safe to trustthe client's own judgement in such matters. Just as is the casewhen working with clients who have been abused, traumatised


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clients will carefully check that it will not harm the therapist tohear their stories. As the client increasingly trusts that thetherapist is strong enough to hear their story, it can start toemerge in a way that can allow accurate symbolisation of theevent and its consequences.


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92In person-centred theory, `depressed process' ispreferred to the concept of depression

There are few references to depression in the person-centredliterature and yet most person-centred practitioners come acrossclients who describe themselves as `depressed' or who are referredto them because of `depression'. There are two main reasons whythis is so. The ®rst is the person-centred resistance to diagnosisand the second is the person-centred belief that therapy is aboutresponding to a person with unconditional positive regard andempathic understanding, not to a `problem'. From a person-centred perspective, when someone says they are depressed theyare describing their subjective experience, not offering a diag-nosis, still less one that requires responses of a particular kind.Moreover, although this subjective experience usually includessome or all of several emotional, cognitive, somatic, social andbehavioural aspects everybody's experience of depression isdifferent ± even the same client may not mean the same thingtwice.

Sometimes clients feel depressed after being physically ill.Sometimes clients may say they are depressed because they aresad or grief-stricken. Sometimes they are reporting an absenceof feeling and general listlessness, sometimes they mean they aredesperate and that life is pointless. Sometimes they mean some-thing else entirely. Rowland (in press) says that perhaps ratherthan depression a more person-centred way to conceptualise theclient experience is in terms of depressed process. In this way,the emphasis shifts from labelling the client to focusing on theclient's experience.

People with depressed process function and think moreslowly and less clearly than usual. Their ability to make contactwith other people (including the therapist) is reduced. They seethemselves as functioning less well than usual and often areunable to perform their role as effectively as normal. Their sense


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of perspective can disappear: they see only what is going oninside themselves. They report feeling a very limited range ofemotion. They do not think they are coping with life, whatevertheir life may look like to others. Their perception is selective,so that they see only failure, misery, and gloom in andaround themselves. They may not sleep well, or may sleep muchof the time.

Rowland takes the view that depressed process can be seen asresulting from incongruence. It is about the distortion or denialof an experience as it is perceived organismically. This may be areaction to loss or trauma or something else. It is essentially aself-protective mode ± even if a maladaptive one. Staying withthe client in their journey is the key to working in a person-centred way with people who are in depressed process, as it is toworking with any client.

In the light of some current person-centred thought, it isimportant to realise that depressed process may very well be aresponse to environmental or social factors and conditions.Someone in ®nancial dif®culty or who is poorly housed may verywell be `depressed'. Similarly social isolation can be depressing.However, not everyone responds to such stimuli in the same way.There are always personal, familial and social reasons why oneindividual responds to an event with depressed process andanother does not.

Rowland states that it may be that depressed process has itsorigins in early loss. For example, children are often `protected'from loss and not allowed to grieve when a family member,friend, or pet dies. The child does not get the chance to symbolisethe loss accurately, or the loss is denied to awareness. Theprecipitating event in the recent past is not the cause, rather it isadded to many events in the past which were not acknowledgedor accurately symbolised. There can be many causes, but thedeath of someone close, adoption, frequent moves of home, aparent who is unable to respond to the child's needs (perhapsbecause they are themselves depressed), abuse, or being sent toboarding school are all common in the background of clientswho present with depression. Any of these make clear to the childthat they are not in control of their world. When the emotional orphysical boundaries of the child are not respected and the child is


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abused, the child, and later the adult, may struggle to know andmaintain their boundaries. In extreme cases, the client maybecome profoundly incongruent, which in mental health termin-ology would be called psychotic depression.


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93A person-centred way of working with depressedprocess

Drawing on her practice with people experiencing depressedprocess, Rowland (in press) says it can be very hard to stay witha client in despair and extensive personal growth work on thepart of the therapist in which their own deep fears have beenconfronted and addressed is likely to be bene®cial in this pro-cess. It is really important that the therapist is able to hear andreceive even the most gloomy, self-abnegating, self-destructivewords and feelings of the client with understanding and accept-ance. Indeed, the therapist may be the only person in the client'scircle who is able and prepared to do this. Others may reject orpull away from such painful feelings or attempt to jolly (orbully) the client into a more positive frame of mind.

