Person-Centered and Experiential Therapy

Chapter 8

Person-Centered Therapy

Person-centered therapy, originally called nondirective therapy in the 1940s and then client-centered therapy in the 1950s, was founded and developed by Carl Rogers (1902–1987). He began what some have considered a revolution in the counseling and therapy field by emphasizing that certain core therapeutic conditions (i.e., congruence, unconditional positive regard, and empathic understanding) provided by the therapist in the relationship with the client are necessary and sufficient to facilitate client change. Rogers also had an optimistic view of human beings, including therapy clients, believing in their capacity for positive change and growth into fully functioning persons, given appropriate support and safety. Rogers’s person-centered approach focuses on the capacity of the client to heal and to grow in the context of a warm, empathic, and genuine therapeutic relationship with the therapist. He de-emphasized techniques and diagnoses that tend to dehumanize people. Instead, Rogers placed the client as a person and the therapeutic relationship in the center of effective counseling and therapy. This was revolutionary at a time when more-deterministic views prevailed, such as Sigmund Freud’s psychoanalytic approach and the beginnings of some behavioristic conditioning approaches that emphasized the clinical expertise of the therapist and therapeutic techniques for helping clients change. Rogers used the term “client” rather than “patient” to refer to the person receiving therapy because he did not perceive the client as someone who is “sick” and in need of a cure.

Rogers eventually expanded his person-centered therapy approach to areas other than counseling and therapy, such as marriage, education, business and management, administration, and politics. In his later years, he even became involved in applying his ideas and approach to efforts at reducing international conflicts and enhancing world peace.

Biographical Sketch of Carl Rogers

Carl Ransom Rogers was born on January 8, 1902, in Oak Park, Illinois, a suburb of Chicago. He was the fourth child in a family of six children, five of whom were boys. His father was a contractor and civil engineer who did well professionally and financially. Although his parents were warm and loving, they were also legalistic and controlling, influenced by their fundamentalist Protestant religious background that frowned on activities such as dancing, drinking, card playing, and going to the theater (see C. R. Rogers 1961). When Rogers was twelve years old, he and his family moved to a large farm near Chicago. A sensitive, shy introvert, Rogers was not very sociable and preferred to spend time with his books and in his own world of thought (H. E. Rogers 1965).

Rogers also spent much of his time in the summers using farm equipment and developing his interest in agriculture and scientific methods in farming (Kirschenbaum 1979). He initially pursued scientific agriculture as his major at the University of Wisconsin. Rogers became involved with the YMCA on campus and was selected to be one of the twelve students from the United States who traveled to Peking (now Beijing), China, in 1922 as delegates to the World Student Christian Federation Conference. In meeting other bright and creative students who had religious beliefs that differed from the strict fundamentalistic beliefs of his parents, Rogers experienced a deep transformation of his own religious views, becoming more open and liberal. He also became more of himself (Bankart 1997, 292), with his true personality emerging after being away for six months on this significant trip.

Rogers changed his major from agriculture to history and graduated from the University of Wisconsin in 1924. Two months later he married his childhood sweetheart, Helen Elliott, and they drove to New York City, where he studied at Union Theological Seminary, a school that was more liberal than his parents would have preferred (Thorne 2003). His father had offered to fund his theological studies at Princeton, but Rogers exercised his independence by going to Union instead. After two years at Union, where he took a few psychology courses, he left the seminary and began a PhD program in clinical and educational psychology at neighboring Columbia University. Rogers completed this doctoral program in 1931.

Rogers worked for twelve years in the Child Study Department at the Society for the Prevention of Cruelty to Children in Rochester, New York, where he gained valuable clinical experience working with underprivileged and delinquent children referred by social agencies and the court system (C. R. Rogers 1961). He also trained and supervised other psychologists and social workers. Eventually Rogers went beyond the traditional psychoanalytic approach to therapy and began to develop a more nondirective counseling approach. He wrote The Clinical Treatment of the Problem Child (1939) during his time in Rochester.

Rogers moved to Columbus, Ohio, to become a full professor at Ohio State University in 1940. In that same year, he gave a groundbreaking lecture titled “Newer Concepts in Psychotherapy” at the University of Minnesota on December 11 and recalled this date as the “day on which client-centered therapy was born” (Kirschenbaum 1979, 112). This significant lecture and his subsequent book, Counseling and Psychotherapy (1942), sparked a major response from mental health professionals, with both enthusiastic support for and scathing criticism of his nondirective counseling ideas (Thorne 2003), which deemphasized technique and diagnosis. Rogers therefore became a “quiet revolutionary” (see Farson 1975).

Rogers’s early ideas on nondirective counseling, or client-centered therapy, were partly influenced by Otto Rank, who, like Carl Jung and Alfred Adler, had broken away from Freud and his psychoanalytic group. Rogers attended a three-day seminar in Rochester conducted by Rank. He was thus exposed to Rank’s ideas emphasizing the uniqueness and experience of the client and the need for the therapist to relinquish the role of an authority and instead become more of a nonjudgmental helper (Rank 1945). Rogers’s thinking was also influenced by two other people with whom he had contact: Elizabeth Davis, a Rankian-trained social worker at the Rochester clinic, and Jessie Taft, who was one of Rank’s students (C. R. Rogers & Haigh 1983).

In 1945 Rogers went to the University of Chicago, where he became a professor of psychology and the director of the university counseling center. He further developed his theoretical ideas and also engaged in research with his colleagues and graduate students to evaluate the effectiveness of his nondirective counseling approach, which eventually was renamed client-centered therapy in his significant book Client-Centered Therapy: Its Current Practice, Implications, and Theory (C. R. Rogers 1951). In 1956 Rogers received the first distinguished Scientific Contribution Award, presented to him by the American Psychological Association, an organization he had served as president in 1946–1947. He thus became a well-known figure in the counseling and therapy field, and client-centered therapy established itself as a major approach to therapy.

