REASSESSING ROGERS NECESSARY AND SUFFICIENT CONDITIONS OF CHANGE

Transcription

1 Psychotherapy: Theory, Research, Practice, Training Copyright 2007 by the American Psychological Association 2007, Vol. 44, No. 3, /07/$12.00 DOI: / REASSESSING ROGERS NECESSARY AND SUFFICIENT CONDITIONS OF CHANGE This article reviews the impact of Carl Rogers postulate about the necessary and sufficient conditions of therapeutic change on the field of psychotherapy. It is proposed that his article made an impact in two ways; first, by acting as a spur to researchers to identify the active ingredients of therapeutic change; and, second, by providing guidelines for therapeutic practice. The role of the necessary and sufficient conditions in process-experiential therapy, an emotion-focused therapy for individuals, and their limitations in terms of research and practice are discussed. It is proposed that although the conditions are necessary and important in promoting clients affect regulation, they do not take sufficient account of other moderating variables that affect clients response to treatment and may need to be balanced with more structured interventions. Notwithstanding, Rogers highlighted a way of interacting with clients that is generally acknowledged as essential to effective psychotherapy practice. Keywords: emotion, therapeutic relationship, affect regulation, emotionfocused psychotherapy, empathy Correspondence concerning this article should be addressed to Jeanne C. Watson, Department of Adult Education & Counseling Psychology, OISE/University of Toronto, 252 Bloor Street W, Toronto, Ontario M5S 1V6 Canada. jewatson@oise.utoronto.ca JEANNE C. WATSON OISE/University of Toronto Carl Rogers 1957 article has served as a beacon to the field of psychotherapy by focusing attention on the manner in which therapists can best interact with clients to facilitate change in therapy. His postulate that the therapist attitudes of empathy, acceptance, and congruence were necessary and sufficient to help clients accurately symbolize their affective experience when they were vulnerable and in a state of incongruence highlighted the importance of a facilitative, responsive relationship with another human being to promote change in psychotherapy. The impact of his article on the field of psychotherapy has been twofold: it provided a spur to researchers to identify the active ingredients of therapeutic change, and it has provided guidelines for therapeutic practice by identifying ways of being and interacting that are helpful and those that are not. Rogers postulate about the necessary and sufficient conditions for psychotherapeutic change is still at the heart of much of the debate that continues with respect to identifying the active and essential aspects of therapeutic practice that foster client change in therapy. Much time and effort has been expended to determine whether therapeutic change is attributable to the therapeutic relationship or specific techniques. Numerous studies show that the best predictors of outcome in psychotherapy are a positive working alliance and client factors (Horvath & Symonds, 1991; Lambert & Barley, 2002). In contrast, research evidence for validating treatment interventions in isolation from the therapy relationship and the individual patient is weak (Norcross, 2002). After an extensive review of the research, the members of Task Force 29 recommended that therapist empathy is essential to psychotherapy and the facilitative conditions of congruence and acceptance are probably effective (Norcross, 2002). However the question that pits the therapy relationship against technique may be irrelevant, contributing to a spurious dichotomy, as the implementation of specific techniques is inseparable from how they are communicated and the context in which they are delivered. Although Rogers 268

2 Special Section: Reassessing Rogers Conditions of Change (1951) developed a specific way of doing therapy that emphasized empathic responding and client autonomy, he recognized that there are a myriad of ways to communicate the facilitative conditions, and different techniques provide multiple ways of communicating to clients that their therapist understands and cares about their distress and can help to alleviate it. Rogers (1957) was very aware that technique and relationship variables are inextricably bound and that any technique can be delivered in a way that is received by the client as empathic, accepting, and congruent, just as any technique intended to communicate the facilitative attitudes may fail to do so. More recently, Norcross (2002), in his summation of the findings of Task Force 29, observed that techniques are not delivered by disembodied therapists to particular Axis I disorders but rather are communicated by a real person to another person within the context of an interpersonal relationship. Rogers (1957) challenged the field to identify those conditions under which his postulate held and to identify times when it did not. Recently, researchers have focused their efforts on trying