She goes on to say that clients in depressed process have oftentried a variety of ways to overcome their feelings. They havetried to think positively and failed. If they have been told tothink positively they may add this failure to the long listof things they have failed to complete, or to start, and viewthemselves as ever more unworthy of help or support. Feelingworthless is often a reaction to depressed process as well as partof it. It is a sort of double-whammy ± not only does the clientfeel awful but they also feel awful for feeling awful. Reassuringclients that they are entitled to feel bad without blaming them-selves is a mistake. The therapist's unconditional positive regardfor the whole client (that is accepting not only the `depressed'feelings but the guilt of having them) and empathic responses toall experienced thoughts and feelings however contradictory orillogical is what is required.

In Rowland's view, when working with someone experiencingdepressed process it is essential to work within their agenda forchange. A common goal for people who are depressed is toreturn to the way they were. They want to be able to cope again


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and not necessarily to address the issues that led them intodepressed process in the ®rst place. Whatever conclusions andhunches the therapist may have about `underlying causes' of thedepressed process, they must accept and empathise with the not-for-growth part(s) of the client as well as the parts that want togrow. Not all clients want to explore the past. Some want thecurrent pain to stop and do not go further.

As with all clients, when working with a person in depressedprocess the direction of therapy is not always apparent to thetherapist. It may seem that the client is talking about minor issuesand avoiding deeper ones. This is common in any therapy andcertainly in clients with depressed process. However, it is axio-matic in person-centred practice that, given the necessary andsuf®cient conditions, clients will be prompted by their actualisingtendencies to do what they need to do for their growth andhealing when they need to do it. As with person-centred therapywith clients of any other kind, working with clients in depressedprocess is a matter of offering the therapist-provided conditionsto the best of the therapist's ability and (in that somewhathackneyed phrase) `trusting the process'.

In an accepting, empathic climate, clients in depressed processmay express the depths of their despair. They may signal this bysaying something like `there is no point in living' or `I'd be betteroff dead'. Often, this is a way of conveying the intensity of thebleakness they are experiencing and how tired they are of it.Sometimes the client is actually expressing a wish to die becausedeath seems preferable to living with depression. Distinguishingbetween the two is not always easy. In person-centred terms, eachdemands an empathic and accepting response and it is certainly amistake to assume that a client who talks about being dead isexpressing an active intention to die. However, working withclients who say and mean they want to die poses legal and ethicalissues. If, after checking in a reasonable, practical way, it seemsthe client means to commit suicide, this is something to beaddressed in accordance with the codes of ethics and practiceunder which the therapist operates.


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94Panic and anxiety can be understood in person-centred terms

In person-centred terms, anxiety is seen primarily as a productof incongruence. It exists when a person's self-concept is underthreat. In other words, according to Bryant-Jefferies (in press),we are anxious when experiences that have been or are beingdenied to awareness or distorted in how they are symbolised inawareness (in order to maintain consistency within the person'sself-concept) are threatening to, or are beginning to, break intoawareness. In this sense, anxiety arises from the promptings ofthe actualising tendency to somehow deal with the denied ordistorted experience. Anxiety and panic may be seen as `symp-toms', effects, evidence of deeper psychological processes, ofcon¯icts within the person's psychological make-up. Anxietytells us something about ourselves, it is a kind of warning signthat something is happening, something is moving and shiftingwithin us, some form of psychological con¯ict or dissonance isthreatening to break into awareness.

Bryant-Jefferies goes on to say as incongruence between aperson's self-concept and their organismic experiencingapproaches symbolisation in awareness, anxiety results. As thisdifference or discrepancy becomes more apparent, any defensiveresponse to threat becomes increasingly dif®cult to achieve ormaintain. Anxiety is therefore seen as the response of theorganism to the `subception' that such discrepancy may enterawareness, which would then force a change in the individual'sself-concept (Rogers 1959: 204).

The individual's ability to selectively perceive his or herexperiences in term of the conditions of worth which havecome to exist in him or her becomes unstable and potentiallyunsustainable.

He considers the severity of the anxious reaction experiencedwhen a person subceives their self-concept as threatened re¯ects


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the degree of difference between what is admitted into awarenessand the content of the new experience the organism and theactualising tendency are propelling towards symbolisation inawareness. For example, a person who has always seen them-selves as strong-willed and coping well with whatever the worldthrew at them may experience much more anxiety when con-fronted by a situation beyond their in¯uence than someone whohas no expectation of always being in control. For the formerperson, the threat to their self-concept is such that they would beleft feeling utterly undermined. The anxiety response may there-fore be extreme, tending towards panic.

