Helping Clients Make Informed Decisions

How nondirective therapy directs: The power of empathy in the context of unconditional positive regard

Marvin Frankela*, Howard Rachlinb and Marika Yip-Bannicqc

aSarah Lawrence College, New York, USA; bStony Brook University, New York, USA; cNew York University, New York, USA

(Received 26 November 2011; final version received 16 May 2012)

This paper explains how acceptance and empathy are vehicles for psychothe- rapeutic change by showing how these factors function in nondirective client- centered therapy. The paper argues that because the nondirective client-centered therapist’s unconditional positive regard may conflict with the client’s conditional self-regard, the therapy cultivates a novel restructuring of the client’s narrative. By revealing how positive therapeutic change can result from the interplay of unconditional positive regard and empathy, the article explains the effectiveness of classical client-centered therapy in particular and accounts at least in part for the effectiveness of other therapies that stress the healing properties of the psychotherapeutic relationship.

Keywords: empathy; unconditional positive regard; Gestalt figure/ground relationships

Wie nicht-direktive Therapie dirigiert

Dieser Artikel erklärt, wie Akzeptanz und Empathie das Agens therapeutischer Veränderung sind, indem er zeigt, wie diese Faktoren in der nicht-direktiven klient-zentrierten Therapie funktionieren. Gerade weil das bedingungslose positive Beachten des nicht-direktiven klientzentrierten Therapeuten im Konflikt liegen kann mit der Sicht des Klienten auf sich selbst, die voller Bedingungen steckt, gerade deshalb kultiviert die Therapie eine neuartige Restrukturierung des Klienten-Narrativs. Positive therapeutische Veränderung resultiert aus dem Zusammenspiel zwischen bedingungsloser positiver Beachtung und Empathie. Die Effektivität der klassischen Klientzentrierten Therapie ist zumindest teilweise die Ursache, wenn es um die Wirksamkeit anderer Therapien geht, die die heilende Dimension der psychotherapeutischen Beziehung betonen.

Cómo dirige la terapia no directiva

Este escrito explica cómo la aceptación y la empatı́a son vehı́culos de cambio psicoterapéutico, mostrando cómo funcionan estos factores en la terapia no directiva centrada en el cliente. El escrito argumenta que al entrar en conflicto la consideración positiva incondicional de un terapeuta no directivo centrado en el cliente con la auto consideración positiva condicionada del cliente, la terapia cultiva una nueva reestructuración de la narrativa del cliente. Al revelar cómo los

*Corresponding author. Email: [email protected]

Person-Centered & Experiential Psychotherapies

Vol. 11, No. 3, September 2012, 205–214

ISSN 1477-9757 print/ISSN 1752-9182 online

� 2012 World Association for Person-Centered & Experiential Psychotherapy & Counseling http://dx.doi.org/10.1080/14779757.2012.695292

http://www.tandfonline.com

cambios terapéuticos positivos pueden ser resultado de la interacción de la consideración positiva incondicional y la empatı́a, este escrito explica la eficacia de la terapia clásica centrada en el cliente y explica, al menos parcialmente, la eficacia de otras terapias que hacen hincapié en las propiedades curativas de la relación psicoterapéutica.

La manière dont la thérapie non-directive est directive

Cet article explique la manière dont l’acceptation et l’empathie sont porteuses de changement dans la thérapie non-directive centrée sur le client, en démontrant la façon dont ces facteurs fonctionnent. Il argumente que le regard positif inconditionnel du thérapeute non-directif centré sur le client peut entrer en conflit avec le regard conditionnel sur soi du client, et que pour cette raison, la thérapie facilite une restructuration nouvelle du narratif du client. En démontrant la manière dont le changement thérapeutique positif peut résulter des interactions entre le regard positif inconditionnel et l’empathie, l’article explique l’efficacité de la thérapie centrée sur le client classique et explique, du moins en partie, l’efficacité d’autres thérapies qui mettent l’accent sur les propriétés guérissantes de la relation thérapeutique.