to identify the mediating and moderating variables of the therapeutic relationship to refine our understanding of the importance of the facilitative conditions so that we can know when, where, and with whom the conditions might be more beneficial and for whom they may have a negative impact (Beutler, Clarkin, & Bongar, 2000; Lambert & Barley, 2002). Zuroff and colleagues (Zuroff et al., 2000) found that the poorer outcomes of perfectionistic patients in a treatment study for depression was mediated by their failure to develop more positive alliances with their therapists. Beutler, Moleiro, and Talebi (2002) reported consistent findings showing that more resistant clients respond better to nondirective approaches than directive ones. However, researchers have only just begun to examine the complex interactions between client variables and the process and outcome of psychotherapy; a lot more work is needed in this area to increase our understanding of effective practice (Beutler et al., 2002; Lambert & Barley, 2002). In addition to spurring research, Rogers provided guidelines for how to practice psychotherapy. He defined both an interpersonal climate that would facilitate growth in person s who were experiencing difficulty symbolizing their experience independently of the expectations, values, and perspectives of others and a way of doing therapy that emphasized a nondirective listening style focused on responsive attunement to clients in-session experience to help clients symbolize and label their inner experience so that they could come to reflect on it and view it in new ways. Rogers (1959) was concerned about helping clients to acquire multiple perspectives and flexibility in their thinking so that they could increase their range of action and feeling. He characterized healthy functioning as a capacity to be aware of inner experience moment to moment and to use that awareness to guide actions for living that are satisfying and enhancing to the organism. The research that has been generated has tended to abstract Rogers hypothesis from the specific client problem or type of dysfunction that he saw the relationship conditions as ameliorating. By incongruence he was referring to those clients who had difficulty being aware of and labeling their inner affective experience. Rogers view of congruence refers to effective emotional processing. His definition of congruence on the part of both therapist and client requires that people be aware of their emotional reactions and symbolize or label these so as to understand what they are feeling. Once the feelings have been identified, a state of congruence requires that people be able to reflect on those feelings and understand their relevance both to their present context and to past experiences. Finally, congruence is manifest to the other by expressing it in a nondefensive and affiliative fashion to optimize the possibility that the other will hear and understand that experience. In essence, Rogers was describing the acquisition of effective affect regulation skills, which are best taught and mastered in precisely the type of environment that he proposed. To promote a facilitative climate, Rogers emphasized a nondirective style of listening and the use of empathic responding to facilitate clients changes in therapy. Empathic responding that is accepting and congruent facilitates the development of clients affect regulation in a number of different ways. One, it fosters clients awareness of their affective reactions; two, it helps clients to label and symbolize their inner experience; three, clients affective reactions are modulated as their experience is represented in words, and clients internalize the accepting, soothing, and nurturing behaviors of their therapists (Barrett-Lennard, 1997; Fosha, 2001; Kennedy-Moore & Watson, 1999; Vanaerschot, 1990; Warner, 1997; Watson, 2001); and four, it 269

3 Watson cultivates clients reflective capacity in so far as empathic responding that is tentative and focuses on clients inner feelings and perspectives conveys that clients worldviews are subjective, thereby suggesting that there are other ways of feeling and viewing the world. As clients assumptions and perspectives are brought into focus, they can be subjected to inquiry and exploration. In addition, the facilitative attitudes help create safety and an ideal working space, contribute to the development of a strong therapeutic bond, and promote autonomy (Watson, 2001). Emotion-Focused Therapy The communication of the relationship conditions of empathy, acceptance, and congruence remains fundamental to the practice of personcentered, humanistic, experiential, and emotionfocused psychotherapy irrespective of clients presenting issues (Bohart & Greenberg, 1997; Bozarth, 1997; Brodley, 1990; Elliott, Watson, Goldman, & Greenberg, 2004; Vanaerschot, 1990; Watson, Greenberg, & Lietaer, 1998). Even in those humanistic approaches that have broadened the range of therapeutic interventions to include more structured interventions and coaching, such as