More and more people seem to be burdened with some sort of mental illness or condition. The medical industry, where much of the psychotherapy is conducted, seems hooked on palliative ‘solutions’ such as medication and curtailed programs of manualized psychotherapy which assume that every patient is the average patient. There’s no time to actually understand them: just patch them up and send them back out there. Yet we know in our bones that it is relationships that sustain us, even as we seem so isolated from each other.
Perhaps we can’t fix society, or guarantee empathic relationships for all. But can therapy and counselling be less alienating?
A different kind of shrink: therapy from the inside out
A while back, in the mid-twentieth century, a psychologist called Carl Rogers began providing psychotherapy that was informed by scientific analysis of clinical experience. This was the first evidence-based form of therapy, yet he was obliged to call it ‘counselling’ because at the time only the medically qualified were legally entitle to call themselves psychotherapists. The idea of psychology-informed therapy was totally new.
To say that Rogers changed things is an understatement. In 2009 a survey of 2400 psychotherapists voted him the most influential therapist ever. This is largely because he put the relationship back into therapy. His approach was the relationship: a highly nuanced, empathic, non-judgmental and transparent relationship. Other modalities still acknowledge his contribution in providing what are often called the three ‘core conditions’ of a therapeutic relationship.
Unfortunately much of what Rogers had discovered was too revolutionary to integrate into the existing models of therapy of his time. These were, and remain, largely based on the idea of the clinical ‘expert’, who somehow assesses, interprets, diagnoses, and appropriately ‘treats’ the client / patient. Like a doctor, magician or mechanic. So they took the core conditions and left it at that. It was unpalatable for the same reason. Could being with the client really be more important than doing something to the client? So why did I spending so long developing all my ‘interventions’?
In the years since Rogers we have learned much more about the nature of human flourishing, psychopathology and the mechanisms of successful therapy. The Rogerian model has been incredibly well supported by mainstream research, including new branches of enquiry including neuroscience, mindfulness studies and positive psychology.
Rogers saw the process of assessment, interpretation and diagnosis as too arbitrary to be of much help in most cases, and risk-laden in many. Today many clinicians hold this view, and research backs it up (psychiatric diagnosis is scientifically meaningless). Anything that anyone can say about another’s inner world is to a very large degree a guess. So why not work with what we actually know? Here we discover the insight that underpins person-centred therapy, the thing that we can say about everyone. Every living thing is always in a state of ‘actualization’, or becoming, over time tending and regressing persistently in that direction, despite diversions, traumas and obstacles. Life is not a random process – it knows what it wants, and this is different to each individual. Like the constant corrections of an auto-pilot, the actualizing tendency seeks over time to maintain a trajectory that allows us to flourish: to grow, learn, adapt, recover, reproduce, and win the appreciation, the positive regard, of those around us.
Actualization is simply what life does, but actualization involves a constant process of valuing: if behaviour is to be self-serving then it cannot be random. At any time one thing must be more important than other things. There must always be a sense of what matters most. This is our nature calling: our instincts, drives, temperament, inclinations, and the vast majority of what we call gender and sexuality, all expressed intuitively and wordlessly as an embodied feeling that Rogers called organismic valuing.
Carl Rogers developed his theory before the age of neuroscience, but he saw the psychological correlate for neural integration, and he called it self-actualization. The self, once it has started life by differentiating itself from the world of what we are experiencing, has to constantly differentiate, reconfigure, adapt and enhance itself in the face of ongoing experience- much of which is interpersonal and socio-cultural. We develop a sophisticated idea of who we are, a self-concept, that is kept afloat and maintained by the ongoing process of self-actualization. This involves a constant flux of decisions about what to admit into the self-concept, and what to keep out there in the world. For self-actualization, as for the overall actualizing tendency, we need a clear sense of priorities, which in turn come from our sense of values.
It’s the relationship that counts
But we are not guided only by our innate organismic valuings. As hyper-social creatures we need to fit in with other individuals, and the wider culture. So we readily absorb ‘shoulds’ and ‘oughts’ from those who socialize us. Rogers believed that interpersonal relationships, especially in early years, are highly vulnerable to these imported values that can corrupt our sense of ‘self’. Relationships, to Rogers, were both the cause of distress and its cure. This is also a mainstream idea now, promoted by popular authors such as Dan Siegel. People aren’t ‘born bad’, and brain chemicals don’t randomly just slip out of balance. It is our sense of self in relation to our frame of reference, and particularly in relation to significant others, which can bring about either sickness or growth. Those who socialize us show us that they like us more when we do the ‘right’ things, and less when we do the ‘wrong’ things’. But sometimes their expectations, the ‘conditions of worth’ they placed on us, are unrealistic and ask too much of us. Perhaps in an acute, harsh way: ‘We don’t do that in our family!’ Or in a chronic, subtle way: ‘A career is more important than motherhood’. It such circumstances nurture can go against nature, and the meme asks too much of the gene.