Como a terapia não-diretiva dirige

Este artigo explica de que modo a aceitação e a empatia são veı́culos de mudança psicoterapêutica, demonstrando como estes fatores funcionam no seio da terapia não-diretiva centrada no cliente. O artigo defende que, uma vez que o olhar incondicional positivo do terapeuta não-diretivo pode colidir com o olhar condicionado que o cliente tem sobre si mesmo, a terapia cultiva uma reestruturação original da narrativa do cliente. Ao revelar como a mudança terapêutica positiva pode resultar da interligação entre o olhar incondicional positivo e a empatia, o artigo explica a eficácia da terapia centrada no cliente clássica e justifica, pelo menos parcialmente, a eficácia de outras terapias que dão ênfase às propriedades curativas da relação psicoterapêutica.

Introduction

The following story highlights the major feature of this article: the directive role of empathy in the context of unconditional positive regard. A few months ago the daughter of a friend of mine informed her father of an insight her client-centered therapist had given her that day. My friend was taken aback. He protested, ‘‘But I said that so many, many times to you to no avail.’’ His daughter insisted that he hadn’t. Then my friend reviewed the last time he had an argument with his daughter and

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reminded her of what he had said. ‘‘Now, wasn’t this what your therapist said?’’ he asked. His daughter replied, ‘‘It’s amazing, I wonder why I forgot!’’ He said, ‘‘You didn’t remember because you hate to give me credit!’’ But the reason why the daughter didn’t remember what the father said was because he did not in fact say the same thing as the therapist. The father offered his insight in the context of anger, criticism, and rejection, or in a word, blame, thus negating the daughter’s openness to critical feedback. In contrast, by offering his insight in the context of acceptance, in other words, without blame, the therapist encouraged the daughter’s self-critical attitude. The insights of the father and therapist were no more the same than gray looks the same on black or on white. Unconscious defense mechanisms such as denial and distortion are not required to explain the daughter’s ‘‘forgetfulness’’ (Rogers, 1959). Therapeutic empathy in the context of unconditional positive regard necessarily provides a novel context for self-criticism. Classical client-centered therapy (CCCT) is thus nondirective with respect to the content of the narrative but directive with respect to the attitude that the client brings to the narrative, which in turn transforms the content.

We agree with Barbara Brodley that it is mistaken to view the nondirective model as merely one that influences the client. As Brodley (2005) aptly stated, ‘‘. . . all therapies influence . . . clients towards growth and healing. A therapymust influence in order to be effective . . .. The non-directive issue exists at a different level from the discourse on therapy as influencing clients’’ (p. 1). We disagree, however, with her about the nature of this difference. Whereas she argued that ‘‘[e]mpathic understanding, unconditional positive regard and congruence are all non-directive with respect to the client’’ (p. 1), we maintain that the therapist’s communication of unconditional positive regard is directive in cultivating the client’s unconditional positive self-regard and enabling the client to view his/her narrative through this lens. This directive component is too systematically employed to be regarded as a mere influential agent. We also consider the model directive rather than influential in the sense that the CCC therapist is going beyond the client’s frame of reference and is thus inconsistent with the alleged essence of nondirective therapy which was to empathically and exclusively respond to the client’s internal frame of reference (Rogers, 1951).

As described by Rogers (1951) in Client-Centered Therapy, one major aim of the CCC therapist is to:

perceive as sensitively and accurately as possible all of the perceptual field as it is being experienced by the client, with the same figure-ground relationships, to the full degree that the client is willing to communicate that perceptual field; and having thus perceived this internal frame of reference of the other as completely as possible, to indicate to the client the extent to which he is seeing through the client’s eyes. (p. 34)

This is, in effect, our operational definition of empathy. We will show, however, that in fact Rogers never empathically reflected ‘‘the same figure-ground relationships’’ as those of the client. Instead he provided a direction by changing the context of the client’s narrative which then transformed the meaning of the client’s experience.

The directivity we will be discussing is different from that of other person- centered therapies (Cain, 2010), such as those that validate or reassure the client’s experience (Bohart, Elliott, Greenberg, & Watson, 2002; Brink & Farber, 1996), offer evocative reflections (Rice, 1974), or empathic responses that attempt to target the client’s ‘‘edge of awareness’’ (Mearns & Thorne, 1999). Some later forms of person-centered therapy (process directive therapy and relational depth therapy, for example) also tend to introduce various directive elements during the course of

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therapy (process guiding techniques, therapist self-disclosures, etc.) that might obscure the subtle kind of continuous directivity that takes place in CCCT. While this analysis focuses on CCCT, it is relevant to all psychotherapies that emphasize the importance of acceptance and empathy as a necessary if not a sufficient condition for effective treatment (Farber, 2007); this would include multi-modal therapy (Lazarus, 2005) or any form of cognitive-behavioral therapy.

