This article originally appeared in the January 2006 Harvard Mental Health Letter and is provided courtesy of Harvard Health Publications.

Client-centered therapy

Sixty years ago, the psychologist Carl Rogers introduced a new approach to psychotherapy, designed as a contrast to the behavioral and psychoanalytic theories dominant at the time. Unlike behavior therapy, the Rogers approach does not emphasize action over feeling and thinking, and unlike psychoanalysis, it is not concerned with unconscious wishes and drives. At first he called his method nondirective therapy, later client-centered and person-centered therapy.

The method can be defined partly by what Rogerian therapists don’t do, or rarely do: ask questions; make diagnoses; conduct psychological tests; provide interpretations, evaluations, and advice; offer reassurance, praise, or blame; agree or disagree with clients or express opinions of their own; point out contradictions; uncover unconscious wishes; or explore the client’s feelings about the therapist.

What that leaves is letting clients tell their own stories at their own pace, using the therapeutic relationship in their own way. The therapist provides a model of reflective listening without trying to point out directions and provide solutions. Rogers popularized the use of the term “client” rather than patient to set the relationship on more equal terms, emphasizing that the person being treated is not passive and the therapist is not an authority but an agent.

Client-centered therapists aim to understand how the world looks from the point of view of their clients, checking their understanding with the client when in doubt. The principle is that clients know more about themselves than the therapist can possibly know. They don’t need the guidance or wisdom of an expert. Instead, the therapist must create an atmosphere in which clients can communicate their present thoughts and feelings with certainty that they are being understood rather than judged.

Client-centered therapists say that their clients have a natural tendency toward growth, healing, and self-actualization. They act self-destructively or feel bad because of an environment that distorts this tendency. But they can find their own answers to their problems if the right therapeutic environment is provided. Psychotherapy does not involve doing something to clients or getting them to do something about themselves, but rather freeing them for movement toward normal maturity, independence, and productivity.

A permissive and indirect approach, according to the theory, makes clients more aware of aspects of themselves that they have been denying. By responding to the client’s feelings rather than to the objects of those feelings, the therapist brings the client’s self into the foreground. By avoiding judgments and not intruding their own personalities, therapists themselves avoid becoming an object of the client’s attitudes and feelings. The aim is not so much to solve particular problems or relieve specific symptoms as to free clients of the sense that they are under the influence of malevolent forces beyond their control.

Facilitating conditions
According to Rogers, the therapist should provide what he calls facilitating conditions: accurate empathy, congruence or transparency, and unconditional positive regard.

Accurate empathy, or empathic understanding, means sensitively tracking the moment-to-moment feelings and thoughts of the client, with all their nuances and implications, and conveying this to the client partly by summarizing or restating what the client says (observers listening to tapes of Rogers’s therapeutic sessions noticed that he even tended to match the tone of voice of the client.)

Congruence or transparency means that therapists must not put up a façade of any kind or deceive clients about their feelings. Congruent responses should be stated in the first person, without false objectivity: “I feel,” “This is how I experience,” and so on. A therapist who cannot or does not want to answer a question should give a personal reason: “I don’t know enough,” “I feel uncomfortable talking about that.” Accurate empathy conveys what the therapist thinks the client is feeling; congruence conveys what the therapist is feeling or thinking, and the therapist should make this distinction clear.

Unconditional positive regard, or unpossessive warmth, is the way a therapist conveys to clients that they are regarded as valuable and worthwhile, without accepting or condoning everything they do or think. It means prizing clients as persons.

It sounds simple, but according to client-centered therapists, can be complicated in practice. They say their methods demand discipline, sensitivity, and restraint. It is too easy to interrupt, to use the wrong words, to reflect the content or object of a client’s remark rather than the feeling behind it. Therapists must take account of facial expressions, body movements, silences, and other subtle clues. They may find it difficult to know how to respond when a client insists on more direction. They must learn when empathy is not appropriate — some clients, in some circumstances, find it intrusive. When they hold a mirror up to the client, it must be held at the right angle.

Empathy and positive regard must be not only felt but effectively communicated. Studies show that therapists and clients are as likely to disagree as to agree about whether the therapist has shown these qualities.

The need for congruence or transparency doesn’t imply that therapists must communicate everything that they think or feel. They should not use the client for their own emotional gratification. They have to distinguish disclosing facts about themselves from admitting resemblances to the client (“I also felt anxious when I had to take tests in college”) and stating present feelings (“I feel angry at you now because you seem to be belittling me”). And they must learn whether and when these different kinds of self-disclosure are appropriate.