Rogers left the University of Chicago in 1957 to assume a new position at the University of Wisconsin in the Department of Psychology and then in the Department of Psychiatry. He had a difficult time in the Department of Psychology, disagreeing with how graduate students were treated in a somewhat oppressive educational environment that did not offer them enough freedom and support to develop their own creative ideas and work. As a result, he had frequent conflicts with his colleagues (Thorne 2003; P. Sanders 2004).

Rogers undertook a large research project that evaluated the impact of the therapeutic relationship on schizophrenics who were hospitalized (C. R. Rogers et al. 1967), but the study encountered several problems and yielded few statistically significant findings. However, two conclusions could be made from the results of this research project: clients who experienced the highest level of accurate empathy were the most successful, and clients’ evaluation of the therapeutic relationship correlated more highly with therapeutic success or failure than the therapists’ evaluation. Rogers managed to write and publish another substantial book, On Becoming a Person (1961), which led to even greater renown for him. In 1957 he published what is now a classic article on the necessary and sufficient conditions of therapeutic personality change, focusing on congruence, unconditional positive regard, and empathy. He resigned from the University of Wisconsin in 1962.

In 1964 Rogers moved to La Jolla, California, where he became a resident fellow at the Western Behavioral Sciences Institute for four years. After leaving the institute in 1968, he helped form the Center for Studies of the Person in La Jolla, where he also became a resident fellow. The center was the base from which he traveled around the world to deal with international conflicts and to work on peacemaking efforts. He continued to publish significant books on a wider variety of topics covering the application of person-centered ideas to areas such as education (1969, 1983), encounter groups (1970), marriage (1972), and personal power, including psychotherapy, family life, administration, education, and politics (1977).

Rogers continued to travel, write, and work on international projects and global issues until the last days of his life. He received many awards and honors in his lifetime, including the Distinguished Professional Contribution Award from the American Psychological Association in 1972. He was even nominated for the Nobel Peace Prize as a result of his tireless efforts to resolve global conflicts in a peaceful way. In 1987 Rogers broke his hip in a fall. He had successful surgery for the broken hip but died shortly thereafter from a heart attack on February 4, 1987 (Cain 1987a). Rogers has been described as a man who lived his life in a way that was consistent with his person-centered theory: as an author, therapist, and person he was consistently the same man (Cain 1987b).

Major Theoretical Ideas of Person-Centered Therapy

Perspective on Human Nature

Person-centered therapy as developed by Rogers has a positive and optimistic perspective on human nature. It views the person as basically good and trustworthy, with an inner and innate tendency toward growth and wholeness leading the person to be all they can be. This actualizing tendency, which is the major motivation in every human person, moves an individual toward self-actualization or becoming mature and autonomous, under appropriate conditions that are supportive and safe for the person (see C. R. Rogers 1961, 35).

Rogers also described the organismic valuing process, which guides the actualizing tendency with an innate capacity to choose what will be self-enhancing or self-actualizing rather than what will be self-destructive. He believed that when person-centered therapists provide the therapeutic conditions of congruence (realness or genuineness), unconditional positive regard (warmth and acceptance or respect), and accurate empathic understanding (of the client’s inner, subjective world) in a way that the client can experience them, then the right conditions of support and safety enable the client to grow and self-actualize. On the other hand, if negative “conditions of worth” are imposed on a person or a client, usually by society and parental figures or other family members, then the actualizing tendency is alienated, and the individual may then develop defensive and maladaptive reactions to an environment that the individual experiences as oppressive and dangerous. The behavior that eventually results may include evil acts of cruelty and hatred, which Rogers acknowledged can and do occur. However, he was convinced that this is not the innate nature of a human being but rather an acquired aspect of human behavior (see Parrott 2003, 178).

Rogers believed that, given appropriate conditions fostering growth, human beings are basically good and trustworthy, capable of choosing their own direction in constructive and insightful ways, and able to be productive and effective in their lives (Cain 1987b). Person-centered therapy therefore focuses on the client and their capacity for healing, growth, and self-actualization as well as self-determination. It does not view the therapist as an authoritative expert. The ultimate responsibility for healing and growth in therapy lies with the client (see Corey 2021, 171), who is capable of becoming a fully functioning person when the actualizing tendency is allowed to blossom and be expressed.

Person-Centered Theory of Personality

Rogers developed and described both a theory of personality as well as a theory of psychotherapy from a person-centered perspective (C. R. Rogers 1959). His theory of personality consists of nineteen propositions that are somewhat complex, and it has therefore attracted much less attention than his theory of psychotherapy (C. R. Rogers 1980, 60).

Rogers’s (1959) theory of personality (including a theory of psychopathology) from a person-centered perspective, with its nineteen propositions, can be condensed into four major features, according to J. Sommers-Flanagan and Sommers-Flanagan (2018, 117–119).

The first feature of a person-centered theory of personality is that it is mainly a self-theory (Bankart 1997). Rogers described the organism as the locus of a person’s total psychological experience and the self as that part of the organism that is “me,” whether conscious or unconscious. Thus a person’s experience of self can differ from their total psychological experience as an organism. Rogers labeled such a discrepancy as incongruence. On the other hand, when a person’s experiences are in line with their total experiences as an organism, congruence exists between self and organism, a highly positive situation that facilitates the development and growth of the individual into a more mature, autonomous, and fully functioning person.

