The Person Centered Journal, Volume 5, Issue 1, 1998
Printed in the
U.S.A. All rights reserved.
Successful Psychotherapy: A caring, loving relationship.
by C. H. Patterson and Suzanne Hidore.
Jason Aronson, Inc.
Northvale NJ, 1997.
I wear two hats. First, I am a client centered/person centered therapist at heart. Second, I am a member of the Society for the Exploration of Psychotherapy Integration. Since this book attempts to provide a universal system for psychotherapy it is both a statement of person centered principles, and an attempt at psychotherapy integration. I will look at it from these two perspectives.
From the perspective of client centered/person centered theory, this book is a comprehensive and eloquent statement of person centered beliefs about psychotherapy, and I highly recommend it. The book begins by defining pychotherapy as " . . . a psychological relationship between a person or persons, designated as the clients, whose progress in self actualization has been blocked or impeded by the absence of good interpersonal relationships; and a person, designated as the therapist, who provides such a relationship" (p. xiii). The authors use Carl Rogers' 1957 "necessary and sufficient conditions" article as a starting point to develop what they claim is a universal system of psychotherapy. They point out that this book adopts a position in contrast to the dominant "specific treatments" view of the therapist as a diagnosing, prescribing expert who actively intervenes with differential techniques for different disorders.
In the first chapter in the book, "Chaos in Psychotherapy," they consider the current state of the field. They argue that there is no evidence to support the "specific treatments" paradigm. They then move on to consider the psychotherapy integration movement. They argue that most advocates of psychotherapy integration do not have as a goal the development of a universal system of psychotherapy. Many, instead, advocate eclecticism, which is the use of a variety of techniques and ideas borrowed from different theoretical perspectives. Research has shown that a plurality of practicing therapists today identify themselves as eclectic, but the authors note that eclecticism is not a well defined idea. While some systems have been worked out for eclectic practice, they have not been empirically supported as of yet. Others who practice eclectically utilize a haphazard mix of techniques and ideas with no clear guiding framework.
They then move on to consider the "common factors" solution to psychotherapy integration – the idea that different therapies work because of common underlying factors that occur in ail of them. They focus on one common factor the relationship between therapist and client and argue that there is considerable evidence that this is not only a powerful facilitator of change in therapy, but the most powerful facilitator. From this they move on to argue for self actualization as the core, common universal motive underlying all behavior. They perform a real service here by countering objections raised by those who do not really understand the idea of self actualization it is not selfish and self centered, it is not anti social, and it does not promote unbridled self-
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indulgence in the name of spontaneity and individual freedom. Rather, self actualization involves a movement towards others, and an integration of aims and desires with others, because of a built in human need for affiliation and communication.
Patterson and Hidore next argue that if there were a common etiology to all psychological problems, then there would be no need to develop specific therapies for specific disorders. Instead a common therapy that was most effective in dealing with this common underlying etiology could be utilized. They argue that the ultimate goal of all psychotherapy is self actualization, and that the lack of good interpersonal relationships is the underlying common etiology of problems because that gets in the way of the self actualization process. Bad interpersonal relationships lead to low self esteem and defensiveness. When an individual is primarily concerned with defending the self, then that individual cannot be open to all available information which might help her/him solve a problem and gets stuck in a rigid self protective stance and is less likely to be able to fluidly adapt. Helping people self actualize means helping them become more open and nondefensive, more fluid and able to creatively re evaluate old ways of being and change to deal with new situations and new information, and become more open to and trusting of their own organism.
The "cure" for the common etiology of lack of a good interpersonal relationship is to provide one. A good interpersonal relationship is one characterized by respect (warmth, unconditional positive regard, caring, etc., empathic understanding, and genuineness. At a basic level, the authors see this as the provision of love. They review what it means to be respectful and caring, empathically understanding, and genuine. In so doing they make distinctions important to clarifying these notions to those who have criticized them. For instance, respect/unconditional positive regard does not mean one uncritically likes or approves of everything or anything a person does. What it means is holding a genuine respect and caring for the underlying person even though they don't always behave in ways one agrees with/approves of.
In the next chapter the authors go on to consider other conditions for successful therapy which have been proposed (primarily by Carkhuff and his colleagues): confrontation, self disclosure, immediacy, and concreteness. They note that these conditions are not necessary to successful therapy, must be subordinated to the three basic therapeutic conditions, but can on occasion be helpful. They provide a service in clarifying what helpful confrontation really is (it is not an attack on the other person), as well as what helpful self disclosure and immediacy are.
They then move on to a consideration of the client's role in therapy, noting that the client is the primary change agent. From that they move on to a consideration of multicultural factors in therapy. After reviewing a number of notions that have been proposed about doing therapy from a multicultural perspective, they argue that there is really no reason to change their basic therapeutic stance on the basis of multicultural factors. While research consistently has found that ethnic minority clients prefer therapists who are directive, the authors note that this is a preference, not a requirement. Further they note that such clients also want the basic therapeutic conditions: to be respected, to be cared about, to be understood, and to be related to in a genuine fashion. Based on this, they see no reason that their model of therapy should be modified to take cultural considerations into account (i.e., by the therapist being more directive and prescriptive).