Criticisms
From the beginning, client-centered therapy has had its critics — for the apparent vagueness of its principles, its antipathy to diagnosis, its claim that therapists need little training, and its emphasis on the client’s self-evaluation as the way to judge the outcome of therapy. Rogers admitted that his ideas left a great deal of room for interpretation. Many thought he was a gifted therapist, and it is difficult to know whether those who follow his model or use his methods are practicing as he intended. Client-centered therapy may also work less well with people who find it difficult to talk about themselves or have a mental illness that distorts their perceptions of reality.

Controlled research providing evidence on the effectiveness of client-centered therapy is scarce. Critics of Rogers’ facilitating conditions say they are only moderately correlated with successful therapy, and may be a consequence rather than a cause of improvement. Even strong advocates of the facilitating conditions do not say they are necessary or sufficient for successful therapy. And Rogers himself always insisted that his ideas were tentative, mainly a stimulus to thinking.

A criticism made 60 years ago is that the distinctive features of client-centered therapy are not effective, and the effective features are not distinctive but characteristic of all good therapy. Today it’s agreed that a crucial condition for successful psychotherapy is a working therapeutic alliance — a mutual understanding between the therapist and the patient about how they will work together and to what end. Some believe that the idea of the therapeutic alliance incorporates most of what is valuable in Rogers’s facilitating conditions. And the same question that is sometimes raised about those conditions has also been raised about the therapeutic alliance — whether it is a cause or an effect of the client’s improvement.

Client-centered therapy today
Rogers died in 1986, and today only a small proportion of mental health professionals regard themselves chiefly as taking a client-centered or person-centered approach. But his ideas about personality are still found in textbooks, and one survey found 50 journals and 200 organizations all over the world now devoted to some variant of client-centered or person-centered therapy. Beyond that, client-centered principles may have influenced the practice of many other therapists. For example, self-disclosure (transparency, congruence) has become more acceptable to psychodynamic and cognitive behavioral therapists.

Client-centered principles are central to motivational interviewing, which has been found as effective as cognitive behavioral therapy in a clinical trial of alcoholism treatment. In this method, clients set the agenda, and the therapist acts as a partner in dialogue rather than an authority. Motivational interviewers avoid warnings, diagnosis, and direct attempts to argue, persuade, or educate. They try to supply accurate empathy and reflective listening. Instead of directly confronting resistance to change, they promote self-efficacy, which is related to self-actualization as conceived by Rogers.

Today many psychotherapists are eclectic in their choice of methods or use several techniques in different situations with the same patient. The client-centered approach of motivational interviewing, for example, is designed for early phases of therapeutic change called the precontemplation and contemplation stages. Rogers wrote in the 1940s that an experienced psychotherapist told him he had made explicit something the therapist had been groping toward for a long time. The legacy of client-centered therapy and its facilitating conditions may persist less as a specific technique than as a permanent background influence.

Resources
PsychNet-UK
www.psychnet-uk.com/psychotherapy/psychotherapy_client_centered.htm
Provides a sampling of articles on client-centered therapy and links to other sites.

Association for Humanistic Psychology
www.ahpweb.org/index.html
510-769-6495
Provides a directory of professional therapists, bibliographies, and Web links. Carl Rogers was one of its founders.

Association for the Development of the Person-Centered Approach
www.adpca.org
An international network of professionals that sponsors an annual conference and publishes a newsletter and journal.

References
Ellis A. “A Critique of the Theoretical Contributions of Nondirective Therapy,” Journal of Clinical Psychology (July 2000): Vol. 56, No. 7, pp. 897–905. Originally published in Journal of Clinical Psychology, 1948.

Goodman RF, et al. “Letting the Story Unfold: A Case Study of Client-Centered Therapy for Childhood Traumatic Grief,” Harvard Review of Psychiatry (July–August 2004): Vol. 12, No. 4, pp. 199–212.

Hathaway SR. “Some Considerations Relative to Nondirective Counseling as Therapy,” Journal of Clinical Psychology (July 2000): Vol. 56, No. 7, pp. 853–59. Originally published in Journal of Clinical Psychology, 1948.

Hill CE, et al. “Client-Centered Therapy: Where Has It Been and Where Is It Going? A comment on Hathaway (1948),” Journal of Clinical Psychology (July 2000): Vol. 56, No. 7, pp. 861–75.

Kirschenbaum H, et al. “The Current Status of Carl Rogers and the Person-Centered Approach,” Psychotherapy: Theory, Research, Practice, Training (Spring 2005): Vol. 42, No. 1, pp. 37–51.

Rogers CR. “Some Observations on the Organization of Personality,” American Psychologist (1947): Vol. 2, pp. 358–68.

Rogers CR. Client-Centered Therapy: Its Current Practice, Implications, and Theory. Trans-Atlantic Publications, 1951.

Rogers CR. On Becoming a Person: A Therapist’s View of Psychotherapy. Houghton Mifflin, 1961.