Campbell Purton's website
HOME Publications: BUDDHISM COUNSELLING FOCUSING PHILOSOPHY
Centre for Counselling Studies, University of East Anglia, Norwich, UK
Campbell Purton is Senior Counsellor, and Director of the MA programme in Focusing and Experiential Psychotherapy at the Centre for Counselling Studies, University of East Anglia. He originally studied philosophy, which he has taught at universities in Canada and Scotland. He is the author of Person-centred Therapy: The Focusing-oriented Approach (Palgrave, 2004).
Keywords: client-centered therapy, person-centered therapy, process-experiential therapy, focusing-oriented psychotherapy, person-centered theory, implicit order
The PCE 2003 Conference on Person-Centered and Experiential Psychotherapy and Counselling had as its central theme two apparently opposing propositions. ‘On the one hand, therapeutic processes need to be differentiated in response to different client problems; while on the other hand, it is argued that it does not matter anyway which problems the client has with respect to our therapeutic actions and attitudes.’ (Takens & Lietaer, 2004).
It can seem that classical client-centered theory is committed to saying that there should be no differentiation as a function of the client’s problems, while process-experiential theory is committed to the opposite view. In this paper I will suggest that the situation is not so straightforward: both approaches imply differential therapist responses, but neither is committed to the view that such responses are to be made in an explicit rule-governed way. A similar conclusion seems to follow when we approach the matter from the perspective of Gendlin’s focusing-oriented therapy, in which the distinction between what is explicit and what is implicit is itself made explicit. I end with the suggestion that what the conference question eventually leads us to is the importance of Gendlin’s notion of the ‘implicit order ’ in psychotherapy.
In connection with the Conference question we can feel pulled two ways, which could be summarized briefly as follows.
(1) First there is the pull towards saying that person-centered therapy should eschew ‘diagnosis’. There are two reasons for this: (a) that diagnostic categories always simplify, and often distort, the actual lived experience of the client. The client is this unique human being, and needs to be responded to as such, rather than as an instance of a general category such as ‘paranoid schizophrenic’ or ‘alcoholic’, and (b) that diagnostic categories derive from the experience and knowledge of therapists and researchers rather from the experience and knowledge of the client. Hence in diagnosing a client we are fitting the client’s experience into categories deriving from our experience; we are not working within the client’s frame of reference.
(2) However, there is also the pull towards saying that to respond differentially to clients who have different kinds of problems is itself an aspect of being client-centered. Surely we should respond rather differently to a very vulnerable client than to a more self-assured client, for example? But is that not a kind of intuitive ‘diagnosis’? And if that sort of diagnosis can be helpful, why should we close our minds to more subtle and sophisticated forms of diagnosis? If through experience and relevant reading we have developed some sensitivity as to whether a client is likely to react in paranoid ways, should we refuse to be influenced by what we know? Would that not be as absurd as to ignore what we know of a particular culture when a client from that culture comes to us as a client?
What I shall try to show is that the two positions just sketched are over-polarised. ‘Diagnosis’ need not be a rigid application of categories which ignore the client’s frame of reference. But also, the application of any general category may need to be queried and revised in the light of the client’s actual experiencing.
CLASSICAL CLIENT-CENTERED THERAPY
It is the classical client-centered therapists who are most drawn to the first position, that diagnosis is to be eschewed. This is partly because Rogers’ theory of psychological disturbance does not differentiate between different aetiologies of disturbance. In Rogers’ view, client-centered therapy is effective because it provides an antidote to introjected conditions of worth (Rogers, 1959, p. 230), a view that has been echoed
for example by Bozarth (1998, p. 197). It seems to follow from this that there is an important sense in which the person-centered therapist should respond in the same way to any client (Schlien, 1989, p.161). Since all psychological disturbance arises from introjected conditions of worth, the task of the therapist is always to offer Rogers’ conditions, since it is these which will be effective in dissolving the conditions of worth. I am not myself convinced that all psychological disturbance arises in the way Rogers says it does, but that is a topic for discussion elsewhere (Purton 2002; Purton, 2004) . However, I think that most therapists will agree that much disturbance arises in this way. So we can ask, for disturbances of this class, is it true that the therapist should always respond ‘in the same way’, that is, by ‘offering the core conditions’?
Clearly some qualifications need to be made. Rogers says that for therapy to be effective the client and therapist must be in psychological contact, and that the client must actually perceive the therapist’s empathy and acceptance. Establishing these conditions may well require different procedures with different clients. In early sessions, indeed, the main work may well be that of establishing a working relationship with the client. And in later sessions the relationship needs to be maintained. How this is done will depend on idiosyncratic aspects of the client, the therapist, and the evolving relationship between them. So far as this aspect of therapy is concerned, the therapist certainly responds in different ways to different clients. The differential response is clearly not a matter of following any explicit rules, but of sensing what is needed in order to establish the conditions. Wilkins and Gill (2003, p. 185) make this the basis for their person-centered theory of assessment.
