Which approach was developed during the 1940s as a nondirective reaction against psychoanalysis?

Client-centered therapy

Client-centered therapy, sometimes referred to as person-centered therapy, was introduced by Carl Rogers in the 1940s. It was a substantial departure from the traditional psychoanalytic therapies of that time. Rogers initially called his approach non-directive therapy and proposed that the therapist’s role was not to direct or instruct the client but to assist the person in understanding his or her own experience of the world and promote positive change through a trustworthy relationship (Brammer, Shostrom, & Abrego, 1989; Krech, Crutchfield, & Livson, 1969). To accomplish this, the therapist has to hold the person in positive regard. In other words, the therapist has to respect and empathize with the client.

The basic tenets of client-centered therapy are highly compatible with PsyR and have influenced the field. Client-centered therapy is based on the belief that people will engage in activities leading to positive growth and development if given the opportunity (Krech, Crutchfield, & Livson, 1969). This belief is consistent with the PsyR value of optimism that everyone has the capacity to recover, learn, and grow. Client-centered therapy asserts that the opportunity for growth exists within relationships that offer empathy, positive regard, and genuineness (Brammer, Shostrom, & Abrego, 1989). In PsyR, we know that the quality of the person-practitioner relationship is crucial to recovery and rehabilitation. Here, too, the relationship is an egalitarian one, based on empathy, positive regard, and acceptance.

Client-centered therapy focuses on the person’s perception of his or her present circumstances and assists the person in identifying his or her own answers to problems or barriers (Brammer, Shostrom, & Abrego, 1989). PsyR practice also focuses on the individual’s current aspirations, concerns, and challenges rather than on rehashing past experiences. An important technique used in client-centered therapy is reflecting back the thoughts, feelings, and experiences that the client has communicated. This technique demonstrates empathy, helps clarify issues that are personally important to the person, and keeps the focus on particular issues that the client wants to work on. PsyR practitioners also use techniques inspired by Rogers, usually called reflective responding or active listening (Carkhuff, 2009). Finally, client-centered therapy places the major responsibility for successful change on the client (Krech, Crutchfield, & Livson, 1969). In PsyR, we also emphasize the value of self-determination in helping individuals achieve personal life goals.

The work of counseling psychologist Robert Carkhuff, author of The Art of Helping, now in its 9th edition (2009), has been a great help to many PsyR professionals. Carkhuff’s writings help to simplify the helping process of client-centered counseling techniques into comprehensible steps that are easily understood by PsyR practitioners who may not be licensed counselors or therapists. An example is the skill of physical attending that enables the practitioner to use a set of specific nonverbal techniques, such as facing the person squarely, leaning forward slightly, and making eye contact to convey empathy (Carkhuff, 2009).

Client-centered therapy is an approach to psychotherapy based on a belief that the client is best able to decide what to explore and how. It is unique in a field where the therapist characteristically acts like an expert who knows how to resolve the client's problems. Psychologist Carl R. Rogers first described this new approach in a talk in 1940. He published verbatim typescripts of his treatment interviews, in contrast to the prevailing subjective accounts of therapy. This provided data for studying therapy objectively, and paved the way for the field of psychotherapy research. Rogers and his students developed methods of classifying client statements and counselor responses, and of measuring self-regarding attitudes. The concept of self emerged as a central construct of personality organization. As his theory, practice, and research developed, Rogers hypothesized that a relationship characterized by genuineness, unconditional positive regard, and empathy would result in a self-directed process of growth. Client-centered therapy broadened into a ‘person-centered approach,’ applicable to groups, education, and conflict resolution.

Person-Centered Therapy

Created by Carl Rogers, this is known as nondirective counseling, client-centered therapy, or Rogerian psychotherapy. The nondirective nature of this method provides evidence that the client, rather than the counselor, can help direct the treatment process by evoking self-change. The counselor–client dynamics invests trust in the client to move in a positive direction, provided that the counselor demonstrates appropriate skills: active listening, genuineness, and paraphrasing. A practitioner must be nonjudgmental and avoid giving advice. This supportive role will help clients feel accepted and allow them to understand their feelings. This humanistic therapy acknowledges and focuses on conscious perceptions rather than some therapist’s presuppositions and ideas regarding “unconscious” mindsets.

