As a person-centred therapist I would continue doing what I was trying to do all along: provide the therapeutic attitudes of empathic understanding, non-judgmental acceptance / respect, and a calm genuineness that is free of any persona or facade. I would be seeing the world through the client’s eyes, through their valuing system, to the extent that this is possible.
As such, the emotional rollercoaster that the client was on would not require tactical decisions related to assessment and intervention. After all, who is the better expert on the client? Me or her? Such an approach is based on the confidence that what we really want in moments of distress is to feel understood for what we are, not classified and manipulated by yet another helper or ‘expert’. We need to make sense of things on our own terms.
I recently wrote a blog outlining how the person-centred approach is radically different from mainstream therapies, yet still just as effective despite not having to worry about exactly how to assess and intervene in any particular situation. Here’s the link:
This might not be the answer you had in mind.
The first serious thing to go wrong before diagnosis is arguably the medical-style training for the ‘expert’ involved. This involves buying into an assumption that a diagnosis will be of more value than harm, and that nothing can be done unless there is a diagnosis. It is widely assumed, without much evidence, that the mind is like the body, and that the concept of ‘illness’ is therefore readily transferable to the psyche.
This assumption leads people to think that the only way forward is to ‘diagnose and treat’: to do something TO the client/patient. In many cases a diagnosis seems to serve largely to make the clinician feel in control and becomes a burden on the client / patient’s agency and confidence. In many cases a diagnosis is so subjective and arbitrary that you’d have to question its value, especially when it is known that the therapeutic relationship is usually more useful to the client/patient than the ‘treatment’.
In other words there is another important question: what serious things go wrong AFTER a mental health problem is diagnosed?
In most cases the process of diagnosis and treatment ignores the fact that the cause of mental distress is usually to be found in interpersonal relationships, and that the ‘cure’ is to be found in the same place. The mind does not need a mechanic. It needs to feel it can understand itself, and be understood by other minds, because these are what lie behind the ongoing process of self-actualization, and the neural integration that underlies it. This means that the disease-diagnosis-drugs medical model will mostly not address the ultimate socio-cultural causes of psychopathology, leaving the individual vulnerable to further distress in future.
In person-centred therapy it should be much less likely to happen because the therapist is working from within the client’s frame of reference. They should be as authentic as possible, with as much ego as possible left at the door before the session begins. The appropriate response would therefore be to empathise with the client’s need to say something like that. Offence could only be taken if the therapist is attempting to maintain a persona of some sort. Otherwise there’s nothing to offend. Unfortunately however, in the age of political correctness it has become so fashionable to tell people that they are offending you that even many person-centred therapists have become keener to judge than to empathise, keener to arbitrarily ascribe ‘hate’ to someone than to actually show an empathic interest in that person. But the individualist ethos of person-centred therapy should mean that the client is the expert. If the client feels something hateful, then the therapist should acknowledge that feeling as part of their reality, and appreciate that is very possibly something they would prefer to be free from.
If they’re a person-centred counsellor / therapist then the questions will not be of the usual sort. A person-centred counsellor will ask questions with the aim of empathically understanding the client’s frame of reference. This is because the client remains the expert, and the therapist does not therefore need to take control by asking questions from their own frame of reference. So there is no forcing the client’s world into someone else’s check-boxes. Once the client feels that the therapist accepts their frame of reference they will begin to accept it for themselves again, leading to a renewed sense of agency. Suddenly their world-map makes sense once more, and they can start navigating again.
As Carl Rogers said, ‘The curious paradox is that when I accept myself just as I am, then I can change’. So, with person-centred therapy it is not about what questions the counsellor asks or answers, but rather what questions the client asks themselves, and answers for themselves. Sometimes called the purist form of therapy, it is soft but strong; subtle, yet broadly as effective as other leading therapies. Yet it leaves the individual intact, indeed strengthened.
Many clients come to person-centred therapists after being disappointed with other types of therapy. Most complaints about therapists are things like ‘they weren’t listening’, ‘they wrongly interpreted my situation’, or ‘they advised the wrong things’. Each of these complaints indicates the danger of a questions-based approach to therapy. Such things are less common with person-centred therapy because it fully accepts and engages the client, and works with their own questions: it is as individual as they are.
As a person-centred therapist I have found that online sessions are actually very much like the ‘real’ thing. Provided that the internet connection is fast and there are no distractions, it is quite possible to establish and maintain relational depth. Issues like body-language don’t really seem to be too much of a problem, and I think this is because of the phenomenological basis of this approach: you’re seeking to empathically understand the client’s world as they see it, rather than trying to interpret and categorise their behaviour. I suspect that most therapists would prefer to meet face-to-face, but perhaps some therapies lend themselves to online work better than others.
We’re not even sure that medical-style ‘illness’ is the most valid way to represent what might more generally be called psychological distress. DSM-style diagnosis is widely regarded as imprecise and subjective. So, if these states of mind are not really illnesses as such, why would any kind of chemical intervention provide a reliable ’cure’?