A novel background creates a novel client narrative

How do unconditional positive regard and empathy contribute to therapeutic change? After all, empathic reflection does not bring anything new by way of meaning into the client’s frame of reference; instead, it captures, as accurately as possible, what is already there in the client’s current frame of reference (Rogers, 1951, 1959). The often-heard client response to an accurate empathic reflection, ‘‘Yes, that’s precisely it,’’ demonstrates this. Rogers’s filmed therapeutic encounter with Gloria (Shostrom, 1965) provides an example of such a response:

Rogers: And you feel, this is a conflict and it’s just insoluble and therefore it’s hopeless and here you’ve looked up to me and I don’t seem to give you any help, to . . .

This empathic reflection lifts any burden of responsibility and blame from Gloria’s shoulders for her predicament, but just as importantly Rogers openly accepts Gloria’s perception that he was of no help without blaming himself, thus modeling a blameless attitude.

Gloria: Right . . .

Gloria’s despair when she utters that single word ‘‘Right’’ was not only a confirmation of Rogers’s empathic reflection but a novel expression of her sense of hopelessness. The written word fails to do justice to her troubled expression when she agrees with Rogers. But how did this come about?

The noted historian and existential phenomenologist van den Berg (1974) captured the point that an accurate empathic reflection, apart from the communica- tion of unconditional positive regard, brings nothing novel to the client’s narrative when he characterized nondirective therapy as one in which the counselor does ‘‘nothing.’’ Of course, van den Berg was not suggesting that Rogers was truly doing nothing, but only that, unlike directive therapies of that time, Rogers did not offer novel interpretations that went beyond or contradicted the phenomenal field of the client. Van den Berg was not suggesting that nondirective therapy was ineffective but only that Rogers was taking an original psychotherapeutic approach by attempting to offer only nondirective reflections of the client’s frame of reference, offering nothing whatsoever from his own frame of reference. Rogers viewed interpretations, self- disclosures, advice and even commendation as reinforcing the undesirable power relations between therapist and client (Rogers, 1942). However, a closer examination will show that Rogers was not offering a purely nondirective response.

Consider the following dialogue between Rogers and a client (Kirshenbaum, 1979, p. 248):

Client: (. . . begins to talk in hard flat voice, quite unlike her usual tone. Does not look at counselor . . .) You feel I want to come, but I don’t! I’m not coming anymore. It doesn’t do any good. I don’t like you. I hate you! I wish you were never born.

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Rogers: You just hate me very bitterly.

Client: I think I’ll throw you in the lake. I’ll cut you up! You think people like you, but they don’t . . . You think you can attract women but you can’t . . . I wish you were dead.

Rogers: You detest me and you’d really like to get rid of me.

Client: You think my father did bad things with me, but he didn’t! You think he wasn’t a good man, but he was. You think I want intercourse but I don’t.

Rogers: You feel that I absolutely misrepresent all your thoughts.

Client: . . . You think you can get people to come in and tell you everything, and they’ll think they’re being helped, but they’re not. You just like to make ’em suffer. You think you can hypnotize them, but you can’t! You think you’re good, but you ain’t. I hate you. I hate you.

Rogers: You feel I really like to make ’em suffer, but I don’t help them.

Client: You think I haven’t been straight, but I have. I hate you. All I’ve had is pain, pain, pain. You think I can’t direct my own life, but I can. You think I can’t get well, but I can. You think I had hallucinations, but I didn’t. I hate you. (Long pause, leans on desk in strained, exhausted pose.) You think I’m crazy but I’m not.

Rogers: You’re sure I think you’re crazy.

Client: (Pause) I’m tired, and I just can’t get loose! (Despairing tone of voice and tears. Pause) I had a hallucination and I’ve got to get it out! . . . (Goes on about her deep conflicts, and tells of her hallucination she has experienced with terrific tension in her voice, but with an attitude very different from that at the beginning of the interview.)