I found their discussion here both illuminating and frustrating. I think they make an important point in arguing that people of all cultural and ethnic backgrounds want warm, empathic, and genuine relationships. Further, I agree that we may be shortchanging clients in assuming that because of their ethnic background they "need" directive therapists. A study by Barbara Lerner long ago found that lower class clients, presumably not able to utilize verbal insight therapy, did quite well with client centered and psychodynamic therapists. In fact, in my experience as a teacher of graduate students of various ethnic backgrounds, I have come to believe that the personal relationship may be more important to individuals who come out of sociocentric
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cultures, in contrast to those who have come out of Euroamerican egocentric cultures. Two Hispanic graduate students a few years ago alerted me to the western bias in some of our ideas about dual relationships and boundaries. They noted that rural Mexican clients expected much more personal involvement, and were put off if they didn't get it, than is mandated by our current rules which stipulate therapists maintaining a good deal of interpersonal distance from their clients (e.g. you are not even supposed to attend their wedding!).
At the same time I felt this was one area where the book failed to deliver. I am glad that the authors point out that clients of different cultural backgrounds also want the basic therapeutic conditions. But I do not think they adequately answer the objection that clients from ethnic minority groups often want more directive therapists. Again, I train a lot of therapists from ethnic minority backgrounds, and they do report that people from their communities do expect the professional to adopt more of a directive stance, and they are more comfortable when the therapist does so. The problem is broader than with mulitcultural counseling. There are clients in general who want a more active, "directive" approach than is offered by a traditional client centered therapist. The question is: If we are to "follow the client," and the client wants us to be more directive, should we not be more "directive"? Am I not "rigidly" imposing my frame of reference on the client if I, in the name of my theory, refuse to be directive when they want me to? Who is running therapy then, me or the client? For me, this presents one of the enduring dilemmas of therapy. I would like to believe there is an "and" here rather than an either/or: we can adopt a more active, "directive" stance and still believe the client is the leader, the creator, and the self healer. But I have yet to figure out a coherent way to do this. And I do not believe that Patterson and Hidore adequately answer this either.
In some sense, they define the problem away. By defining psychotherapy as they do as the provision of a good relationship to people who are not self actualizing because they did not have good relationships in the past, therapy ipso facto becomes the provision of a relationship whose goal is self actualization. Any other way of viewing therapy, then, is no longer psychotherapy. For instance, more directive approaches are allowed to exist, but as education, not as psychotherapy. This is neat, may have some validity, but is also problematic (although personally I think it may be time that our field begins to distinguish between the different activities that have been lumped under the global appelation "psychotherapy"). It is problematic because many behaviorists would argue that therapy is education. Marsha Linehan's dialectical behavior therapy for borderline personality disorder, for instance, largely consists of skills training. Her argument is that highly dysfunctional early childhoods led to a failure to develop a host of life skills such as communication skills, problem solving skills, and emotional management skills. Seen this way, her "therapy" is to teach these skills. She, at least, and many others, would claim that the distinction between therapy and education is false, thus throwing us right back into the horns of the dilemma. If our clients want us to be more directive, can we do that and still be "therapeutic"? Again, I do not have the answer, but neither do the authors either.
Part of the problem, I think, is in the word "directive." If pose a simple dichotomy between directive and nondirective, and lump anything beside empathic following under the "directive" label then I think we miss more subtle distinctions. Patterson and Hidore get at this when they note that they prefer the term "noncontrolling" to "nondirective." I don't like being directive at all, but I do like being "suggestive" at times. I see classical empathically following nondirective therapy as a beautiful, pure, almost Platonic ideal form of providing a context for client growth and self-actualization. But in my experience as a therapist and trainer of therapists, some clients clearly "want" the therapist to do more than empathically follow. As Patterson and Hidore point out, empathic following and responding is not a passive procedure, but rather is highly active. Nonetheless, it is comparatively inactive compared to therapists who more actively structure, suggest techniques, over interpretations, and so on. For some time I have struggled with the
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dilemma that not only do some clients want this, but they really want it, i.e. they actively want the therapist to do "more" than empathically follow. Some clients want someone who they perceive "challenges" them more than a therapist who primarily listens and empathically reflects. Furthermore, they in no way lose their autonomy when the therapist is more active in the ways I have identified above. To the contrary, it seems to mobilize them to actively think, experience, and work things out for themselves. If the therapist is not controlling, there simply is no evidence that these clients are being somehow hindered and oppressed by the therapist's taking a much more "active" role. I now believe that we should respect clients ' "personal styles" and wishes in this regard. (One such "client" is a colleague of mine, a person who adheres to person centered philosophy and primarily practices in a relatively pure client centered way. Yet when she sees a therapist she wants the therapist to argue with her, debate with her, express opinions, suggest techniques, and so on, while respecting her self directed growth process and autonomy. In no way does an active, "directive" therapist squelch her self directed growth process. To the contrary, it seems to contribute to it.