The second feature of Rogers’s theory of personality is his emphasis on phenomenology and the valuing of experience. It highly values personal, subjective experience that is direct and nonverbal, what has been called “intuitive knowing” (Bohart 1995, 91). Person-centered therapy seeks to help clients be more open to their own wide variety of subjective, personal experiencing and to decide which experiences can help them become more fully functioning persons.

The third feature of a person-centered theory of personality is its focus on learning and growth potential. Rogers emphasized that every person has an innate actualizing tendency that moves them in the positive direction of growth, maturity, and autonomy, becoming more who they really are. It is a potential for learning and growth in every moment of one’s life and experiences. Rogers observed: “There is one central source of energy in the human organism. This source . . . is most simply conceptualized as a tendency toward fulfillment, toward actualization, involving not only the maintenance but also the enhancement of the organism” (C. R. Rogers 1980, 123).

Sidebar 8.1: Features of Person-Centered Theory

(see J. Sommers-Flanagan & Sommers-Flanagan 2018, 117–119)

Self-theory

Phenomenology and the valuing of experience

Learning and growth potential

Conditions of worth

The fourth and final feature of a person-centered theory of personality concerns conditions of worth. In addition to one’s innate actualizing tendency to maintain and enhance oneself as an organism, there are also two important learned or acquired needs: the need for positive regard and the need for self-regard. If the need for positive regard or approval from significant others, especially parents or parental figures in one’s life, is not met because disapproval or negative feedback is sometimes given to the person for specific behaviors, then conditions of worth are set up for that person. The individual will then experience positive regard or approval from others for some of their behaviors, but negative regard or disapproval for other behaviors. This will result in a similar mix of internalized positive and negative self-regard and an incongruent sense of self, with discrepancies between the social self based on others’ expectations and the true self based on one’s actual feelings about personal experiences. Internal genuine values that are unconsciously appreciated organismically by the person often clash with externally imposed and consciously incorporated values from significant others. Under conditions of worth that are not supportive or safe, an individual will usually become increasingly out of touch with their true self, that is, become more incongruent and therefore ultimately unable to learn or grow from experience, leading to psychopathology. It is therefore crucial for an individual to experience unconditional positive regard in order for them to have appropriate self-regard, to recover from psychopathology, and to grow again as a person. We should also note that Rogers viewed people as capable of perception without awareness, a process called subception.

In addition to these four major features of Rogers’s person-centered theory of personality, he also provided descriptions of fully functioning persons that individuals are motivated to become as they allow their organismic valuing processes to be more fully utilized. According to Rogers, “Fully functioning persons are open to experience, are characterized by existential living, trust their organisms, are creative, and live richer lives than do other people” (1961, 187–196, emphasis in original, see also Ryckman 2008, 454). Rogers later expanded and elaborated on these characteristics of the fully functioning person to include the following descriptions of what he termed emerging persons (e.g., corporate executives who are committed to living a simpler life, countercultural young people, nuns and priests who have overcome dogmatism to live more meaningfully, and ethnically diverse people and women who have overcome passivity to live more assertive and constructive lives): “They are honest and open; they are indifferent to material comforts and rewards; they are caring persons; they have a deep distrust of cognitive based science and a technology that uses that science to exploit and harm nature and people; and they have a trust in their own experience and a profound distrust of all external authority” (C. R. Rogers 1977, 255–274, emphasis in original; see also Ryckman 2008, 455–456).

Therapeutic Process and Relationship

Rogers’s theory of psychotherapy, compared to his theory of personality, is much better known and more widely applied in the practice of counseling and psychotherapy. It focuses on the therapeutic process and the therapeutic relationship between the therapist and the client as the crucial factors in effective therapy. Rogers believed that a client should lead in the process of therapy and be free to choose specific goals or direction in therapy. The basic aim of person-centered therapy is not to solve problems but to provide the necessary and sufficient therapeutic conditions of congruence, unconditional positive regard, and empathic understanding so that the client can freely grow to become more of a fully functioning person in a safe and supportive therapeutic environment.

Clients who are becoming more fully functioning or more actualized have been described by Rogers (1961) as being open to experience, trusting in themselves, evaluating themselves more internally than externally, and being willing to continue growing.

More specifically, Rogers described the following necessary and sufficient conditions of therapeutic personality change in his theory of psychotherapy:

For constructive personality change to occur, it is necessary that these conditions exist and continue over a period of time:

1. Two persons are in psychological contact.

2. The first, whom we shall term the client, is in a state of incongruence, being vulnerable and anxious.

3. The second person, whom we shall term the therapist, is congruent or integrated in the relationship.

4. The therapist experiences unconditional positive regard for the client.

5. The therapist experiences an empathic understanding of the client’s internal frame of reference and endeavors to communicate this experience to the client.

6. The communication to the client of the therapist’s empathic understanding and unconditional positive regard is to a minimal degree achieved. (1957, 95)

Rogers was firmly convinced that these core conditions alone are sufficient and necessary for therapeutic or positive personality change to occur in any client. He believed that no other conditions or therapeutic methods are necessary for therapeutic personality change to take place in a client. Such a person-centered approach places major emphasis on the equality and mutuality of the therapist-client relationship, in which the therapist is a fellow traveler with the client on the client’s journey through life. The therapist is not viewed as an expert with specialized knowledge for accurate diagnosis of the client and techniques for solving the problems of the client. Instead, the therapist is a guide who provides and communicates congruence or genuineness, unconditional positive regard or acceptance, and accurate empathic understanding to the client to facilitate the client’s growth into a more fully functioning person. However, this therapeutic process is not as easy to achieve as one might think. The therapist must trust the client and provide this special kind of therapeutic relationship with the client (see J. Sommers-Flanagan & Sommers-Flanagan 2018, 119), both of which are more difficult to maintain than they seem. Both the therapist and the client are imperfect human beings, with obvious limitations. Therefore, a therapist, even a person-centered therapist, cannot be expected to always be real, accepting, and understanding (with congruence, unconditional positive regard, and accurate empathic understanding) with and for every client. However, the person-centered therapist will attempt to develop these therapeutic conditions and attitudes toward a client.