(Later in interview)

Client: I knew at the office I had to get rid of this somewhere. I felt I could come down and tell you. I knew you’d understand. I couldn’t say I hated myself. That’s true but I couldn’t say it. So I just thought of all the ugly things I could say to you instead.

Rogers: The things you felt about yourself you couldn’t say, but you could say them to me.

Client: I know we’re coming to rock bottom.

In a footnote, Rogers wrote: ‘‘Just as it is impossible to convey on paper the venom and hatred in the client’s voice, so it is utterly impossible to convey the depth of empathy in the counselor’s responses. The counselor states, ‘I tried to enter into and to express in my voice the full degree of soul-consuming anger which she was pouring out. The written words look incredibly pale, but in the situation they were full of the same feeling she was so coldly and deeply expressing’’’ (italics added). But if Rogers’s version of what he did is true, if he is merely providing an empathic understanding that remains entirely within the phenomenal field of the client, then why doesn’t the client simply say to each and every one of the empathic reflections: ‘‘But you are simply repeating the meaning of what I just said’’?

The answer is that although Rogers is repeating the words, he is not repeating the context of the words and hence the meaning of the words. The client’s assertions are contextualized by her contempt for herself (‘‘I couldn’t say I hated myself’’). Rogers’s statements are contextualized by his compassionate acceptance (uncondi- tional positive regard) of the client. The client was in effect saying: ‘‘I hate you Carl Rogers!’’ In response Rogers asserted, ‘‘I appreciate but do not blame you for the extent of your contempt of me.’’ Indeed, each of Rogers’s empathic reflections could be preceded with the statement, ‘‘I appreciate but do not blame.’’ For this reason, the client did not say to Rogers, ‘‘That is what I just said,’’ since Rogers is never just repeating the meaning (I hate you, Carl Rogers) of the client’s assertions but

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conveying his unconditional positive regard for them. When Rogers wrote that ‘‘it is utterly impossible to convey the depth of empathy in the counselor’s [Rogers’s] responses,’’ he was, in our terms, referring to his unconditional positive regard for the client, which frames his empathic response, rather than just his empathic response. Consequently, the client does not understand Rogers as giving a redundant response. On a more clinical level, the client is expressing her feelings of self-contempt and in return is finding herself not only understood but prized by Rogers.

Conceptually, empathy and unconditional positive regard are independent of each other (Rogers, 1957; Shlien, 1997). In fact, a person may be empathic and rejecting at the same time. The journalist Gita Sereny was mainly empathic with the former commandant of a death camp, Franz Stangl, over a period of months but had to excuse herself from one particular interview in utter disgust when confronted with the moral perversity of the commandant (Sereny, 1995). Shlien was so critical of the tendency to blur the distinction between empathy and unconditional positive regard among contemporary person-centered therapists that he highlighted how empathy can ‘‘be a weapon of war, an advantage in every form of competition as well as in cooperation’’ (Shlien, 1997, p. 64).

But a person can mistakenly feel accepted and safe when being empathically understood. In her book, The Journalist and the Murderer, Janet Malcolm commented on the moral dilemma journalists face when they win the confidence of an alleged criminal simply by understanding them in an empathic way. The alleged criminal feels so accepted that he lets his guard down only to discover, when he reads the journalist’s negative written account, that he was betrayed (Malcolm, 1990). Like Malcolm, existential therapists use empathy to establish rapport and allow clients to be feel accepted when they are lying (to themselves) only at a later time to express their criticism of the clients’ moral position. Prochaska and Norcross (2003), summed up this approach in contrast to the approach of CCC therapy by offering the following description:

Existentialists do not agree, however, that a therapist must maintain unconditional positive regard toward the patient. In order to be authentic, the therapist can respond with positive regard only toward honesty and authenticity but never toward lying and pathology. That the therapist at first allows the patient to lie and objectify without overt judgment is accepted in order for the therapist to experience the patient’s phenomenal world. But an authentic therapist can hold no positive regard for a patient’s lying. (p. 124)

For Rogers, the client’s perception of the CCC therapist’s unconditional positive regard is accurate and not illusory since Rogers has no ulterior motive (writing an article, making an evaluation, inducing a change in a specific direction, etc.) in his relationship with the client. The client is thus justified in feeling unconditionally accepted.