Then there is the point that clients may vary in which of the core conditions they need to experience most. The therapist may sense that one client feels very vulnerable to criticism over certain things which they have done, and above all needs to feel that the therapist will not condemn them. Here therapist acceptance seems especially important. Another client is worried about other people finding them strange and incomprehensible. In that case therapist empathy may be especially helpful. A third client finds it hard to trust that people really mean what they say, and here it could be crucial that the therapist is open and authentic with them. Elke Lambers (2003a &b) suggests that congruence should be emphasised in connection with psychotic clients (p. 114), and acceptance in connection with clients who have personality disorders (p. 119). There are some general principles here which most therapists may not think about explicitly when with a client, but which probably, in an implicit way, inform what the therapist does.
Then there is the point that the core conditions can be embodied in different ways. One of the early developments in client-centered therapy was the change from thinking of empathic responses as constituted by the procedure of reflection, to thinking of them as arising from an attitude which could be embodied in all sorts of ways. In Bozarth’s term, empathic responses can be idiosyncratic, meaning that their form can depend very much on the therapeutic context at the time. There are no rules for idiosyncratic empathy responses; again, it is a matter of the therapist having a sense for what will help at that particular time with that particular client. Bozarth (1984) gives some beautiful examples of this.
Rogers (1951, p. 223) himself had an interesting perspective on diagnosis. He wrote:
In a very meaningful and accurate sense, therapy is diagnosis, and this diagnosis is a process which goes on in the experience of the client, rather than in the intellect of the clinician.
By this I think he meant that the nature of the client’s trouble becomes clear to the client only in the course of therapy, that ‘diagnosis’ cannot be made prior to the client’s own formulation of their trouble, which takes place in the course of its resolution. Yet while this is an appealing perspective on diagnosis, it does not entail that the therapist should refrain from making differential responses which are informed by past experience or theoretical knowledge. Such responses may help the client in reaching a diagnosis/resolution of their difficulty.
My conclusion is that although Rogers’ theory implies that all clients need to be responded to with the core conditions, and in that sense all clients should be treated in the same way, when it comes down to the detailed ways in which the core conditions are to be embodied, the idiosyncrasies of client, therapist and therapeutic relationship require a wide variety of response. Just what the response should be is in some sense determined by the client’s problems and needs, and there could even be something like a person-centered manual which would lay out the kinds of points which I have just discussed. What might then go wrong would not be due to the fact that there was a manual, but that the concepts and guidelines in the manual might be applied in an unhelpful way. This suspicious client may not at this moment be helped by therapist openness (just as this client from another culture may not be typical of that culture). And always, of course, what is ‘in the manual’ catches at best only certain aspects of the client’s lived experiencing.
Nevertheless, the ‘manual’ can sensitise the therapist to possibilities of response to which they might not otherwise have been sensitive. The fact that a clumsy and insensitive use of the ‘manual’ can lead the therapist away from the client’s experiencing is a difficulty in how the therapist uses the ‘manual’. If we do not appreciate this point then the fact that a therapist knows a great deal about depression, for example, can be made to seem irrelevant to their working with depressed people. But this absurd conclusion does not follow once we recognize that the therapist’s general knowledge can function implicitly as one aspect of their whole engagement with the client. It is not that the therapist has to formulate their knowledge in terms of an explicit rule, but that through having that knowledge they will be present with such clients rather differently, and more sensitively, than they would otherwise have been.
The issue here is one about how we are to relate our explicit and general knowledge to our much richer implicit understanding of this client now. I will return to this point later.
I will now consider briefly how the issue of differential therapist response looks from the perspective of process-experiential theory. In this theory a particular form of diagnosis, and of differential responding, is central.
In the theory, developed by Leslie Greenberg and his colleagues (e.g. Greenberg, Rice and Elliott 1993; Greenberg, Lietaer & Watson 1998; Elliott, Watson, Goldman and Greenberg 2004), psychological disturbance is seen as arising from problems in symbolising one’s experiencing. Some of these problems arise from lack of attention to one’s immediate experiencing, others from one’s experiencing being disturbed by dysfunctional emotion-schemes. The role of the therapist is to access both the experiencing and the emotion-schemes so that experiencing can be restructured in a way which is more adaptive. Rogers’ core conditions may have a direct therapeutic impact in the course of therapy, but they also provide a safe context within which the client can explore their experiencing without interference due to interpersonal anxiety. Early sessions, especially, are often concerned with empathic attunement, and establishing a therapeutic bond with the client. Only then can attention be usefully be directed to the problems which the client has in processing their experience.