Rogers realized that his theory of psychotherapy was radical and controversial because he strongly asserted that his six conditions of therapeutic personality change are the only sufficient and necessary ones for clients, as well as for other people, to grow and become more fully functioning. He therefore disagreed with therapists who insisted on other necessary conditions, such as specific therapeutic techniques, to bring about therapeutic change. However, even when therapists view Rogers’s core conditions of congruence, unconditional positive regard, and empathic understanding as neither necessary nor sufficient to produce therapeutic change, or as necessary but not sufficient for such change, most of them still appreciate these conditions as helpful. They are often taught as the clinical foundations for any effective approach to counseling and psychotherapy, and therefore they have been incorporated into almost every contemporary school of counseling and psychotherapy. Congruence or genuineness, unconditional positive regard or acceptance, and empathic understanding or accurate empathy will now be covered in more detail as crucial components of the therapeutic relationship, especially in person-centered therapy.

Congruence

Congruence in the therapist is also referred to as genuineness, or authenticity and transparency. In other words, a person-centered therapist who is congruent or integrated in the therapeutic relationship with the client is real, honest, and open, engaging in appropriate self-disclosure to the client, involving both positive as well as negative feelings. When the congruent therapist is genuine with the client, the client is enabled to be more real as well, and hence to be more truly in touch with their own real self. Congruence or genuineness is therefore essential for effective counseling and psychotherapy from a person-centered perspective (see C. R. Rogers 1961).

Unconditional Positive Regard

Unconditional positive regard is also referred to as acceptance, warmth, prizing, or respect. It is a nonpossessive deep and real caring for the client that is nonjudgmental and positive, allowing and accepting the client to have the feelings they are experiencing at the moment in the therapeutic relationship. There is also a total valuing of the client in an unconditional way, respecting the client regardless of their behavior. Such unconditional positive regard of the therapist for the client will more likely lead to forward movement or therapeutic change, according to Carl Rogers (1986, 198). The therapist’s unconditional positive regard for the client will enhance the client’s own unconditional self-regard and therefore help the client to grow and become a more fully functioning person, because conditions of worth have been reduced or removed. Rogers was aware that therapists are not perfect people and therefore cannot experience and communicate unconditional positive regard to all their clients all the time. However, it is essential from a person-centered therapy perspective for therapists to have deep respect and genuine caring or warmth for their clients in effective therapy (C. R. Rogers 1977; see Corey 2021, 175).

Empathic Understanding or Accurate Empathy

Empathic understanding, or accurate empathy, refers to the therapist’s ability to enter deeply into the client’s subjective world or internal frame of reference, and feel with the client as sensitively and accurately as possible. Although it involves deep listening, it is more than just reflection of the client’s feelings. It is an entering into the client’s subjective experiences, feeling the client’s feelings without losing the therapist’s own identity or being overwhelmed by the client’s feelings. Such empathic understanding experienced and expressed by the therapist to the client will help the client be in deeper touch with and understanding of their subjective experiences or feelings, including those that may not be as clear or obvious initially.

There are therefore at least two levels of accurate empathy, or empathic listening (see C. R. Rogers 1975, 1980): empathic understanding of what the client is feeling or experiencing and deeper empathic listening for and understanding of meanings in the client’s experiences, meanings of which the client is hardly aware. This latter deeper empathy is sometimes called advanced empathy, whereby the therapist deeply hears the message behind the message (G. Egan 2002).

Empathy is actually a multidimensional rather than a simple construct (see A. J. Clark 2007, 2010; Elliott, Bohart, Watson, & Greenburg 2011). In his integral model of empathy, Arthur Clark (2010) describes the following three ways of empathic knowing that are crucial in the process of counseling:

1. Subjective empathy involves the therapist’s identifying with the client’s present experiences through intuition and imagining the experiences of the client.

2. Interpersonal empathy involves the therapist’s communicating deeply with the client about their inner and subjective phenomenological experiences, with the client’s feedback.

3. Objective empathy involves the therapist’s making use of theoretical knowledge and other sources of knowledge outside the client’s inner experiences, to facilitate deeper understanding of the client (cited in J. Sommers-Flanagan & Sommers-Flanagan 2018, 121).

Empathy has been the most researched and discussed of the three core therapeutic conditions of congruence, unconditional positive regard, and empathic understanding described by Rogers in person-centered therapy (see Bohart & Greenberg 1997; J. C. Watson 2002; see also Norcross & Lambert 2019). Most recently, in reviews and meta-analyses of the research on psychotherapy relationships that work, empathy and positive regard (and affirmation) are now both listed as demonstrably effective, and congruence/genuineness is rated as probably effective (see Norcross & Lambert 2019, 632). In the meta-analysis on empathy (Elliott, Bohart, Watson, & Murphy 2019, 259–261) eighty-two studies were used, sixty-four in the meta-analysis on positive regard and affirmation (Farber, Suzuki, & Lynch 2019, 303–305) and twenty-one in the meta-analysis on congruence/genuineness (Kolden et al. 2019, 337–338). Empathy has been acknowledged by almost every major approach to counseling and psychotherapy as a crucial factor or even necessary ingredient in effective therapy (Cain 2010).