Person-centered therapy most often demands more responsibility from the client. An “actualizing tendency” in every living organism is the survival instinct: this internal dynamic leads people toward growth, development, and realization of their fullest potential. Person-centered therapy is a positive, directional form based on release and support.

9 Enduring Influence

Major factors in Rogers' impact on psychology and the helping professions were his personal example, longevity, and prolific writings. He presented a vivid role model of the person-centered approach for almost six decades, demonstrating his theories through teaching, lecturing, live demonstrations and workshops, and audio-visual recordings. By all accounts, he embodied his theories by being an exceptional listener and communicator and a decent, honorable person. He wrote 17 books and over 200 professional articles and research studies. Millions of copies of his books have been printed, in over 60 foreign language editions. His most popular book On Becoming a Person (1961), written for both a professional and general audience, continues to spread his ideas.

Critics of Rogers' work have argued (sometimes fairly, sometimes not) that client-centered therapy is superficial, unworkable with some populations, and unmindful of recent advances in behavioral, drug, or alternative therapies; that Rogers' views on human nature are unrealistically optimistic and underestimate human evil; that encounter groups and humanistic psychology have fostered widespread selfishness, narcissism, and moral permissiveness; and that Rogers' experiments with organizational change were naive and counter-productive. Nevertheless, in the USA, although no longer a central figure in popular psychology, Rogers' influence endures. In 1972, he was awarded the American Psychological Association's Distinguished Professional Contribution Award, becoming the first psychologist to receive the organization's highest scientific and professional honor. The citation read:

His commitment to the whole person has been an example which has guided the practice of psychology in the schools, in industry and throughout the community. By devising, practicing, evaluating and teaching a method of psychotherapy and counseling which reaches to the very roots of human potentiality and individuality, he has caused all psychotherapists to reexamine their procedures in a new light. Innovator in personality research, pioneer in the encounter movement, and respected gadfly of organized psychology, he has made a lasting impression on the profession of psychology.

After Rogers' death in 1987, the greatest new interest in his work has been outside the USA, including Russia, Eastern Europe, and Latin America. As a Japanese counselor explained in the 1960s, Rogers helped ‘teach me … to be democratic and not authoritative.’ His life's work demonstrated how supportive, growth-producing conditions can unleash healing, responsible self-direction, and creativity in individuals and groups in all walks of life. As countries strive to resolve intergroup tensions and practice self-government and self-determination, many have recognized in Rogers' work not only useful methods for helping professionals, but a positive, person-centered, democratic philosophy consistent with their national aspirations. Rogers eventually recognized the political implications of his theories and methods and explored these in Carl Rogers on Personal Power (1977). At Rogers' memorial service, Richard Farson eulogized him as ‘a quiet revolutionary.’

Client-Centered Therapy

Rogers' approach to counseling and psychotherapy was based on a core hypothesis about human growth and personality change, which he summarized in 1950:

Client-centered therapy operates primarily upon one central and basic hypothesis which has undergone relatively little change with the years. This hypothesis is that the client has within himself the capacity, latent if not evident, to understand those aspects of his life and of himself which are causing him pain, and the capacity and the tendency to reorganize himself and his relationship to life in the direction of self-actualization and maturity in such a way as to bring a greater degree of internal comfort. The function of the therapist is to create such a psychological atmosphere as will permit this capacity and this strength to become effective rather than latent or potential (p. 443).

While other therapies might profess similar beliefs, Rogers' method of creating the therapeutic psychological atmosphere was radically different from other approaches commonly employed. Avoiding questions, interpretation, or other directive techniques, Rogers' initial ‘nondirective’ method relied exclusively on careful listening and skillful ‘reflection of feelings,’ leading to client insight and positive action. Although he always remained primarily nondirective in his practice, Rogers soon recognized that the counselor's attitudes of acceptance and understanding were more important than his particular techniques. Still later he clarified that it was the relationship in therapy, which the attitudes helped create, that was growth-producing. Rogers called this therapeutic relationship ‘client-centered’ and described three ‘core conditions’ in the relationship which bring about positive change in clients.