There are a number of difficulties which can arise in the processing or symbolising of experience. Each of them requires a different kind of therapeutic intervention. For example, a client may be able to discuss their difficulty in an abstract, intellectual way, but be unable to feel it experientially. The processing difficulty here is one of bringing emotional experience into relation with cognition. In this situation the appropriate therapeutic move would be to help the client to focus on the experiential felt sense of the difficulty in the focusing kind of way which has been described by Gendlin (1996).
Another client may have lingering bad feelings toward a significant other arising from unresolved traumatic experience; in other words there is an issue involving ‘unfinished business’. The processing difficulty is that the normal course of emotional expression has been cut off. For example, the anger or sadness has not been fully expressed and is therefore re-activated whenever current situations remind the client of the unfinished situation. Here the appropriate move could be the Gestalt therapy procedure of encouraging the client to ‘talk to’ the significant other, imagined as sitting in another chair, so that the blocked emotions can run their course.
A third client may be troubled by their problematic reactions in particular kinds of situations. The origin of the problem is probably that the client is responding in ways which were laid down in childhood, but which are no longer appropriate to current situations. But what maintains the problem is the processing difficulty whereby new experiencing is filtered by the old scheme and thus cannot correct the scheme. Here the appropriate response would be to help the client to re-experience slowly, in imagination, an example of the situation which gives rise to the problematic response. In this re-experiencing they have the opportunity to appreciate what the salient feature of the situation is which gives rise to the reaction, and how they are construing or misconstruing that feature.
Process-experiential therapy thus marks out a number of recognisable kinds of client processing difficulties, to each of which there is a specific kind of response which is likely to be therapeutic. Thus in a sense process-experiential therapy makes a diagnosis of the client, but it is a diagnosis of the kind of difficulty which the client has in processing their experience, rather than a diagnosis of what is wrong in their relationships, or attitudes or beliefs.
At first sight it may seem that process-experiential therapy lies at the opposite extreme from classical person-centered therapy so far as the issue of differential therapeutic response is concerned. While at first sight the classical person-centered therapist offers the same relational conditions to any client, regardless of their problem, the process-experiential therapist has a list of markers of process difficulties, and a corresponding list of appropriate procedures to be employed at those markers.
Yet, as with classical person-centered therapy, the situation looks rather different once we go further into the actual practice. Greenberg, Rice & Elliott (1993, p. 290) write: ‘Although we emphasize differential interventions for different momentary states, …more global characteristics also need to be taken into account’. The global characteristics include such matters as the degree of client distress, the extent to which the client has an internal rather than an external focus of attention, and the client’s degree of interpersonal independence. A balance must also be maintained throughout between attention to the therapeutic relationship and the more task-oriented process work. Within the flow of the session there is, ideally, a seamless transition between the processing difficulties which are emerging and the therapeutic procedures which are introduced at the appropriate markers. Greenberg, Lietaer and Watson (1998, p. 465) make it clear what they have in mind, when they talk about proposals for the training of therapists:
Means of training therapists to seamlessly integrate these specific forms of responding with an overall ability to be present will be developed, such that, like fine concert pianists, their final performance will be a holistic integration of explicit skill and tacit knowledge into an artistic rather than a technical accomplishment.
I conclude that the position regarding differential response is not different in principle between classical person-centered and process-experiential therapy. In both cases there is a background theory which suggests guidelines about how the therapist might respond to particular client situations. These guidelines are internalised in training and in the experienced therapist they function implicitly in the therapist’s choice of appropriate responses. If we ignore this point about ‘internalisation’ and ’implicit functioning’ it can seem that process-experiential therapy imposes the therapist’s (process) categories on the client. What saves the process-experiential approach from ‘imposing’ its process categories and markers is the fact that the therapist is sensitive to the client as a whole, and to the interpersonal interaction between client and therapist. The therapist’s knowledge of processes and markers (when internalised) functions implicitly in guiding the therapist’s responses. The therapist is responding to the whole situation, not to the marker as such, though they probably would not have responded in the same way had they not learned about experiential processes and their markers.
The distinction here between explicit and explicit knowledge is one that is central to Gendlin’s focusing-oriented psychotherapy. A brief discussion of this approach may help to clarify the issues further.