However, in reviewing the writings of Rogers on these three core therapeutic or therapist conditions, Jerald Bozarth concluded that genuineness and empathic understanding can be viewed as the two contextual attitudes for the primary condition of therapeutic change: unconditional positive regard (1996, 44). Bozarth therefore believes that unconditional positive regard, together with genuineness and empathic understanding, should all be considered a single crucial condition for therapeutic change to occur in the client, and this condition is essentially an attitude that the therapist must have toward the client for effective counseling and therapy to take place (see also Tyler 1999). Person-centered therapy ultimately requires this kind of therapeutic attitude on the part of the therapist, not just techniques; only when the therapist thus successfully communicates positive regard can the client be therapeutically changed.

Major Therapeutic Techniques and Interventions

Person-centered therapy as developed by Rogers does not espouse specific therapeutic techniques or interventions. It also does not formally engage in psychological diagnosis but rather treats each client as a unique individual (although some contemporary practitioners of person-centered therapy may provide diagnoses for their clients for the sake of medical insurance reimbursement). Rogers himself felt that formal psychological diagnosis is not necessary for therapy and may even have deleterious effects on the process of therapy (C. R. Rogers 1957, 220).

Sidebar 8.2: Techniques in Person-Centered Therapy

(see J. Sommers-Flanagan & Sommers-Flanagan 2018, 125–128)

1. Experiencing and expressing congruence

2. Experiencing and expressing unconditional positive regard

3. Experiencing and expressing empathic understanding

More traditional person-centered therapy following Rogers emphasizes that only six conditions are necessary for therapeutic change to occur in the client. The first two conditions focus on a client who is experiencing incongruence, with feelings of vulnerability or anxiety, but who is in psychological contact or therapeutic relationship with a therapist. Three other conditions focus on the therapist being congruent, experiencing unconditional positive regard for the client, and experiencing empathic understanding of the client’s internal frame of reference and communicating this to the client. The final condition requires the congruent therapist communicating empathic understanding and unconditional positive regard to the client to the degree that the client perceives and experiences this understanding and regard. The key therapeutic “technique” or intervention in person-centered therapy thus concerns the therapist having the right therapeutic attitude toward the client and effectively communicating or expressing that attitude to the client.

Although there are no specific techniques in the practice of traditional person-centered therapy, the therapeutic attitude of the person-centered therapist toward the client can be described as consisting of three major “techniques” or interventions: experiencing and expressing congruence, experiencing and expressing unconditional positive regard, and experiencing and expressing empathic understanding (J. Sommers-Flanagan & Sommers-Flanagan 2018, 125–128).

Experiencing and Expressing Congruence

For the therapist to be congruent means that the therapist is real, open, genuine, and honest in relating to the client. However, this does not mean that the therapist engages in total self-disclosure or shares every thought or feeling that the therapist may have during the therapy session with the client. Some discernment and self-control are still needed so that the therapist shares only what is appropriate and helpful to the client. It can include sharing negative feelings such as feeling bored, but some feelings, such as sexual attraction for the client, are better shared with a clinical supervisor or consultant than with the client, who may feel threatened by the therapist’s disclosure of such feelings.

Rogers seems to have believed that therapists can use techniques in therapy but only if they occur spontaneously, not in a preplanned way (J. Sommers-Flanagan & Sommers-Flanagan 2018, 125). In other words, if techniques are ever appropriate in therapy, they should come up in a genuine and spontaneous way, consistent with the behavior of a congruent therapist. More-contemporary practitioners of person-centered therapy, therefore, may use techniques at times but in a genuine way appropriate to specific clients (see Bozarth, Zimring, & Tausch 2002; Cain 2002a, 2010).

Experiencing and Expressing Unconditional Positive Regard

Experiencing and expressing unconditional positive regard for the client is another core therapeutic condition, according to Rogers. Bozarth (1996) concluded that unconditional positive regard is the primary condition for therapeutic change to occur in the client. It is an attitude of warmth, respect, deep caring for, and acceptance of the client, in which the client is valued simply for being a person, without considering any conditions of worth (C. R. Rogers 1959). Rogers clarified that such unconditional positive regard is a kind of love that is equivalent to “agape,” a term used by theologians, but not related to the romantic and possessive meanings usually associated with the word “love” (see C. R. Rogers 1962, 422).

Since there are no perfect clients or perfect therapists, it is impossible in practice for even person-centered therapists to experience and express unconditional positive regard for every client all the time. However, the person-centered therapist will strive as much as possible for an attitude of unconditional positive regard for a client.

Unconditional positive regard can be communicated or expressed to a client in various ways. The more direct way of simply saying, for example, “I value and prize you as a whole person” or “I accept you and care about you for who you are as a person” or “I won’t judge you” oftentimes may not be the most appropriate means of expressing unconditional positive regard. Clients may be overwhelmed by such direct statements and react with unrealistic expectations of perfect caring and even romantic love from the therapist, or respond with fear or distancing because of their discomfort with such caring intimacy offered by the therapist (see J. Sommers-Flanagan & Sommers-Flanagan 2018, 125–126). However, sometimes a direct expression of unconditional positive regard or warmth and deep caring can be helpful, for example, when Rogers himself responded to a client who didn’t care what happened with “You just don’t care what happens. And I guess I’d just like to say—I care about you. And I care what happens” (C. R. Rogers et al. 1967, 409).