The first is to accept the client as he is, as a person of inherent worth possessing both positive and negative feeling and impulses. Adopting a term coined by his student Stanley Standal, Rogers called this acceptance and prizing of the person ‘unconditional positive regard.’ The second is “the therapist's willingness and sensitive ability to understand the client's thoughts, feelings and struggles form the client's point of view…to adopt his frame of reference” (1949: 84). Rogers used the term ‘empathy’ to describe this condition, popularizing a concept already in use in the field. The third is, be “genuine, or whole, or congruent in the relationship…It is only as [the therapist] is, in that relationship, a unified person, with his experienced feeling, his awareness of his feelings, and his expression of those feelings all congruent or similar, that he is most able to facilitate therapy” (pp. 199–200). He most often used ‘congruence’ to describe this third ingredient of the therapeutic relationship.

When a counselor is in psychological contact with a client and is able to communicate these attitudes so that the client can perceive them, the ‘necessary and sufficient conditions for therapeutic personality change’ are present. Rogers argued and demonstrated that the client has within himself the ability and tendency to understand his needs and problems, to gain insight, to reorganize his personality, and to take constructive action. What clients need is not the judgment, interpretation, advice, or direction of experts, but supportive counselors and therapists to help them rediscover and trust their ‘inner experiencing’ (a concept borrowed from Gendlin), achieve their own insights, and set their own direction.

Until Rogers, the fields of counseling and psychotherapy had been dominated by the guidance movement and psychoanalysis, respectively. While Rogers was not the first to argue for a ‘newer approach’ to counseling and psychotherapy – an approach that relied less on the professional's expertise and direction and more on the client's direction and resources – Rogers' system was arguably the most clearly described, comprehensive, and extreme, and the newer direction in mental health work became associated with him.

6.07.2.3 Humanistic Approaches: The Rise of Gestalt Therapy

Gestalt psychotherapy took root as a counter-response to the negativism of psychoanalysis. It was a logical extension of the movement toward personal direction and freedom that characterized Logotherapy and client-centered therapy. It did so, however, without relying on the abstract concepts of spirituality of these former approaches. Although the emergence of Gestalt therapy is generally thought to have been in the postwar years of the 1940s, its genesis actually was some 20 years earlier.

Friedrich (Fritz) Perls (1893–1970) was born in Berlin (Patterson & Watkins, 1996). He obtained an M.D. degree from the Frederich Wilhelm University in 1920. Following his medical training, Perls worked under the direction of Professor Kurt Goldstein at the Frankfurt Neurological Institute for Brain-Damaged Soldiers. With the advent of WWII, Perls took his family to South Africa and in 1935, he established the South African Institute for Psychoanalysis. In 1946, he emmigrated to the US having become disillusioned with the arise of apartheid in South Africa.

By training, Perls was a psychoanalyst, but he was heatedly dissatisfied with the dogma and structure of psychoanalysis. He was also influenced by the experimental work of Kohler, Wertheimer, and Lewin, with whose work he gained familiarity during his early years in Germany. Other existential philosophers with whose work he also became familiar also eventually affected his work, but initially he was too preoccupied with orthodox psychoanalysis to assimilate their work (Perls, 1947). Perhaps this is why he came to identify more closely with psychology than with psychiatry.

Fritz Perls met Laura Posner in 1926 while she was working on her Ph.D. in psychology. She was to become his wife and cofounder of Gestalt therapy. Laura Posner Perls' family was very affluent and culturally enriched, while Fritz was from a lower middle-class Jewish family. These class distinctions were to influence their relationship for many years.

Laura Posner Perls was heavily influenced by Martin Buber and Paul Tillich who were prominent contemporary existentialists. Laura and Fritz Perls worked closely together for nearly 25 years until they separated in the 1950s. Fritz Perls wrote his first book Ego, hunger and aggression subtitled “A Revision of Freud's theory and Method” in 1941 and 1942 while serving as a captain in the South African Medical Corps. Although it was not for many years that the name and character of “Gestalt therapy” was succinctly expressed, this first book introduced many of the Gestalt concepts which would later become central ideas in Gestalt therapy.