emotion-focused therapy (EFT; Elliott, Watson, Goldman, & Greenberg, 2004; Greenberg, Rice, & Elliott, 1993), the Rogerian attitudes are emphasized and seen as essential elements of practice. In EFT, the relationship conditions are integral to identifying relevant interventions, implementing different ways of working, and resolving specific cognitiveaffective difficulties. EFT therapists integrate the use of gestalt interventions such as two-chair work with the Rogerian facilitative conditions. Greenberg et al. (1993) realized the importance of attending to clients moment-by-moment affective experiences to guide clinical practice and develop productive working spaces to enable clients to explore their conflicts and the issues that brought them into therapy. The facilitative conditions form the bedrock of EFT with empathic reflections that convey empathic understanding, acceptance, and positive regard for the clients moment-by-moment experience comprising a large proportion of the work even within specific tasks such as two-chair and empty chair work. EFT therapists use their own empathic responsiveness and expressions of empathy to track their clients experience and affect in order to assist them to identify which interventions might be appropriate at different times. Watson and Greenberg (1994) suggested that offering appropriate tasks is an enactment of the relationship conditions to the extent that they convey an understanding of clients problems, goals, and objectives and show that the therapist is concerned with helping them resolve their problems, while being congruent and transparent. Acceptance and congruence work together with empathy to establish trust and facilitate the clients opening up to explore their experience with their therapist. Limitations There is general recognition that the facilitative conditions, particularly empathy, are necessary (Bohart, Elliott, Greenberg, & Watson, 2002; Norcross, 2002) but insufficient to promote change. Critics have argued that Rogers formulation does not take into account the complexity of the therapeutic encounter and the numerous different variables that come into play in effecting client change including client variables, clients environmental and social contexts extraneous to therapy, and the demands of different phases of treatment (Farber & Lane, 2002; Gelso & Hayes, 2001). Rogers himself was aware of client factors and acknowledged that clients needed to be aware of their inner experience for the facilitative conditions to be effective (Klein, Kolden, Michels, & Chisholm-Stockard, 2002). He also recognized that clients needed to be ready and motivated to change. In the event of clients not having ready access to their inner affective experience, clinicians need to develop specific techniques or interventions to facilitate clients becoming aware of their inner experience, for example, focusing (Gendlin, 1974, 1996) and two-chair work (Greenberg et al., 1993) among others. Another limitation that has been noted in the provision of the facilitative attitudes is that clinicians may be too laissez-faire and fail to adequately structure and guide their clients process (Watson, Kalogerakos, & Enright, 1998). If Rogers facilitative conditions are mapped onto Benjamin s (1974) circumplex model of social behavior, we see that the negative extreme of acceptance and understanding is too much freedom so that insufficient guidance and protection is provided. At the other 270

4 Special Section: Reassessing Rogers Conditions of Change extreme when people move toward offering more structure, guidance, and protection, they run the risk of becoming overly controlling and managing thereby excessively limiting other people s autonomy and becoming overly intrusive. From this perspective, it becomes clear that when therapists are very accepting and do not structure clients inquiry, they run the risk of being neglectful as they allow clients to ramble and avoid issues. Rogers, like others, recognized that a therapeutic relationship is structured, has limits, and teaches specific ways of representing experiences that are socially acceptable (Benjamin & Karpiak, 2002; Rogers, 1951; Wyatt, 2001); setting limits and creating structure does not only pertain to the structural aspects of the therapeutic relationship but also applies to how clients can work effectively in therapy. Klein, Mathieu-Coughlan, and Kiesler (1986) in their examination of successful cases in clientcentered psychotherapy observed that clients who changed engaged in focused exploration and examination of specific questions that they formulated with respect to their own interpersonal or intrapersonal functioning. This suggests that an important adjunct to the effective communication of empathy, acceptance, and congruence is the provision of stimulation, guidance, and structure to engage clients effectively in the work of therapy. It is the optimal ratio of empathy, acceptance, and congruence to guidance, stimulation, and structure that facilitates clients changes in psychotherapy that needs to