By changing the meaning of the client’s narrative through his/her unconditional positive regard, the CCC therapist is introducing a novel feature to the therapeutic discourse and in this significant sense CCCT is directive. The novel context (unconditional positive regard) dramatically alters the text (empathic understand- ing). Thus, in the above dialogue, the client is liberated from her self-protective strategy when she states: ‘‘I couldn’t say I hated myself. That’s true, but I couldn’t say it.’’ In other words, the client offered her narrative with conditional self-regard but received the meanings and feelings of her narrative with unconditional positive regard. In offering his words with a tone of compassion and acceptance, it is as

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though Rogers is saying in each exchange: ‘‘Here is what you might say if you did not blame yourself but had instead unconditional positive self-regard.’’

The power of empathy in the context of unconditional positive regard should come as no surprise since Gestalt psychologists have demonstrated that figure- ground relationships govern all perception. Thus a gray circle on a black background will be seen as white while the same gray circle on a white background will be seen as black. As Rachlin (1994) described this phenomenon:

The two spots differ in brightness not because the different backgrounds fool the observer creating an illusion . . . but because of a fundamental fact about phenomenal experience; what you perceive in the first place . . . is the relationship between the spot (gray figure) and its background. . . . [Consequently] on the most fundamental level of perception the two gray spots differ in brightness. Context is thus not a correction to perception or a distorter of perception but a vital component of the fundamental perceptual process. (pp. 7–8)

For example, the client offered her narrative, ‘‘You think I had hallucinations, but I didn’t. I hate you’’ (the figure) against the implicit background of her conditional self- worth: ‘‘maybe as much as I hate myself.’’ And so to carry the analogy one step further, the narrative figure is black indeed. The client, if alone at home, may not even be able to experience hostility towards Rogers lest she think less of herself (lowered conditions of self-regard) for attacking her therapist. However, in the context of the therapy, Rogers offered an empathic and compassionate reflection, ‘‘You’re sure I think you’re crazy’’ (the figure) against the background of unconditional positive regard, rendering the narrative figure white. In effect, then, the narrative the client initially authored is not the same narrative that is expressed by the therapist. The client’s attack on Rogers resulted in her being accepted by Rogers in no less a way than she was prior to the attack. Indeed, Rogers embraced her rage. Consequently, in listening to Rogers’s response, the client is directed to reflect on a novel meaning of her narrative, and re-view her hatred of Rogers without adding the insult of conditional self-acceptance. In this formulation, Rogers’s unconditional positive regard encouraged the client’s hopes that despite her rage she is beyond blame or praise and thus broadened her perceptual field. In this case, the broadened perception includes the fact that the client hates herself rather than Carl Rogers.

Yet, why do clients so often say, ‘‘Yes, you understand me perfectly,’’ when, in fact, their conditional self-regard (implicit or explicit) goes counter to the therapist’s unconditional positive regard? For example, a client who is familiar with Rogers’s vocabulary (Rogers, 1959) might say, ‘‘It is evident that you have unconditional positive regard for me, but I have only conditional positive self-regard. Your empathic reflection captures the essence of my feelings perfectly but your total acceptance of me is contrary to the way I feel about myself.’’ Clients do not say this but instead more often than not claim that they feel understood. How then can we make sense of the client’s subjective experience of being so understood? We suggest that it is not entirely accurate to describe clients as simply having conditional positive self-regard (Rogers, 1959). It would be more correct to say that clients are ambivalent about their conditional worth and may hope that their narrative will be utterly acceptable (unconditionally) and even prized by the therapist even as they may fear their narrative will only be conditionally accepted or in fact rejected. Clients often reveal this ambivalence when they express the wish to see themselves in the same benevolent way as their therapists do. One of the authors (MF) recalls from his internship at the Counseling Center of the University of Chicago, one client

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saying in so many words: ‘‘If I saw myself as you see me I would have little need of you, right?’’

In effect, then, we are suggesting that the unconditional positive regard of the therapist fulfills the client’s hopes of acceptance while the empathic reflection illumi- nates the content of the narrative which often expresses shame, guilt, and fears of rejection. The subtext of ‘‘Yes, that’s exactly what I mean,’’ could be understood to mean: ‘‘Yes, you have understood my unspoken hopes to be accepted as well as what I have said.’’ It is true that the CCC therapist will empathically communicate the client’s ambivalence about her self-worth when this is the explicit subject matter of the client’s narrative (the figure), but even then the CCC therapist’s unconditional positive regard conveys a more positive view of the client than the client’s view of herself.