For Bryant-Jefferies, panic is a more extreme manifestationof anxiety. It arises in the same way as its milder sibling butbecause of (for example) the greater gap between the organismand the self-concept, the person's conditions of worth and theirlocus of evaluation, it is felt more intensely and is more dis-abling. More rarely, denied material breaking into awarenessdisrupts the individual's self and in extreme cases can shatter it,leading to what some might call a `psychotic' breakdown or`panic disorder'.

Another possible origin for anxiety and panic is when anintense and damaging relational experience has resulted in a self-image that is a speci®c response to the injurious relationship.This could be seen as simply an element within the self-structureor as a `con®guration of self' (Point 27). In such cases, thecon®guration established centres on deep pain and sensitivityand when it manifests in awareness an overwhelming rush ofpain and anxiety threatens to engulf the individual. Lastly,Mearns and Cooper (2005: 22±23) speculate that, for at leastsome types of anxiety (for example `social anxiety'), a lack of in-depth connections with others may be causal. However, thisleaves the origin of an inability to make in-depth connectionsopen to debate. Nevertheless, whatever the cause of anxiety andpanic and the theoretical explanation for it, the way a person-centred therapist responds to someone in an anxious state isthe same.


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95Anxiety and panic can be worked with in a person-centred way

For person-centred practitioners, dealing with anxiety and panicis not about managing a set of experiences but rather ofgenuinely and unconditionally accepting the anxious person andresponding to them with empathic understanding. As a result,rather than simply learning to manage or suppress anxiousbehaviour, in the course of person-centred therapy clients arelikely to ®nd that whatever is behind the anxiety or panicemerges into awareness and along with them the experiencesthat have been denied to awareness in order to protect andpreserve the person's self-structure. There is then a readjustmentin the self-concept in the direction of fuller functioning. This isnot necessarily an easy or comfortable process.

Of his practice with clients experiencing anxiety and panic,Bryant-Jefferies writes that a climate in which the therapist-provided conditions are consistently extended to the client pro-vides an opportunity for the person to risk acknowledging theexistence of the discrepancy or contradiction between their self-concept and the new material entering awareness. This can thenbe integrated in such a way that there emerges a more completeand consistent, and therefore more congruent, sense of self.Such a sense of self will be more authentic, characterised by afuller and more accurate range of experience and less modi®edby conditions of worth and denial to awareness as had pre-viously been the case.

However, there will be situations in which the implications ofthe emerging awareness cannot be easily absorbed. The insightcan be so shattering that the client cannot cope with the tensionthat arises. From a person-centred perspective it is important totrust the client to know what is right for them. When an anxiousclient is confused by the emerging awareness and perhaps evendoubts who they are (a long-maintained self-concept may be


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under threat of extinction) what is required is not active inter-vention or reassurance but a steadfast maintenance of thetherapist-provided conditions. It is not for the person-centredtherapist to make sense of the experience for the client.

It is possible that when a person-centred therapist is workingwith a client for whom panic and/or anxiety is within the rangeof disturbing or disruptive experiences that client may experi-ence high anxiety or even panic in the course of a session. Asdistressing as this is (perhaps for both parties), in a way this is apositive thing. This is because not only does it indicate the depthof trust by the client of the therapist (the client is sure enough ofthe relationship to become extremely vulnerable) but it is also asign of movement. That which has been denied to or distorted inawareness is moving from subception to perception. As always,the person-centred therapist will need to be very focused, clearlymaintaining unconditional positive regard for the client regard-less of what is happening, conveying empathic understandingand being congruent. When a client's incongruence emerges intothe open in the form of panic or high anxiety it is essential thatthe therapist remains congruent and non-directive. Don't bepanicked by panic! Of course it may be that sometimes to offer apanicking client a calming strategy (perhaps suggesting ways ofcontrolling the physiological expression by, for example, breath-ing into a bag) is the helpful thing to do but any such offershould be made tentatively, calmly and in accord with theclient's needs and frame of reference and not because the ther-apist has a need or desire to stop the client's active experiencehowever well-intentioned that need or desire may be.

Of course, this whole process raises the question as towhether, as material emerges into awareness, the therapeuticfocus could be on the anxiety reactions associated with the newmaterial or the material itself. One client may place more focuson the anxiety reaction, another on the insights that are break-ing into awareness. In practice there is often movement betweenthe two. Here, as ever, the therapist takes direction from theclient.