During the years that Fritz and Laura Posner Perls were together, Gestalt therapy was developing and maturing, although the particular contributions of Laura Perls often are obscured in the available writings. Although Gestalt therapy was first introduced in the US by Fritz and Laura Perls, it was not until Fritz found a home at Esalen Institute at Big Sur, California, in the 1970s that Gestalt therapy was recognized nominally as an independent theory. It was Fritz, not Laura, who came to be recognized as the discoverer, the father, and developer of Gestalt therapy. His estranged wife, Laura Perls, was residing in New York City, outside the mainstream of the human potential movement which was beginning in California. She published few papers, and her contributions to the theory and methods of Gestalt work were known only to a handful of people (Corsini & Wedding, 1989).

Those familiar with the work of Laura, and Fritz Perls note interesting differences in how they implemented Gestalt therapy. One of the most noted of these differences pertained to the dimension of control and permissiveness that they applied in treatment. Laura employed procedures that were characterized by apparent permissiveness, while Fritz's work emphasized therapist authority and control (Hatcher & Himmelstein, 1976).

The 1930s and 1940s were a dynamic time for Fritz Perls. He was heavily influenced by a number of prominent people including Wilheim Reich, who was Perls' analyst in the 1930s, Karen Horney, and Otto Rank. Horney was said to have directed the young and rebellious Perls to a very eccentric and rebellious Reich. Most notable in his influence was Reich, who introduced Perls to a theory of psychosomatic medicine that considered physical movement and symptoms as the body's armor against threat (Perls, 1947). The body work and physical techniques of Gestalt therapy was a product of this earlier association.

However, it was Freud's theory of psychoanalysis that provided Perls with a theoretical framework for all of his future thinking; despite their differences, psychoanalytic theory was the major foundation upon which Perls built his understanding of human behavior, and it was psychoanalytic theory that he used as a standard against which to evaluate his own emerging theory. In Fritz Perls' autobiography, In and out of the garbage pail (Perls, 1969), he makes the following comment on Freud, “Rest in peace, Freud, you stubborn saint-devil-genius,” reflecting his own ambivalent attitude toward both Freud and psychoanalysis.

Gestalt therapy differs from other systems and models in a number of important ways. For example, Perls accepted psychoanalysis as a general theory from which his own view derived. However, he chose to omit certain aspects of Freud's theory from his own view, such as psychosexuality, the tripartite anatomy of the personality (id, ego, and superego), and the nature of the unconscious. As applied to technique, these omissions led Perls to emphasize how rather than why, and explored experience within the “here and the now” rather than the “there and then.”

Another difference is in the value assigned to various bodies of scientific research. Gestalt therapy draws from a broader scientific literature than most systems of psychotherapy. It placed greatest value on research that describes the nature of perception and information processing, as well as from literature on defense and psychopathology. At the same time, traditionally it has eschewed psychotherapy outcome research. This priority of values contrasts with client-centered therapy, for example, that has always valued outcome research, but has given little acknowledgment to research on psychopathology and personality development.

Still another distinguishing aspect of Gestalt therapy is its adoption of a holistic view of behavior. It regards individuals as being inherently integrated; their behavior reflects an integrated system whose collective activity cannot be understood by simply viewing isolated acts or structures. This humanistic view is borrowed from Rank, whose concept of the “total organism” contrasts with the psychoanalytic view that separated mind and body and divided the psyche into discrete elements, for example, id, ego, superego, that engaged in a struggle for power over one another. Instead, Gestalt theory asserts that people struggle and experience conflict because of the difficulty of incorporating new information into perceptions based on old knowledge.

Finally, Gestalt therapy defined self-actualization in a manner that contrasted with other experiential approaches. Self-actualization was reflected in balance, differentiation, and integration of cognitive, sensory, and emotional systems, rather than a motive toward social goodness. The ability of conceptual systems to communicate was manifest in the concept of self-response-ability, that is, the ability to choose to be active and to overcome apathy. Rather than encouraging social compliance, as might psychoanalytic therapy, Gestalt therapy encourages social rebellion and individualism.