Other appropriate ways of indirectly expressing unconditional positive regard include establishing a relationship of respect and warmth with the client by keeping appointments, addressing them in a way that person would like to be addressed, and listening intently and caringly to them; letting the client freely talk in whatever manner is comfortable for them; hearing and remembering specific details of the client’s story, for example, by using paraphrases, summaries, and occasional interpretations; responding with empathy and compassion when the client expresses emotional pain and conflicts; and making an intentional effort to accept and respect the client in a warm and caring way (see J. Sommers-Flanagan & Sommers-Flanagan 2018, 126).

Experiencing and Expressing Empathic Understanding

Although it is impossible to fully and directly experience another person’s feelings (C. R. Rogers 1959), person-centered therapists do their best to experience and express empathic understanding of their client’s internal frame of reference or subjective feelings with as accurate an empathy as possible. Based on Rogers’s description of what being empathic really means (see C. R. Rogers 1975, 4), J. Sommers-Flanagan and Sommers-Flanagan briefly describe the following four major components of experiencing and expressing empathic understanding to the client: “Entering and Becoming at Home in the Client’s Private Perceptual World; Being Sensitive from Moment to Moment with the Client’s Changing Meanings and Emotions; Temporarily Living and Moving About Delicately in the Client’s Life; and Sensing Deep Meanings, but Not Uncovering Feelings That Are Too Far Out of Awareness” (2018, 127–128).

With regard to temporarily living and moving about delicately in the client’s personal world, there is a real danger of the therapist becoming too involved, so much so that the empathic therapist loses their own sense of self in a way that is unhealthy and potentially harmful to the therapist as well as to the client. Rogers himself became too involved in the subjective world of one of his female clients and ultimately lost his sense of self in the relationship (see C. R. Rogers 1967, 367; see also C. R. Rogers 1972).

Nevertheless, empathic understanding of or accurate empathy for the client is a core therapeutic condition in person-centered therapy, and virtually every school of counseling has acknowledged it as an integral part of effective therapy. It is crucial to remember that empathic understanding is more than merely reflecting feelings or paraphrasing the feelings expressed by a client, what has been described as the basic counseling technique of active listening. Early in his professional career, Rogers himself stopped writing about reflection of the client’s feelings because many clinicians erroneously concluded that empathy simply involves paraphrasing and summarizing the feelings expressed by the client. Carl Rogers (1975) chose instead to emphasize the need for a person-centered therapist to have an empathic attitude rather than focus on reflecting a client’s feelings or listening empathically.

Carkhuff (1971, 170–171) has extended Rogers’s three core therapeutic conditions to six core conditions: the facilitative conditions of empathy (understanding), respect (unconditional positive regard), and concreteness (being specific); and the action conditions of genuineness (or being real or congruent), confrontation (or telling it like it is), and immediacy (or what is really going on between the therapist and the client). The extra core therapeutic condition that is most often added to congruence (genuineness), unconditional positive regard (respect), and empathic understanding (empathy) is concreteness or specificity (see, e.g., G. Egan 2006). Traditional person-centered therapy still focuses on the three core therapeutic conditions and the six necessary and sufficient conditions of therapeutic personality change first described by Carl Rogers (1957). It has been applied not only in individual therapy but also in play therapy (Axline 1947) and client-centered work with children (K. Moon 2002), client-centered group process, classroom teaching, the intensive group or basic encounter group, and peace and conflict resolution between larger groups and even nations (see Raskin, Rogers, & Witty 2019).

As noted, more-contemporary versions of person-centered therapy have built on and gone beyond Rogers’s approach, with a wider array of therapeutic techniques and practices. The following are examples of “second generation person-centered therapies” (J. Sommers-Flanagan & Sommers-Flanagan 2018, 128): focusing (Gendlin 1996); motivational interviewing (W. R. Miller & Rollnick 2013; see also Rosengren 2018); emotion-focused therapy (L. S. Greenberg 2017); child-centered or nondirective play therapy (VanFleet, Sywulak, & Sniscak 2010); and expressive arts therapy (N. Rogers 1993), including such person-centered creative connection in groups (N. Rogers 2011).

Motivational Interviewing (MI)

Motivational interviewing (MI) is a well-known and more specific contemporary version of a person-centered approach to therapy that includes specific techniques. It was developed by William R. Miller, based on his clinical work and research on problem drinking and addiction. Described by Miller as Carl Rogers in new clothes (Prochaska & Norcross 2018, 117), MI has been defined as “a directive, client-centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence” (Rollnick & Miller 1995, 326). It focuses on enhancing the intrinsic motivation to change in a client by using a person-centered style with warmth, empathy, and an egalitarian therapeutic relationship, in conjunction with person-centered “techniques” such as reflective listening and asking key questions. However, MI also adds other therapeutic techniques that go beyond traditional person-centered therapy, such as using specific therapeutic interventions to help clients move toward behavior change and including the therapist’s goals for therapeutic changes in the client (Moyers & Rollnick 2002).

William Miller and Stephen Rollnick have previously identified and described four major principles for the practice of MI (see Prochaska & Norcross 2018, 118) based on their view of Rogers’s approach to person-centered therapy (which they felt was not nondirective because Rogers did guide his clients, though gently, to explore their pain, agitation, or confusion, and stay with such experiences in order to work through them):

1. Express empathy by using reflective listening skills to understand the client and convey such empathic understanding as well as genuine caring to the client.

2. Develop discrepancy between the client’s deep values and present behavior. The therapist helps the client to perceive or notice such a discrepancy, which can powerfully motivate the client to initiate change that the client desires. It is the client who argues for change and talks about changing, not the therapist.