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96There are person-centred understandings of theexperiencing of different realities

Rundle (in press) notes that person-centred theory is clear thatthe need to make sense of experience is so strong that humanbeings will try, in any way possible, to process it. Also, the self isseen as a process of becoming rather than as a ®xed entity. Thusall behaviours, feelings and ways of being in the world fall alongcontinua. So, one way of looking at `mental illness' is as the bestresponse to their experienced world that the person whosereality is noticeably different from `normal' has at their disposal.Not only that, but there is no great gulf between `madness' andeccentricity (of which we are all capable). In addition, from aperson-centred perspective, an experienced altered or differentreality is part of a person's experiential ®eld, an experienced wayof processing. It does not de®ne who or what they are. Forexample, Margaret Warner proposes that some unusual ways ofbeing can be accounted for in terms of `dif®cult process' (Point36). Dif®cult process results when early childhood dif®cultiesmean important processing capabilities are not developed.Warner's concepts of fragile, dissociated, psychotic and meta-phact process (see Warner 2007b: 143±144) are helpful descrip-tors of ways of being in the world but they are not intended tooffer prescriptive diagnoses.

Rundle points out that withdrawal from a shared reality,isolation and diminished social functioning can be the results ofan inability to express one's experiencing in a way that makessense to others or to the cultural values one holds oneself.Sometimes people are aware that others do not understand themand, perhaps, they do not understand themselves. They may alsobe aware that their reality is not shared by others and that theirways of expressing it are not understood by anyone else. Othersare seemingly unaware that their reality is different from thosearound them. Whatever the degree of awareness of it a person


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may have when they are experiencing reality differently theassumption in person-centred theory is that withdrawal fromshared reality is a protective device. It may involve distortionand denial and be a response to conditions of worth and becharacterised as `psychological maladjustment' but somehowand for some reason, given the world as they experience it, it isthe best expression of the actualising tendency for that person atthat time. This does not mean that it is satisfactory but it doesindicate that the imposition of a medical diagnosis and conse-quent `treatment' to restore the individual to some assumed levelof `normality' may not be the most useful intervention. Also,there is an increasingly prevalent view in the person-centredworld that those who experience different realities are reactingto their social and physical environments. In other words,`insanity' is a sane reaction to an insane world. Worsley andJoseph (2007: 2) emphasise the signi®cance of this view stressingthat since the behaviours and ways of being that some mightjudge to be symptoms of mental illness are actually responses toenvironmental or socio-psychological stress, they are meaningfuland `too important to medicate away'. If the `symptoms' are notheard and responded to the person experiencing them willcontinue to be distressed by them. They (p. 3) go on to writethat `the relief of distress depends on the establishment andinhabiting of psychological contact'.


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97There are person-centred ways of working withpeople who experience reality differently

Of her work with people who experience reality differently,Rundle writes that the most important principle when workingwith clients whose levels of mental and emotional distress leadthem to experience reality differently from most of us is torespond to the person, not the distress. Of course, this is nodifferent from the attitude person-centred therapists carry intotheir work with clients of other kinds. However, it can bedisconcerting to be confronted with a client with an unusual wayof being and a diagnosis of `mental illness' but to put the symp-toms before the experiencing person (that is `understanding' theclient in terms of a set of labels, diagnoses and prognosticationsand responding accordingly) would be a mistake.

She goes on to say that placing the `person' at the centre ofthe therapeutic process avoids objectifying the client as a`patient'. Often, even for a person who seems so divorced fromthe therapist's reality that there appears to be little connection,the process of being responded to as a person and not asa `schizophrenic', `psychotic' and so on is bene®cial. Thetherapist's empathic understanding fosters the development oftrust, re-connection with others and enhances the client's abilityto look at their experiencing in a different way. Respondingempathically and acceptingly to an expressed different realitydoes not involve `collusion'. As with any other client, theseattitudes have nothing to do with notions of objective truth butare about connecting with the client's lived experience howeverbizarre that may seem. That the therapist remains congruent isvital. If a client ®ghting to retain a sense of self becomes awareof any incongruence on the part of the therapist, it will only addto feelings of fragmentation, alienation, barrenness and panicand con®rm that relationships are untrustworthy and unreliable.Then again, consistent communication of the therapist-provided


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conditions can help even the most fragmented person amelioratetheir distress.