GENDLIN’S FOCUSING-ORIENTED THERAPY
At the heart of Gendlin’s (1962/1997, 1991, 1996, 1997) theory is the notion of experiencing as an interaction between concepts and symbols on the one hand, and a non-conceptual implicit order on the other. Human experiencing is a process of interaction between a particular here-and-now individual experiencing and general forms (words, concepts, etc) which are there in the individual’s language and culture. In therapy clients often reach a point where they are aware of something which they cannot yet articulate. They are, for example, noticing how they feel when they meet a particular person. It is not exactly fear, or embarrassment, but there is something there which is quite uneasy. The client can refer to that feeling, without yet having a means of articulating it. There may be no words that will do, and the client may cast around for images or metaphors in trying to express the experience. Such an experience is very specific; it is a ‘this’ rather than a ‘such’ like fear or disappointment. Yet it is not something purely particular; Gendlin (1962/1997) suggests that all human experiencing has a general aspect and when the client refers to ‘this feeling’ there is implicitly a kind of feeling which becomes explicit when the client says, for example, ‘it is a feeling of being made to feel awkward.’ As the client says this the feeling comes more into focus. It becomes specified. It is no longer simply a ‘this’; it is now of a kind. The articulated feeling is not the same as it was before it was articulated. Nevertheless, that feeling has been articulated, and the client has moved forward a small step.
For Gendlin the articulation or symbolisation of experiencing is the central process in psychotherapy. It is the same kind of process which takes place in any creative activity, when one comes to a point where something needs to be expressed for which the existing forms are inadequate. There is a ‘felt sense’ of what is needed, and we need to bring into interaction with that felt sense either our attention, or a question, or a possible word or image, and then wait to see what arises from the interaction.
The process of creative change depends on our being able to move freely back and forth between the implicit and the explicit, but this process can get stuck. We can, in Gendlin’s (1964) terminology, become ‘structure-bound’. In the area of psychotherapy structure-boundedness can take several forms. There is the kind of case where we ‘intellectualise’, that is, stay within a familiar framework of thoughts about a situation without dipping into our felt experiencing of the situation. Then there is the kind of case where we talk about external events without giving attention to the felt experience we have of those events. And there is the kind of case where we repeatedly go over a familiar emotional reaction without noticing exactly how the emotion is for us, right now in our present situation.
To be structure-bound is to be caught in a general pattern which prevents us from dipping into our present, particular, lived experiencing which might allow the pattern to change. We get caught in patterns. Rogers’ notion of the introjection of conditions of worth could be seen as a special case of this more general phenomenon.
Where a client is not structure-bound the task of the therapist is to be present in a way that helps the client to move back and forth between their experiencing and the formulations that arise from it and which carry the client forward. This helpful presence may simply involve being with the client in silence or reflecting back what they say, so that the client can better sense whether a particular symbolic form does carry them forward.
Where the client is structure-bound in some aspect of their life, the task of the therapist is to help the client to re-engage with their immediate experiencing. There are places where the client cannot do this – that is the problem, but there will always be related places where engagement is still possible (Gendlin, 1964). For example a client may talk about their relationship with a relative in a very externalised, story-telling way, but the therapist can be sensitive to those places where the client is touched by something that happened. The therapist can then reflect that, for example, the client felt a bit ‘irritated’ or ‘sad’ at that juncture. The reflection can be phrased in a way which helps to point at what the client was experiencing in that moment - for example ‘That made you feel something….sort of a bit sad…or maybe….how was it when she said that?’ In Prouty’s (1994) work with schizophrenics we see clients whose experiencing is almost entirely structure-bound, but with gentle, patient and persistent reflection of their immediate experiencing, such as ‘You are sitting in a chair. There is traffic noise outside’ the client can begin to make contact with their immediate experiencing.
In Gendlin’s (1990) view, the therapist needs primarily to be there with the client, to help the client to engage with their experiencing. In that sense the therapist responds in the same way to every client. However, as with classical person-centered therapy and process-experiential therapy, this general mode of relating can encompass a wide range of specific responses, depending on the circumstances. Gendlin (1996) sees the procedures used by the different therapy schools as alternative avenues of therapy. Such procedures as dream-work, interpretation, two-chair work, or behavioral desenitisation do not have to remain the exclusive property of the schools in which they were developed. Any of these procedures can be used, so long as the therapist continually checks with the client whether the procedure is helpful. Most of a focusing-oriented therapy session will involve the therapist in reflecting the client’s current experiencing, but every so often the therapist can tentatively, and in a spirit of shared experimentation, offer suggestions about other things which could be done.