The issue then becomes: can one adopt a much more "active, directive" stance and still honor the principles of client centered/person centered therapy? I realize that this has been an ongoing debate in our field for a number of years, and no resolution is in sight. I believe the answer is "yes," but have yet to clearly work it out for myself. Partly, I believe the answer may lie in making the same attitude behavior distinction we have made with regard to empathy, genuineness, and unconditional positive regard. Following Rogers, most of us see those as attitudes rather than behaviors, and reject the efforts of those who tried to reduce them to particular ways of behaviorally responding (see Bozarth, 1997 for a discussion with respect to empathy). Is it possible that we could think of the nondirective attitude as an attitude, and distinguish it from some set of behaviors which we call "being nondirective?" If so, then it is possible to express nondirectiveness in a variety of ways, and, I suspect, be able to be nondirective while giving advice, suggesting techniques, offering interpretations, and so on. This fits with Patterson's and Hidore's distinction between nondirectiveness and noncontrollingness. That is, what may be more important than the particular mode of response is whether it is offered in a noncontrolling fashion, or whether it is given as the voice of truth from above. If this distinction makes sense, then it may be possible to act more "directively" (in the sense of providing more structure, offering advice and techniques, and so forth) while still believing that the client is the true leader in therapy, and the real change agent. Therapeutic dialogue, then, becomes a true give and take, of which empathic following may be a more or less significant component, depending on the nature of the dialogue with any given client. Therapists could then be more "directive" with clients who want that in their service, just as if you hired a personal exercise trainer and then told him or her "Now tell me when I'm doing it wrong! " The issue is important, I think, because we need to find ways of offering technology in a human, respectful way, in a world where consumers are increasingly being brainwashed or forced to demand technology rather than truly human psychotherapy. In any case, while I felt Patterson and Hidore did an excellent job of defending a rationale for doing client centered therapy "as usual" with multicultural clients, they did not really deal with the question of clients' preferring more directive therapists.
Moving on from this thorny issue, Patterson and Hidore conclude the book by arguing that love can provide primary prevention to the development of psychological problems, and by providing several case histories.
As an eloquent, well reasoned and researched defense of a person centered approach to psychotherapy, I think this book is highly informative, and I strongly recommend it. Turning to my other "hat," that of an integrative psychotherapist, I still think the book is highly provocative and well worth reading, but more problematic. I think it provides a strong positive case for the thesis that client centered therapy may provide the basis for a universal system of therapy. But
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only "may". Many objections come to mind. First, while the authors have a right to define therapy as they wish, and to exclude things they do not think of as "therapy," this, I think weakens their claim to have come up with a universal system of therapy. As I have noted, many behaviorists would argue that therapy is the educational training of life skills, and this is entirely excluded under the authors' rubric. Second, I can imagine some of my psychoanalytic colleagues reading this and wondering where are considerations of transference, repression, interpretation, and so on. Similarly, my cognitive behavioral colleagues would read it and wonder why there is no mention of dysfunctional schemas or the use of homework to challenge dysfunctional thoughts. Finally, my process experiential colleagues would wonder why there is no mention of the systematic use of role play, focusing, or evocative reflections. They all might join in arguing that all the authors have done is claim that Rogerian therapy is "the" universal therapy, and they may counter by claiming that their point of view is "the" universal therapy (this has, in fact, already been claimed by some cognitive therapists). They might even argue (and some have) that they agree that the therapist should be warm, empathic and genuine, but that this can be subsumed in their framework, which is, in fact, "the universal system of psychotherapy. Some of the cognitive-behaviorists would go on to dispute the claim that research has not shown differential effects of differential treatments. They would refer to the recent "empirically validated treatments" document from Division 12 of the American Psychological Association, which purports to document around 50 studies showing differential treatment effects, almost always in favor of cognitive behavioral treatments. Ultimately, I think, they would argue that a truly universal system of psychotherapy would incorporate insights from all the approaches, and this has not yet been achieved, primarily because of differing epistemological assumptions among the differing approaches. In sum, I think my colleagues, while finding this book provocative, would ultimately not be persuaded. At the same time, I would hope they would read this book because I think it does provide "a" universal model of therapy, if not "the" universal model of therapy.
Thus: should you read this book? If you are a client centered/person centered therapist, yes. It spells out the relationship/actualization model in a clear, coherent, well reasoned manner. If you are a therapist interested in psychotherapy integration, the answer also is "yes." It provides a provocative argument. You might not end up agreeing with it, but it will get you to think, and, at the very least, I would hope take more seriously active client self healing potential and the power of the relationship.
Bozarth, J. D. (1997). Empathy from the framework of client centered theory and the Rogerian hypothesis. In A. C. Bohart & L. S. Greenberg (Eds.). Empathy Reconsidered. (pp. 81 102). Washington DC: American Psychological Association.
Reviewed by
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