Case History 3: A Korean Patient's Delusion of Being Possessed

A Korean priest of a Christian sect was responsible for inflicting a patient of the same nationality with short-term exogenous psychosis by means of a syncretistic atmosphere and deprivation of sleep. This led to an attempted suicide. Mutual trust between patient and doctor was developed by therapeutic intervention according to Roger's client-centered therapy Further anamnestic details were obtained, particularly in connection with the dead grandmother who was a mudang or shaman priestess. Knowledge of the patient's cultural background explained her reaction of feeling possessed by a bad spirit, and we, by showing a neutral respect for this particular culture, including the involved shamanism, presented the patient with a favorable prognosis for successful therapy. The conclusions resulted in a transcultural-transpersonal portrayal for diagnosis and treatment; it became obvious that there were syncretistic factors, but no real shamanistic transformation act or traditional healing process involved.

The second “trans” aspect concerns, on the one hand, the intracultural cooperation between the indigenous medical system of the immigrant and the Western medical system. On the other hand, it deals with intercultural cooperation. This may be in the form of influence or inclusion of aspects and methods from traditional medical systems together with our Western medical system. Some patients have better access to psychotherapeutic measures from other cultures. The use of foreign and archaic instruments in music therapy or therapeutic means from traditional Chinese medicine or Indian ayurvedic or Arab unani-tibb medicine may prove effective.

III.C. Experiential Schools

The experiential schools of psychotherapy trade intellectual cognition and insight for emotion and experience, forsaking the there and then of the distant past for the here and now of the immediate present. Experiencing is a process of feeling rather than knowing or verbalizing; occurs in the immediate present; is private and unobservable, but can be directly referred to by an individual as a felt datum in his own phenomenal field; acts as a guide to conceptualization; is implicitly meaningful, although it may not become explicitly so until later; and is a preconceptual organismic process. The many implicit meanings of a moment's experiencing are regarded not as already conceptual and then repressed; rather, they are considered in the awareness but as yet undifferentiated. Here therapeutic change occurs because of a process of experiencing in which implicit meanings are in awareness, and are intensely felt, directly referred to, and changed—without ever being put into words.

One variation of this thesis, especially applicable to Roger's client-centered therapy, reflects the underlying positive belief that every organism has an inborn tendency to develop its optimal capacities as long as it is placed in a optimal environment. The patient is offered an optimistic self-image and the understanding that the patient is basically good and full of potential. Therefore, the therapist does not need to challenge or shape the patient, only to offer a warm and understanding milieu that will enable the patient to unfold latent potentials.

Unlike transference, which is dependent on the revival of a former interpersonal relationship, experiential encounter works through the very fact of its novelty. Through encounter the therapist serves as a catalyst in whose presence the patient comes to realize his or her own latent and best abilities for shaping the self. In this behalf, there are schools of psychotherapy within the experiential theme that recoil at the idea of therapeutic technology. These schools, which are predominantly existential, renounce technique as part of their philosophy of understanding human existence. They feel that the chief block in the understanding of man in Western cultures has been an overemphasis on technique and a concomitant tendency to believe that understanding is a function of, or related to, technique. Rather, they feel that what distinguishes existential therapy is not what the therapist would specifically do, but rather, the context of the therapy. In other words, it is not so much what the therapist says or does, as what the therapist is. However, in this regard the existential schools of psychotherapy have been criticized for their vagueness about technical matters in the conduct of psychotherapy.

The experiential schools aspire to flexibility or innovation in their actual methods, as long as these methods are useful in the therapist's attempt to experience and share the being of the patient. Here the aim of all techniques would be to enter the phenomenological world of the patient. In direct contrast to the view of the analytic therapist, the experiential therapist does not concern himself or herself with the patient's past, the matter of diagnosis, the aspiration of insight, the issue of interpretation, or the subtle vicissitudes of transference and countertransference. Unlike the behavioral therapist, the experiential therapist expressly does not set goals for the patient and does not direct, confront, or otherwise impose his or her personality on the patient with directives in the form of behavioral instructions or problem-solving preferences.

Although they share the same basic faith in the therapeutic encounter and an emphasis on feelings, schools under the experiential umbrella are often antiverbal in approach. Such schools (e.g., Gestalt therapy) view overintellectualization as part of the patient's problem, that is, a manifestation of defense against experiencing or feeling, and discourage it as part of the therapeutic endeavor. These therapies attempt to accentuate activity over reflection, emphasize doing rather than saying, or, at the minimum, aim to combine action with introspection. The goal of experiencing oneself includes developing the patient's awareness of bodily sensations, postures, tensions, and movements, with an emphasis on somatic processes. Awareness of oneself as manifested in one's body can be a highly mobilizing influence. The main thrust of therapy is therefore to actively arouse, agitate, or excite the patient's experience of self, not simply to let it happen.