3. Roll with resistance by responding to the client’s resistance with reflection instead of confrontation. Client resistance is viewed as an expression of ambivalence about change, and the therapist should not confront it directly or try to persuade the client to change. The therapist should instead roll with the resistance by using empathic reflection and understanding.

4. Support self-efficacy by actively communicating that the client is capable of change, building optimism, using brief and small interventions that allow change to successfully occur, and reinforcing optimism for further change. However, the therapist still lets the client lead in coming up with possible solutions for change. (1991, 2002)

William Miller and Gary Rose proposed a theory of MI with two major components: “a relational component focused on empathy and the interpersonal spirit of MI, and a technical component involving the differential evocation and reinforcement of client change talk” (2009, 527). More recently, William Miller and Rollnick, in the third edition of their classic text on MI, provided three levels of definition of MI:

1. Layperson’s definition: Motivational interviewing is a collaborative conversation style for strengthening a person’s own motivation and commitment to change

2. Practitioner’s definition: Motivational interviewing is a person-centered counseling style for addressing the common problem of ambivalence about change

3. Technical definition: Motivational interviewing is a collaborative, goal-oriented style of communication with particular attention to the language of change. It is designed to strengthen personal motivation for and commitment to a specific goal by eliciting and exploring the person’s own reasons for change within an atmosphere of acceptance and compassion (2013, 29, emphasis in original)

They also replaced their earlier emphasis on phases and principles of MI with a description of four broad or key processes of MI: engaging, focusing, evoking, and planning (2013, vii). Engaging involves the process of having a helpful connection and collaborative or working relationship. Focusing is the process in which a certain direction is clarified and followed in the communication concerning change. Evoking is at the heart of MI: it involves the process of bringing out the motivations for change from the client. Planning is the process of facilitating commitment to change as well as developing an action plan that is concrete. The five crucial communication skills used in MI are asking open questions, affirming, reflecting, summarizing, and providing or giving information and advice, yet with permission (W. R. Miller & Rollnick 2013, 36).

David Rosengren (2018), in his revised practitioner’s workbook on building MI skills, noted that the active nature of these five core skills of MI have been described by Miller and Rollnick (2013) as asking, affirming, listening, summarizing, and exchanging information. However, he suggests using an acronym for easier recall: “OARS + I (open-ended questions, affirmations, reflective listening, summaries, and information exchange)” (Rosengren 2018, 16).

Miller and Rollnick have also emphasized that MI’s “underlying spirit” is definitely “within the longstanding tradition of person-centered care” (2013, 22), with four major but overlapping components: collaboration, acceptance, compassion, and evocation. They further elaborate on a profound acceptance of the client, with the following features: absolute worth of the client (with unconditional positive regard for the client), accurate empathy, autonomy support (for the client’s right and potential for self-direction), and affirmation of the client (2013, 17). Compassion is crucial because it focuses on the best interests and the welfare of the clients and not the self-interest of the therapist or practitioner. The techniques used in the process of MI (OARS + I) are for the purpose of helping clients not to get stuck in sustain talk, which focuses on their lack of motivation or ability or need to change, and to be more involved in change talk, which focuses on their motivation or ability or need to change and their commitment to an action plan for change.

There is also a more recent series of books on applications of MI that cover a broad range of topics, reflecting the tremendous impact that MI has made in the field of counseling and psychotherapy and beyond. They include books on motivational interviewing in these contexts: health care (Rollnick, Miller, & Butler 2008); adolescents and young adults (Naar & Suarez 2011); social work practice (Hohman 2021); the treatment of anxiety (Westra 2012); helping people change (W. R. Miller & Rollnick 2013); groups (C. C. Wagner & Ingersoll 2013); the treatment of psychological problems (Arkowitz et al.2015); diabetes care (Steinberg & Miller 2015); nutrition and fitness (Clifford & Curtis 2016); schools (Rollnick, Kaplan, & Rutschman 2016); offenders (Stinson & Clark 2017); MI and CBT (Naar & Safren 2017); a practitioner workbook on building MI skills (Rosengren 2018); coaching athletes to be at their best: sports (Rollnick et al. 2020); and using MI with leaders in the helping professions for facilitating change in organizations (Marshall & Nielson 2020). Miller, Forcehimes, and Zweben (2019) have also coauthored the second edition of a guide using MI for professionals in treating addiction.

Person-Centered Therapy in Practice

This hypothetical transcript of a small part of a traditional person-centered therapy session demonstrates the experience and expression of unconditional positive regard (warmth and deep caring) as well as empathic understanding by a genuine or congruent person-centered therapist for a client who is struggling with much deep emotional pain and feeling overwhelmed by it. The person-centered therapist engages in intense reflective listening and conveys unconditional positive regard and empathic understanding by using paraphrases and brief summaries of the client’s feelings and experiences, as well as by being present in deeply caring moments of silence and offering the client tissues at appropriate times when the client is crying. The person-centered therapist does not use other specific therapeutic techniques such as problem solving of the job situation, cognitive restructuring of the client’s thinking, or behavioral methods for emotional control.

Client: I lost my job again, . . . the second time in just a month! I feel like a loser; I feel that people must be laughing at me and thinking that I’m a failure, that I’m good for nothing.

Person‑Centered Therapist: You just lost your job, twice in one month, . . . and you’re feeling lousy about it, like being a loser, and you feel that others are looking down on you, thinking of you as no good and a failure.

