VOLUME 22 NUMBER 7

JANUARY 2006

Client-centered therapy
ixty 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 personcentered therapy. The method can be defined partly by what Rogerian therapists dont 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 clients 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 dont 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 clients feelings rather than to the objects of those feelings, the therapist brings the clients self into the foreground. By avoiding judgments and not intruding their own personalities, therapists themselves avoid becoming an object of the clients 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.

INSIDE
The duty to protect
A court decision that worried psychotherapists has proved to be less trouble than they expected. . . . . . . . . . . . . . . 4

Update on St. Johns wort

The latest findings on an ancient remedy for depression.. . . . . . . . . . . . . . . . . . 5

Comparing antipsychotic drugs

A new study shows few differences in effectiveness or side effects. . . . . . . . . . . . . . . . . 7

Q&A
What is vagus nerve stimulation? . . . . . . . . . . . . 8

In future issues
Depression after a heart attack Contingency management Testing psychodynamic therapy

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
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Client-centered therapy
Editor in Chief Editor Founding Editor Editorial Board Michael Craig Miller, MD James B. Bakalar, JD Lester Grinspoon, MD Mary Anne Badaracco, MD Paul Barreira, MD Jonathan F. Borus, MD Barbara Coffey, MD Steven H. Cooper, PhD Christopher B. Daly Frank W. Drislane, MD Anne K. Fishel, PhD Donald C. Goff, MD Alan I. Green, MD William E. Greenberg, MD Shelly Greenfield, MD, MPH Thomas G. Gutheil, MD Michael Hirsch, MD J. Allan Hobson, MD Steven J. Kingsbury, MD, PhD Michael J. Mufson, MD Andrew A. Nierenberg, MD Hester H. Schnipper, LICSW, BCD Barbara Wolfe, PhD, RN Editorial Board members are associated with Harvard Medical School and affiliated institutions. They review all published articles.

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implications, and conveying this to the client partly by summarizing or restating what the client says (observers listening to tapes of Rogerss 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 faade 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 dont 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 clients 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 appropriatesome 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
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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 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 PersonCentered Approach www.adpca.org

An international network of professionals that sponsors an annual conference and publishes a newsletter and journal.

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 doesnt 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 criticsfor the apparent vagueness of its principles, its antipathy to diagnosis, its claim that therapists need little training, and its emphasis on the clients selfJANUARY 2006

HARVARD MENTAL HEALTH LETTER

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. Clientcentered 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.

sometimes raised about those conditions has also been raised about the therapeutic alliancewhether it is a cause or an effect of the clients 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 a recent survey found 50 journals and 200 organizations all The therapist provides a model over the world devoted to some variant of client-centered or person-cenof reflective listening without tered therapy. Beyond that, client-centrying to point out directions tered principles may have influenced the practice of many other therapists. and provide solutions. For example, self-disclosure (transparency, congruence) has become Controlled research providing evi- more acceptable to psychodynamic dence on the effectiveness of client- and cognitive behavioral therapists centered therapy is scarce. Critics (See Harvard Mental Health Letter, of Rogers facilitating conditions say October 2002). Client-centered principles are centhey are only moderately correlated with successful therapy, and may be tral to motivational interviewing (see a consequence rather than a cause of Mental Health Letter, March 2005), improvement. Even strong advocates which has been found as effective of the facilitating conditions do not as cognitive behavioral therapy in a say they are necessary or sufficient for successful therapy. And Rogers References himself always insisted that his ideas were tentative, mainly a stimulus to Ellis A. A Critique of the Theoretical Contributions of Nondirective Therapy, thinking. Journal of Clinical Psychology (July A criticism made 60 years ago is 2000): Vol. 56, No. 7, pp. 897905. that the distinctive features of clientOriginally published in Journal of Clinical Psychology, 1948. centered therapy are not effective, and the effective features are not Goodman RF, et al. Letting the Story Unfold: A Case Study of Client-Centered distinctive but characteristic of all Therapy for Childhood Traumatic good therapy. Today its agreed that a Grief, Harvard Review of Psychiatry crucial condition for successful psy(JulyAugust 2004): Vol. 12, No. 4, pp. 199212. chotherapy is a working therapeutic alliancea mutual understanding Hathaway SR. Some Considerations Relative to Nondirective Counseling as between the therapist and the patient Therapy, Journal of Clinical Psychology about how they will work together (July 2000): Vol. 56, No. 7, pp. 85359. and to what end. Some believe that Originally published in Journal of Clinical Psychology, 1948. the idea of the therapeutic alliance incorporates most of what is valuHill CE, et al. Client-Centered Therapy: Where Has It Been and Where Is It able in Rogerss facilitating condiGoing? A comment on Hathaway tions. And the same question that is
JANUARY 2006 www.health.harvard.edu

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 clientcentered therapy and its facilitating conditions may persist less as a specific technique than as a permanent background influence.

(1948), Journal of Clinical Psychology (July 2000): Vol. 56, No. 7, pp. 86175. Kirschenbaum H, et al. The Current Status of Carl Rogers and the PersonCentered Approach, Psychotherapy: Theory, Research, Practice, Training (Spring 2005): Vol. 42, No. 1, pp. 3751. Rogers CR. Some Observations on the Organization of Personality, American Psychologist (1947): Vol. 2, pp. 35868. Rogers CR. Client-Centered Therapy: Its Current Practice, Implications, and Theory. Trans-Atlantic Publications, 1951. Rogers CR. On Becoming a Person: A Therapists View of Psychotherapy. Houghton Mifflin, 1961. For more references, please see www.health.harvard.edu/mentalextra.

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