be specified to guide how much of what therapy is needed for whom and when. The optimal balance of therapist behaviors will depend on client personality factors such as level of resistance, perfectionism, coping style, as well as chronicity and severity of clients problems, their level of functional impairment, quality and quantity of social support, and affect regulation skills (Beutler et al., 2000). For example, therapists may need to spend more time providing empathy, acceptance, and congruence for those clients who have difficulty being aware of and labeling their inner experience to promote the development of these skills. For those clients who have difficulty modulating their experience, therapists may need to coach them in methods of self-soothing, such as meditation, relaxation, and breathing exercises (Watson, Goldman, & Greenberg, 2007). Enduring Contribution As we consider the enduring contribution of Rogers work, it is important to distinguish between the facilitative conditions as climate versus specific techniques. There are few research clinicians who would argue about the importance of a therapeutic climate that conveys empathy, acceptance, and congruence for the work of therapy to be effective. Although it is difficult to test this hypothesis because of ethical constraints, there is some evidence that therapist behaviors characterized as critical, controlling, or neglectful are associated with poor outcome (Henry, Schacht, & Strupp, 1986, 1990; Najavits & Strupp, 1994). Additional support for the importance of the facilitative conditions in promoting psychological health and well-being can be found in other areas of psychology. For example, empathy, acceptance, understanding, openness, and transparency are qualities that contribute positively to an individual s psychological, social, emotional, and moral development (Benjamin, 1974; Bohart & Greenberg, 1997; Gottman, 1993; Siegel, 1999), whereas more negative behaviors including criticism, control, oppression, annihilation, neglect, and withdrawal are inimical to psychological health and well-being (Strachan, Leff, Goldstein, Doane, & Burtt, 1986). Even though there is agreement on the necessity of a facilitative climate, there is less agreement among psychotherapists of different schools about how to create such a climate and communicate empathy, acceptance, and congruence. Although differences among various schools of psychotherapy in how to provide the facilitative conditions are more a matter of degree rather than kind, there are discernible differences in the type of empathy that is emphasized, with some schools highlighting cognitive empathy and others emotional attunement (Khan, 2002; Rogers, 1951; Watson, 2001). There is also debate about how to communicate the facilitative conditions effectively. Some schools of psychotherapy have developed more explicit strategies to stimulate clients awareness of their inner experience, modulate their affective reactions, and develop reflective capacities including interventions like Socratic dialogues, thought records, two-chair tasks, empty chair work, systematic evocative unfold- 271

5 Watson ing, free association, and interpretations of clients transference, among others. However, empathic reflections are less didactic and directive than some of these other interventions, which make them more suitable for more resistant clients; other clients might benefit from more direction and guidance (Beutler et al., 2002). Notwithstanding the disagreement among different schools, Rogers distilled some of the essential conditions for the development of affect regulation and good interpersonal communication. It is through receiving empathic responses to being in the world that human beings learn interpersonal skills and ways of communicating with others as well as how to regulate and manage their affective reactions (Siegel, 1999). Therapist attitudes of empathy, acceptance, and congruence can facilitate clients awareness, labeling, reflection, and communication of their affective states to others (Watson et al., 2007). These skills are fundamental to clients development of affect regulation, and to effectively meeting their needs in interactions with others and as such they are vital to the acquisition of self-knowledge and self-regulation in normally functioning individuals. However, to be sufficient, the attitudes of empathy, acceptance, and congruence may need to be balanced with guidance, stimulation, and structure so that clients can acquire effective ways of regulating their affect and expressing it to others. References BARRETT-LENNARD, G. T. (1997). The recovery of empathy: Toward others and self. In A. C. Bohart & L. S. Greenberg (Eds.). Empathy reconsidered: New directions in psychotherapy (pp ). Washington, DC: American Psychological Association. BENJAMIN, L. S. (1974). Structural analysis of social behavior. Psychological Review, 81, BENJAMIN, L. S.,& KARPIAK, C. P. (2002). Personality disorders. In J. C. Norcross (Ed.). 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