Rundle states that normal defences become inadequate whena client's sense of self is disintegrating or fragmenting. Barriersto understanding and relating are then further reinforced andcan only be penetrated by empathic understanding of a personalmetaphor or code and the communication of this understandingto the client. The therapist must accept the reality of the unusualexperience ± as it is for the client ± without changing it, denyingits existence or keeping distant from it. Any re¯ections, para-phrasing or challenges must be grounded in what is actually saidbut it is also important to listen for clues to discover the idio-syncratic meaning. Misunderstandings, incorrect assumptions ordenials con®rm a client's sense of being un-understandable sothat no further risk at communicating is taken.

Behaviours which seem peculiar to others may be the indi-vidual's attempt to impose some sense of control on theirawareness of self and their experience. It sometimes happens thatpeople will appear to create a whole other world to live in or willseem to withdraw from the world or from relationships. Thesereactions are almost always a means of self-protection. Also,what appears to be thought-disordered or delusional speech canbe a metaphor for something else. Responding empathically tothe metaphor is likely to be helpful. Similarly, dissociating ±seeing oneself as separate ± from previous or current experiencesis often used as a defence against some dreadful happening. Byaccepting the reality of the dissociated experience the therapistenables clients to explore the meaning of it at a safe distance.That distance creates a safe environment for clients ®nally tolook at, and then integrate the triggering event(s) (such aschildhood trauma or abuse) into realistic, adult selves.


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98There is a person-centred understanding of theexcessive use of drugs and/or alcohol

Considering the theory underpinning her practice with peoplewho use drugs or alcohol, Cameron (in press) states that person-centred theory admits no drive towards atrophy or self-destruction but the effects of excessive use of an addictivesubstance can lead to the conclusion that the actualising tendencycannot be at work in someone so self-damaging. However, theopposite is true. Rogers (proposition XII, 1951: 507) discusseshow some needs are denied symbolisation in awareness ifincompatible with the self-concept. The next proposition (1951:509) implies that sometimes we ®nd ourselves doing something wethink we shouldn't, or can't, and then saying, and believing, that`it wasn't me', or `something took me over'. The `something' wasthe actualising tendency pressing to meet an organismic need.Alcohol and other mood-altering drugs facilitate this process.

Cameron goes on to say that alcohol softens the controlexercised by the self-concept. People who use substances prob-lematically often do so because this frees denied feelings ordenied aspects of `self ' (perhaps even enabling a suppressed`con®guration' to the fore). Looked at another way, mood-altering substances may help the user overcome one or moreconditions of worth. For example, an introjected value whichnormally prevents the person expressing a particular emotion(such as anger, affection or lust) may fade into the backgroundin response to the effects of the user's drug of choice and so the`forbidden' behaviour is allowed. This is not necessarily prob-lematic and (arguably) is the reason for the great popularity ofalcohol. However, when the condition of worth can only beovercome by substance use and the suppressed feeling or beha-viour is craved, it may cause dif®culty.

Cameron notes that disinhibition is particularly characteristicof alcohol but not of all mood-altering drugs, yet these too may


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meet a denied need. Heroin, for example, is a very powerfulpainkiller, as effective an anaesthetic for emotional pain as forphysical pain. Not only do substances help the user to meetdenied needs, they also help to ease the psychological tensionthat arises from denying them. The greater the incongruencebetween the self-concept and organismic experience, the greaterthe internal pressure to satisfy denied needs, creating ever morepsychological tension. Drugs like heroin that depress the centralnervous system promote a feeling of relaxation. The discomfortof the psychological tension that results from incongruence iseased as the client begins to feel warm, sleepy and relaxed.Stimulants like amphetamines also ease psychological tension.Warner, writing about `low intensity fragile process' (see Mearnsand Thorne 2000: p. 147), suggests that un-integrated aspects ofthe self may result in a lack of energy and a feeling of emptiness,rather than anxiety. Psychological tension characterised bydepressed process can be eased by stimulants which make theuser feel full of life. However, using a substance in order toreduce or tolerate incongruence helps only in the short term. Inthe longer term, the individual will not experience satisfactionof the underlying need until it is acknowledged and integratedinto the self-structure. Continued denial of organismic needs iseasier if the need-seeking behaviour can be attributed to theeffect of a mood-altering substance (`it was the drink talking').In this way incongruence is ultimately prolonged and intensi®ed.