A flourishing mind, or sense of self, needs feedback from empathic, encouraging relationships, especially early in life. A coherent and content sense of self will be able to balance the individual’s innate valuing process with the valuing process that is learned as part of socialization. Psychopathology sets in when these two valuing systems give conflicting messages about the elements of one’s experiencing that are important at any one time (in extreme cases this presents as psychosis). As Carl Rogers, and more recently Dan Siegel, have pointed out, it is relationships that make and break us.
Once we recognise the central importance of relationships in psychological distress, we can see how relationship-based therapies (such as person-centred therapy) are so effective. And we can see why treatment-based therapies are no more effective than the relationship-based ones, no matter what fancy techniques are cooked up. We are hooked on the notion that the answer is to do something to the patient, rather than with them.
There is no cure for mental illness because it is not mental illness. It is the self struggling, but failing, to actualize, to self-regulate in a way – in accordance with personal values – that leads to optimal integration. In this it needs the help of another person – another self, a genuine, authentic self who provides empathic understanding, and who offers a model for unconditional acceptance and symbolization of its difficult situation.
As a degree-qualifed person-centred therapist I feel I can perhaps help with this question, if only to correct some of the statements made in other responses.
Client / person-centred psychotherapy‘s non-directive, phenomenological approach is unique, and its emphasis on respect for the client’s agency and self-determination is unrivalled. It is the only therapy in which the positive regard for the client is truly unconditional – because it sees the client as the best expert on their experiencing. It is as individual as each client, because it works from the inside out. In comparison everything else is some kind of sausage machine.
It has been shown by numerous large-scale meta-analyses to be broadly as effective and efficacious as other leading approaches, for all conditions. It is particularly good at getting to lasting change, because it aims for personal growth towards a more authentic state. Yet it is so radically different from directive therapies that it remains gravely misunderstood, and mistrusted, even by many who profess to teach about it. One persistent myth is that it only works for relatively ‘easy’ cases. This myth appears to spring from a baked-in prejudice toward intervention-based approaches (‘we must do something TO him!’). But the client is never helpless, they just need to know that they can make sense of their world, and this can be greatly encouraged by the therapist’s empathic understanding – empathy with the underlying instincts and temperament, rather than with the unsatisfactory ways in which the client’s current personality might express these. If the therapist can accept the client’s world, then the client learns they can do the same.
PCT’s soft-but-strong approach allows depths of relating and processing that cannot be accessed by directive approaches. With PCT it is like you are at the back of the client’s head alongside them, looking at the confusion of their world as they see it. And they really appreciate the company! It is, contrary to myth, helpful for psychosis and schizophrenia, because it is so accepting of the clients’ experiencing. And it can be astonishingly quick – because it is driven by the client’s processing, profound change tends to happen in the session, rather than outside it. Another correction I need to make is that PCT does not feel like friendship. Friendship, like directive therapy, is persona-based, not phenomenological. It is conditional and directive. A client in PCT will frequently say something like, ‘I’ve never felt listened to, or understood, like this, with anyone’. And ‘mutual sharing’- as in personal disclosure – is not part of PCT.
But it is not for everyone, and this is almost certainly due in large part to a lack of well-trained practitioners. Many won’t take the time to explain how it works at the outset, leaving the client more and more bewildered as time progresses. But clients vary too. Many people prefer to be told what is wrong with them, and what to do about it. They would see therapy more as engineering than gardening. PCT is more for those who want to dive deep into themselves, understand their situation in their own terms, and make the most authentic decisions on that basis.
As time goes by, the world is slowly catching up with Carl Rogers’ ideas: many now recognize that diagnosis is not particularly valid or valuable, that it is our relationships that make or break us, and that values lie at the heart of things. Advances in genetics and neuroscience are very supportive of Rogers’ theory. In his excellent 2011 lecture, ‘Self-deception in Psychopathology’ Jordan Peterson managed to largely ignore Rogers, yet ironically also proposed that the best definition of mental illness might be: ‘‘Mental illness is the inability to regulate perception, action, emotion, cognition in accordance with desired values’. Rogers would have applauded.
If you are wanting to get a proper understanding of PCT, the best references would be ‘Client-centered Therapy’ by Carl Rogers (1951), and the more detailed 1959 ‘Koch paper’. You can also check out my Youtube channel and blog:
I hope this helps.
This is yet another reason why I love working with the person-centred approach. “What’s transference?” 🙂
Yes, person-centred therapy has proven effective with psychotics.
This should not come as a surprise: its non-directive, phenomenological approach is highly respectful of the the client’s sense of agency and self-determination. This empathic, tentative approach makes it very powerful with highly disturbed and vulnerable people who struggle to stay present in ‘objective’ reality.
Carl Rogers had found that schizphrenic patients responded more positively to him than to other (directive) therapists. He was willing meet them in ‘their’ world, and this meant a lot to them. A major research study was undertaken in the 1960’s, looking at the effectiveness of PCT with schizophrenic patients. Unfortunately the research team had a fall-out and the full data set was never included in the analysis. As a consequence there is a persistent myth the PCT is not effective with psychosis. The reality is different, and if the missing data is taken into account the research verifies that PCT works well with psychosis.
These days ‘pre-therapy’, a type of person-centred therapy, helps people with severe psychosis prepare for therapy.
It is important to note that noting works for everyone, and this is particularly true with mental illness. But certainly PCT has a lot to offer those with psychosis.