Whence the power of unconditional positive regard?

Why does the client care at all about being accepted by the therapist? So far as the client is concerned the therapist may be a perfect jerk in his/her own personal and professional life. The therapist does not possess a Ph.D. in maturity or wisdom. Is the unconditional positive regard of the therapist important because of the client’s misperception and overvaluation of the therapist’s character (sensibility, wisdom, expertise)? Freud certainly thought so. The power of the analyst, psychoanalysts argue, resides in the childhood wishes of the client to have a powerful ally. Without the preservation of these wishes, the analyst would be powerless (Freud, 1966). This is the essence of positive transference which was itself viewed as a neurosis that eventually had to be extinguished. From this perspective, then, it is only because of ‘‘a positive transference neurosis’’ that the interpretations of the analyst or the explicit empathy and unconditional positive regard of the client-centered therapist are seriously entertained by the client.

Rogers eschewed transference and instead stated that people have a need for positive regard that may either be innate or quickly learned and is an expression of the actualizing tendency (Bozarth & Wang, 2008; Rogers, 1959). But to say the client desires the positive regard of the therapist because the client has a need for positive regard and to define the need for positive regard in terms of the client’s desire for it is circular. In any case, we do not seek the positive regard of everyone but only of those we respect. We propose instead, that the CCC therapist’s empathic communications and unconditional positive regard earn the trust and respect of the client. While all therapists may sincerely claim to have a nonjudgmental attitude towards the client, only CCC therapists refrain from offering any comments from the therapist’s frame of reference and in so doing demonstrate a singular openness to the client’s narrative. In this way, the CCC therapist is offering a relationship different from other therapeutic relationships. For example, CCC therapy goes contrary to the current practice of personal self-disclosure by therapists to influence their clients to live more optimally (Hill & Knox, 2002, pp. 255–266). In brief, the CCC therapist is providing a unique experience for the client; therein may reside the power of his/her unconditional positive regard.

Summary and conclusions

This paper offers an alternative to Rogers’s understanding of the effects of uncon- ditional positive regard and empathy by explaining how they work in conjunction with

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one another. In his introductory comments to the interview with Gloria, Rogers discussed the probable consequences of his empathic and accepting attitude:

She’ll explore some of her feelings more and attitudes more deeply. She is likely to discover some hidden aspects of herself that she wasn’t aware of previously. Feeling herself prized by me, it is quite possible she’ll come to prize herself more. Feeling that some of her meanings are understood by me, then she can more readily perhaps listen to herself, listen to what is going on within her own experience. (Shostrum, 1965)

In his description, Rogers isolated the effects of his unconditional positive regard (his prizing of her will result in her prizing herself) from the effects of his empathic understanding (‘‘. . . feeling that some of her meanings are understood by me then she can more readily listen to herself’’) (Shostrum, 1965). Bohart, Elliott, Greenberg and Watson (2002) offered a similar explanation for the positive therapeutic effects of empathy. Our view differs in two ways. First, we suggest that the unconditional positive regard of the therapist will be effective only if it triggers the client’s hopes that indeed she is acceptable. The client does not see herself solely through Rogers’s eyes but through the lens of her own hopes. Second, we argue that the effects of unconditional positive regard and empathy cannot be isolated from one another in the therapeutic encounter, since the client only values acceptance when understood. If the client felt unconditionally accepted but utterly misunderstood, CCCT would likely have a very different effect than it does.

In a review of studies on positive regard, Farber and Lane (2002, p. 177) offered considerable documentation that ‘‘. . . there has been a historical confounding in Rogers’s (and his followers) writings among the concepts of ‘warmth,’ ‘respect,’ ‘acceptance,’ ‘openness,’ ‘genuineness,’ and empathy.’’ Bozarth exemplified this tendency when he stated, ‘‘Rogerian empathy is, in fact, inseparable from unconditional positive regard and, ultimately . . . they are the same condition’’ (Bozarth, 1998, p. 52). In this paper we have argued that such confabulation is more apparent than real. Empathy in the context of a respectful, genuine unconditional positive regard is not a confabulation of these conditions but a novel gestalt that is different from its parts.

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