If life is what happens where the gene interfaces with its environment, for humans life is very largely what happens where the gene meets the meme, because we are such highly social creatures. We are each others’ environment. But we are vulnerable: if there is a serious, or long-term clash between these two valuing systems they can become dissociated, producing a tense state of cognitive dissonance that Rogers called incongruence. Suddenly our world-map is not highlighting its guiding features with enough clarity. We become snagged on our conditions of worth, which we carry with us, unacknowledged and un-integrated, at the edge of our awareness. We defend our self-concept in the face of this constant tension by denying and distorting our frame of reference. But decisions become harder, as the mind defaults to doubt. Wanting gives way to worrying. We feel we are not coping.
Problems, and a sense of pressure, stack up around us, causing us to behave in ways that can be diagnostic of common mental health conditions. We might develop attitudes that are ‘incongruent’ with our behaviours. We might, for example appear plainly angry, or sad, or gay, yet also be utterly convinced that we cannot be those things, preferring to say (and believe) ‘that’s not me’. These elements of being cannot be associated with our self-concept because we were never permitted and encouraged to accept and express them. In extreme cases the sense of self is so overwhelmed that our valuing system can buckle under the pressure, providing random signals about what is important, what to say next, or what is being seen or heard. We call this psychosis.
In his research Rogers found no evidence to suggest that any particular treatment or intervention was better than any other. This is still pretty much the picture; such is the variability of human nature, the arbitrariness of diagnoses, and the tight constraints that must be placed on any study purporting to evaluate the effectiveness of psychological therapies from within a medical framework. To Rogers, relationships were the channel for both harm and help, and the actualizing tendency is the curative force which will do its work if we can allow it.
So how can we tap into the actualizing tendency, to our growth potential? Rogers thought he knew the answer: the nature of the therapeutic relationship, as influenced by the skilfully applied attitudes of the therapist. It is difficult to provide and maintain such a relationship. It is necessary to be with the client, yet not direct or distract their train of thought. It is necessary to see the client’s life from within their frame of reference, to accompany the inner client as they gradually accept, articulate and symbolize the unresolved elements of their situation. To name it (in your own terms) is to tame it.
Still misunderstood, but still as good as any
All the research into which types of therapy work best have concluded that all major types of therapy are equally effective, including the one (person-centred therapy) that has no ‘treatments’ in it! Rogers’ relationship-based approach is as effective as other leading types of therapy, and for all types of condition. But a consequence of person-centred therapy’s radical phenomenological and non-directive outlook is that a number of misunderstandings about person-centred therapy have became entrenched. One common misconception is that the approach is merely ‘active listening’. Another is that Rogers, a man who had clearly seen more than his fair share of human malevolence, somehow had a rather naïve idea that humans are innately ‘good’, whatever that means. This came to annoy him so much that he wrote an article to address it, making a comparison with lions: if a lion is healthy and happy do we say that it is good? No, it is simply a flourishing lion.
Another common myth is that the relationship is not enough: interventions must surely be essential in addition to the relationship. Here again the evidence proves otherwise, and anyway, the quality of the relationship would be compromised if the judgments of interpretation and intervention were brought into play. It has also been said that the person-centred approach is not effective with psychosis. Again, the reality is different: internal squabbling among the researchers on Rogers’ final study (with schizophrenia patients) led to a failure to incorporate all available data. When the missing data is taken into account there is good evidence for effectiveness.
Here we come to perhaps the most outrageous implication of Rogers’ theory. You don’t necessarily need training, or experience, to provide a growth-nurturing relationship. There, I‘ve said it. But we all know its true: some people are just able to help others in that kind of way. And the evidence again proves his point: on average there is no strong correlation between a therapist’s experience and results, nor between their training and results.
So Rogers’ approach is still radically different. Counter-intuitive, even. As neuroscience and positive psychology march on, it increasingly seems he was way ahead of his time. Person-centred therapy’s uniqueness means that therapy as a whole can genuinely offer different things to different people. Many clients prefer to be told what is wrong, and what they should do about it. These people would seek directive therapies, with therapists willing to present themselves as such an ‘expert’ on another’s world. This works for plenty of people, and this is a very good thing. Others, however, need to explore unknown territory, to go deep into themselves, interpreting things in their own way so they can find genuine lasting change. Perhaps unsurprisingly, person-centred therapy seems particularly well-suited to people with a high sense of independent-mindedness, who need to see things their own way. Such people can respond very well to non-directive (person-centred) therapy.
And the best advice for someone seeking help? Decide broadly what kind of therapy you want and then pick the therapist you feel most comfortable with. Don’t get bedazzled by diagnoses, interpretations, jargon, treatments and scout badges. It is the relationship that matters most.
Learn more about person-centred therapy and related ideas on my Youtube channel: Person-centred Therapy – Tim Harvard
 Cook, J. M., Biyanova, T. and Coyne, J. C. (2009) Influential psychotherapy figures, authors and books: an internet survey of over 2,000 psychotherapists, Psychotherapy (chic) Mar;46(1):42-51. doi: 10.1037/a0015152.