As in process-experiential therapy the therapist is making a kind of diagnosis of what might help at this particular point, but Gendlin (1996, p. 285) is quite explicit that the ‘procedures’ which can be employed must not interfere with the therapeutic relationship. At the start of a session Gendlin imagines that he puts all his theoretical knowledge of procedures down beside him, not too far way because he may need them, but still set aside so that nothing comes between him and the client. The setting aside of the procedures is a metaphorical way of saying that the procedures drop back into implicit rather than explicit awareness. Through having learned the procedures the therapist has become different, has become sensitised to possibilities of response to which they were not sensitive before. Through learning the procedures the therapist has changed, [C1] and what the client saysand what the client says may now call forth a response in the therapist which they would not have made without their training. But the therapist is responding in a holistic way to a holistic felt sense of the client, rather than consulting an internal rule-book which says that when clients are like this, one should do that. Such a rule-book approach will clearly be ineffective since in any therapeutic situation there are limitless factors to be taken into account in making any response, including much that only the client can be aware of. These factors could not possibly all be articulated. The therapist, like a fighter pilot, has to ‘fly by the seat of their pants’, but training in procedures will normally enable one to fly better. The general point here is the same as that which is conveyed by Greenberg’s image of the ‘fine concert pianist.’
We come then to the same point we reached in connection with classic client-centered and process-experiential therapy: in a sense the therapist responds in the same way to all clients, but within the overall response there is differentiation according to how the client is, and the differential responses are made not in a rule-book way, but out of a tacit, implicit awareness of what is required in the immediate situation with the client.
THE IMPORTANCE OF THE ‘IMPLICIT’
This is not the place to go into a detailed account of Gendlin’s (1991, 1997) philosophy of the implicit, but I would like to say a little more about why it is relevant to the theme of differential therapeutic response. In Gendlin’s view the human form of experience always involves a movement between our rich but not fully articulated experiencing and the forms (concepts, words, images, etc) in which we articulate it. The articulation of experiencing (of which ‘diagnosis’ is an example) can sometimes deaden the experiencing (as when we say that ‘to put it into words would spoil it’). At other times the articulation of an experience (perhaps in a poem or a metaphor) deepens the experience and carries it further. The important issue is not whether we should try to articulate our experiencing, but whether the articulation helps us in the process of deepening or carrying further.
In our modern ‘scientific’ culture there has been an emphasis on what is explicit. The making of explicit distinctions has carried us forward in all kinds of technical fields. Along with this has gone a tendency to regard the explicit as all that there is, but especially in the case of human beings, it is clear that there is there is more to our experiencing than that which can be explicitly formulated. Often, when we encounter difficulties, it is because we have remained caught in one explicit formulation of the problem, and have not dipped back into the experiencing from which that formulation arose.
In contrast to what might be called the ‘culture of the explicit’, with its ‘mission statements’, ‘performance indicators’, and their analogues in psychiatric diagnosis, the person-centered approach emphasises the experiencing person. A writer such as Bozarth (1998, p. iii) will have nothing to do with diagnosis. He writes:
I know not what you will do or become
at this moment or beyond;
I know not what I will do except stay with you
at this moment…
Take me and use me
at this moment
to be whatever you can become
at this moment and beyond.
Differential responses to different clients, and to different kinds of difficulties, involve therapists in formulating for themselves what the difficulty is, but then always checking that formulation back against its impact on the client. A formulation which helps one client, and opens up further experiencing for them may have the opposite effect on the next client. The person-centered therapist’s role is not to impose on the client’s experiencing concepts drawn from the therapist’s theories, but at the same time the therapist’s knowledge, their store of experience and concepts, may enable them to respond more effectively to the client than if they did not have that knowledge. The function of theoretical knowledge in psychotherapy is not to tell us how our clients are, but to sensitise us to how they might be. If our use of a theoretical concept or a diagnostic term helps the client, then whatever doubts we might later have about the ‘truth’ of the theory or the ‘accuracy’ of the diagnostic category, the client remains helped.
I have tried to show that what seem to be serious differences between the different ‘schools’ of person-centered therapy in relation to ‘diagnosis’ and ‘differential response’ do not involve any real conflict. It only seems that there is conflict if we do not make the distinction between implicit and explicit knowledge. Hence I believe that it is important that in person-centered theory we give more attention to the distinction between the explicit and the implicit. It is a distinction which was emphasised by the philosopher of science Michael Polanyi (1958) (with whose work Rogers was familiar – see Kirschenbaum & Henderson, 1989), and which is central to Gendlin’s (1991, 1997) ‘process model’. The groundwork for developing a theory of person-centered therapy which emphasises what Gendlin calls ‘the implicit order’ is already in place. I think that from the perspective of such a theory much of the current tension between the different ‘schools’ of person-centered therapy will dissolve.
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