Among the techniques for expressing one's self-experience in such schools is the combination of direct confrontation with dramatization, that is, role-playing and the living out of a fantasy in the therapeutic situation. This means that under the direction (and often the creation) of the therapist, the patient is encouraged to play out parts of the self, including physical parts, by inventing dialogues between them. Performing fantasies and dreams is typical and considered preferable to their mere verbal expression, interpretation, and cognitive comprehension. In variations of the somatic stance, body and sensory awareness may be fostered through methods of direct release of physical tension, and even manipulations of the body to expel and/or intensify feeling.

In yet other attempts to unify mind, body, and more especially, spirit, the immediate experience of oneself by focusing on one's spiritual dimension is sought. This is most often accomplished through the primary technique of meditation. The ultimate state of profound rest serves to transcend the world of the individual ego, forming a higher reality or state of consciousness that the individual ego subserves. Major methods of will training and attention focused on a special word sound or mantra, for example, serve to create an egoless transcendent state.

II.B. Psychotherapy Research versus Behavior Therapy Research

For many years (from about the 1950s through the 1970s), therapy researchers themselves drew a clear distinction between behavior therapy research and psychotherapy research. The distinction reflected what aptly has been described as an internecine struggle between those who endorsed forms of therapy that were grounded in theories and findings of subdisciplines of psychology known as learning and behavior (“behavioral” therapies), and those who favored therapies derived from Freudian psychodynamic theory or from humanistic principles (e.g., Rogerian client-centered therapy). The distinction was instantiated in the founding by psychologists of two scientific organizations at approximately the same time: the Association for the Advancement of Behavior Therapy (1966) and the Society for Psychotherapy Research (circa 1968). Both flourish to this day.

By the late 1970s, tangible signs of a rapprochement between the two camps emerged. One such sign was the “psychotherapy integration movement” that was spearheaded by psychologists such as Paul Wachtel and Marvin Goldfried. The period of rapprochement was spurred in part by outcome findings that indicated that behavior therapy-based and psychotherapy-based treatments both were associated with measurable benefits, often of comparable magnitude. Neither camp could claim unqualified victory Indeed, contrary to the hopes and expectations of many, some studies in which a behavioral therapy was compared directly to a non-behavioral therapy (e.g., psychodynamic psychotherapy) failed to detect statistically significant outcome differences. A prototypic study like this was published in a 1975 book by Sloane, Staples, Cristol, and colleagues, Psychotherapy vs. Behavior Therapy.

At least partially due to mutually humbling outcome research findings, animosity between the camps substantially diminished, and some cross-fertilization even occurred. The two arms of therapy research also retained some distinctiveness, as reflected in one of the field's most influential recent milestones, a listing of empirically supported forms of therapy (“ESTs”) for specific types of problems. The list was first published in 1995, based on the work of the American Psychological Association's Task Force on Promotion and Dissemination of Psychological Procedures. The Task Force was chaired by Dianne Chambless from 1993 to 1997. (Initially, the term “empirically validated therapies” was used for the list. It was changed to ESTs in part because the word “validated” could mistakenly connote that the process of validation for a therapy had been completed and no additional research on it was needed.) The list includes some therapies that are essentially behavioral (e.g., exposure and response prevention for obsessive–compulsive disorder), as well as some that are not such as interpersonal psychotherapy for depression (a type of psychotherapy that was developed by psychiatrist Gerald Klerman and colleagues, published in 1984).

The long-standing distinction in the literature between behavior therapy and psychotherapy, and between the corpus of research focused on each, marks a historically important epoch in the development of research on psychologically based interventions. Herein the term “psychotherapy research” includes research on all forms of psychologically based treatments.

2.35.2 Postgraduate Education

After they have graduated from university (i.e., after the first phase of four years), students have several options. Most of them prefer further training in practice or research in the area of clinical psychology, but only few of them actually get the chance to enter one of the formal postdoctoral training programs. This training includes two training programs in clinical practice and one training program in clinical psychology research.