Cameron points out that excessive substance use eases psycho-logical tension in some ways but can also increase it. For example,the person who uses alcohol to help meet a denied need or liberatea denied aspect of themselves may well feel ashamed afterwards,leading to an increase in psychological tension. In addition tofeelings of shame, the chemical after-effects of many substancesleave the person depressed and anxious. Shame, fear of beingcaught, and `coming down' all create more psychological tensionand an increased desire for the feelings of relief produced bytaking something. A self-perpetuating cycle may ensue, in whichthe person `uses' to ease psychological tension, feels wonderful(or at least better) whilst under the in¯uence but even moreanxious when the effect wears off and more inclined to seek reliefthrough being under the in¯uence.


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Person-centred theory suggests that an objective of workingwith drug and alcohol issues is to reduce the psychologicaltension that created the need for substance use in the ®rst place.Practice, however, suggests that underlying issues may oftenonly be reached by edging very carefully along a precipice.


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99Person-centred work with people for whom theiruse of mood-altering substances is problematic

Writing of her practice, Cameron (in press) points out that aswith clients of other kinds, for clients whose use of mood-alteringsubstances is problematic constructive change begins when theclient perceives the counsellor to be genuinely empathic andunconditionally accepting. However, there is an ever-presentdanger that, as the client becomes more aware of underlyingpsychological tension, the internal pressure to use again, or usemore, will become overwhelming. The client who stops orreduces drug or alcohol use, and takes time to adjust to thisbefore exploring very sensitive issues, gives themselves the bestchance of working through these without resuming their previoushabit. Understanding and respecting the client's process ofcoming to terms with a substance problem is an essentialfoundation to offering a relationship that is neither directive norcollusive. As with any client group, working with people whoexperience their substance use as problematic requires only thatthe necessary and suf®cient conditions are consistently present.Any difference lies in the therapist and how the therapist ensuresthat they can congruently offer unconditional positive regard andempathic understanding. This may involve making judgementsabout the nature of contact possible for them and dealing withtheir own reactions to (and judgement of ) people who use mood-altering substances.

She says that a dilemma in working with someone who isconcerned about their substance use is whether or not to seethem when they are under the in¯uence. From a person-centredperspective, the issue is the degree to which the requirement forcontact can be met. However, psychological contact involveseach person being affected in some way by the other's presence.Being under the in¯uence will not prevent some contact unlessthe client is actually unconscious. However, a client who is


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incoherent and unable to see straight will not be able to use thesession in the usual way but the therapist's continued acceptanceof them may be therapeutic.

The question of psychological contact concerns not onlyclients whose state is highly altered but also clients who aremore moderately affected by what they have taken. Some mayneed some alcohol or something else just to feel well enough toget to the session ± it may be that suf®cient psychological con-tact only becomes possible if the client has used something.

Although in many ways the qualities required of a person-centred therapist working with substance users are exactly thesame as those required when working with clients of any otherkind, Cameron says that there are some things of which to beaware. For example:

· As a result of hiding their use, most users of mood-alteringsubstances become expert in the art of deceit and can detectincongruence with paranormal speed and accuracy. It maybe temping to try to hide a reaction of disgust or dis-appointment so as not to shame the client further but it isprobable that the client's skill in detecting incongruence willoutweigh the therapist's skill in hiding it.

· Maintaining unconditional positive regard can be challen-ging when a client is behaving in a way that seems very self-destructive. This is not just because it is painful to stayemotionally connected to people who are hurting themselvesbut also because unconditional acceptance of the clienthowever they behave means not minimising their behaviour.There may be a temptation to minimise the client's beha-viour in order to ameliorate their shame. However, thiswould impede the therapeutic need to symbolise the experi-ence without distortion.

· With respect to empathic understanding, some knowledgeabout the general effects of a substance can be useful inunderstanding what using it, or not using it, may mean tothe client. For example, a client using heroin is likely tohave been in considerable emotional (or physical) pain priorto using it. Amphetamines on the other hand make the userfeel wide awake and fully alive and a client who particularly


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likes their effect may have a low intensity fragile processthat leaves them feeling deadened inside. Although somepeople do move from one substance (or excessive beha-viour) to another, for others their chosen substance does aunique job and it may be important to appreciate just whatit is that is so satisfying about that particular substance inorder to understand their inner world more fully.


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100`The facts are friendly': research evidence indicatesthat person-centred therapy is effective and atleast as effective as other modalities

There is research evidence for the ef®cacy and ef®ciency ofperson-centred therapy. Although this has been there from thevery start of the approach, the most relevant and persuasive ofthis evidence dates from the 1990s onwards. In his review ofrecently published outcome research studies Bozarth (1998:172±173) found no evidence that speci®c treatments are effectivefor speci®c dysfunctions but that it is the quality of the rela-tionship between therapist and client which is signi®cant. Thishe understood to include the necessary and suf®cient conditions.

The contemporary research evidence for the ef®cacy ofperson-centred therapy is presented in four forms (after Sanders2006b: 104±108):

· Outcome studies: meta-analyses (for example Elliott et al.2004a) indicate that a signi®cant proportion of peopleimprove as a result of person-centred therapy when com-pared with being on a waiting list or not receiving therapy.

· Comparative studies of person-centred therapy and otherapproaches: when `researcher allegiance' is accounted for,Elliott et al. (2004a) show that an apparent differencebetween the ef®cacy of person-centred therapy and otherapproaches disappears. In terms of outcome, they areequally effective. This is true of studies across the psycho-therapy research literature. One of the most recent of these isthe study by Stiles et al. (2006) using CORE-OM (ClinicalOutcomes in Routine Evaluation ± Outcome Measure) anddata from 1,309 `patients' in which outcome data forcognitive-behavioural therapy, person-centred therapy andpsychodynamic therapy was compared. This showed thatclients receiving each therapy markedly improved and thatthere was no real difference between the approaches.

AND LAST BUT BY NO MEANS LEAST

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· The effectiveness of person-centred therapy for differentpsychological problems: Elliott et al. (2004a), once researcherallegiance is controlled for, indicate that person-centredtherapy is as effective as cognitive-behavioural therapy(CBT) and process-experiential therapy for a range ofmental and emotional dif®culties including anxiety dis-orders, depression and schizophrenia.

· The key ingredients of an effective therapeutic relationshipand the necessary and suf®cient conditions: the largest reviewof empirical studies of the elements of the therapeuticrelationship and how these affect outcome (see Norcross2002) demonstrates that empathy is an effective element oftherapeutic relationships and indicates that positive regardand congruence are probably effective.

Elliott and Freire (2008) completed a major project tointegrate sixty years of research on the effectiveness of person-centred and related therapies. Their sample of more than 180scienti®c outcome studies provide multiple lines of evidencedemonstrating that these therapies are highly effective. Theirmain ®ndings were:

· Person-centred and experiential therapies (PCE) are associ-ated with large pre±post client change. On average, thesetherapies make a big difference for clients. Furthermore,this is particularly true for symptom measures like theCORE-OM, as indicated by the two large UK-based studiesby Stiles et al. (2006, 2008).

· Clients' large post-therapy gains are maintained over earlyand late follow-ups. Clients retain the bene®ts of PCEtherapy over time. If anything, clients in PCE therapiesshow slight further gains during the ®rst year after therapy.This stability of post-therapy bene®t is consistent with thePCE philosophy of enhancing client self-determination andempowerment, indicating that clients continue to developon their own after they have left therapy.

· Clients in PCE therapies show large gains relative to clientswho receive no therapy. In order to show that there is acausal relationship between PCE therapy and client change,


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it is necessary to compare clients who get therapy to thosewho don't.

· PCE therapies in general are clinically and statistically equi-valent to other therapies. That is, PCE therapies were neithermore nor less effective than other therapies.

· PCE therapies in general might be trivially worse than CBT.It is commonly assumed by CBT therapists, governmentof®cials, and the general public that CBT has better out-comes than other therapies such as PCE therapies. At ®rst,PCE therapies appeared to be slightly but trivially lesseffective than CBT. However, this effect disappeared whenresearcher allegiance is statistically controlled for.

· So-called `non-directive/supportive' therapies have worse out-comes than CBT but other kinds of PCE therapy are aseffective or more effective than CBT. It seems that in somestudies what are referred to as `non-directive/supportive'therapies are watered-down, typically non bona ®de versionsof PCE therapies, commonly used by CBT researchers,especially in the USA. Once the non-directive/supportivetherapies are removed from analyses, it is clear that bona ®dePCE therapies are statistically equivalent in effectiveness toCBT.

AND LAST BUT BY NO MEANS LEAST

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