Client: Yeah, . . . and it hurts real bad inside because I’ve tried very hard to keep my jobs, . . . but I guess I’m not good enough and never will be good enough . . . (with tears welling up)

Person‑Centered Therapist: Um-hmm . . . It’s really painful, especially when you tried so hard to keep your jobs, and feeling you’re not good enough, . . . and will never be good enough? . . . (silence for a few moments, with more tears from the client)

Client: It’s . . . It’s really hard . . . to feel like no matter how much I try, it’s no use; . . . it’s not going to make a difference at all . . . because I’m no good at all at keeping a job . . . or even at anything else. . . . I’m such a failure, such a loser . . . (weeps a little)

Person‑Centered Therapist: Um-hmm . . . Here are some tissues if you’d like some. . . . You really feel crushed inside, . . . like you’re a total failure, and no matter what you do or how hard you try, it’s not going to work out; . . . it’s not going to be good enough, . . . about your job . . . as well as about anything else in your life. . . . Is that what you said? Am I getting it right?

Client: Yeah, yeah . . . that’s right. I don’t know where to go from here and what to do; . . . but I feel I’m just a total nothing, a big zero . . . who can’t do anything right . . . (weeps a little more) (silence for a few more moments)

Person‑Centered Therapist: Sounds like you’re experiencing an overwhelming feeling of being a complete failure, . . . being a total nobody, . . . and you feel stuck, not knowing what to do or where to go from here, . . . and it just hurts . . . and hurts . . . and hurts . . . more and more deeply . . . (client begins to weep more)

Client: Yeah . . . it’s just so hard, . . . and it hurts so much deep inside . . . (sobs for a few seconds) (silence for a few moments)

Person‑Centered Therapist: Um-hmm . . . so much pain inside; . . . it hurts so badly and deeply that the tears just flow . . .

Client: Um-hmm . . . (weeps for a few more seconds)

Person‑Centered Therapist: (remains quiet for a few seconds while handing more tissues to the client)

Critique of Person-Centered Therapy: Strengths and Weaknesses

Person-centered therapy has several strengths, many of them similar to the strengths of existential therapy covered in the previous chapter. First, person-centered therapy involves a genuine and deep respect for the client as a person. It is thus client centered, with a deep trust in the individual’s actualizing tendency to learn and grow to become a more fully functioning person. It has a basically positive view of the goodness of human nature. As a humanistic approach similar to existential therapy, it strongly opposes any therapeutic attempt to dehumanize or objectify the client and therefore does not focus on therapeutic techniques per se or on formal diagnosis and psychological testing and assessment of the client.

Second, it emphasizes the therapeutic relationship as the key factor in effective counseling and therapy for all clients. In fact, according to Rogers, there are only six necessary and sufficient conditions for therapeutic personality change to occur in the client; chief among them are congruence, unconditional positive regard, and empathic understanding, which the therapist needs to experience and communicate to the client. Traditional person-centered therapy therefore exalts such a therapeutic relationship to the highest level of necessity for therapeutic change in the client to occur, without the need for any other therapeutic techniques or interventions. No other approach to counseling and therapy places such a premium on the therapeutic relationship as the essential and only healing factor in effective counseling and therapy. Empathy, especially, has received tremendous attention and research support for its crucial and essential role in effective therapy (J. C. Watson 2002; see also Elliott, Bohart, Watson, & Murphy 2019).

Third, a related strength of person-centered therapy is its focus on the person of the therapist and the need for congruence or genuineness and maturity on the part of therapists so that they effectively experience and express unconditional positive regard and empathic understanding to their clients. The person of the therapist is more important than techniques.

Fourth, Rogers has been credited with opening the counseling and therapy field to empirical scrutiny and research. He tried to put his person-centered ideas into hypotheses that could be empirically tested in research (see Cain 2002a, 2002b). He also insisted on allowing therapy sessions to be recorded and then objectively rated by impartial judges or researchers to investigate how the core therapeutic conditions of genuineness, unconditional positive regard, and empathic understanding or empathy are related to therapeutic outcomes. Person-centered therapy has therefore contributed significantly to research on therapy process and outcome, despite its eschewing of technique and diagnosis.

Fifth, person-centered therapy has greatly influenced virtually every major approach to counseling and therapy, but this impact has not always been explicitly acknowledged or sufficiently appreciated (Farber 1996). Nevertheless, innovations in more-contemporary person-centered approaches to therapy have been made, with appropriate acknowledgments of the pioneering work and influence of Rogers.

Sixth, and finally, person-centered therapy may be especially helpful to clients who need space, deep acceptance, and genuine caring from a therapist in order to explore issues and their own inner experiences and feelings, without being judged or having external conditions of worth imposed on them. Such clients have typically included middle-class college students and others struggling with developmental and identity issues, many of whom were seen in early client-centered therapy, the forerunner of person-centered therapy.

Person-centered therapy also has several weaknesses. First, the radical focus on the individual and deep respect and trust in their innate goodness and actualizing tendency can result in an overly optimistic reliance on the client to provide self-appraisals that are accurate and to engage in healthy growth or actualization as a person. Such an individualistic focus on the self and its ultimate importance and autonomy may well lead to grosser forms of individualism and inflated views of the self that are unhealthy and may even become pathological. Human beings are capable not only of healthy and constructive growth but also of more negative and destructive actions such as crime and war—and not just because of conditions of worth imposed on them (see Parrott 2003, 190–191).

Second, the individualistic focus on person-centered therapy tends to neglect the importance of other factors such as social, cultural, political, economic, and biological forces that can lead to psychopathology in individuals. A more holistic and contextual view of an individual’s functioning and dysfunctioning is needed for person-centered therapy to be more balanced and comprehensive.

Third, the emphasis on self-actualization and the importance and autonomy of the self in person-centered therapy is also problematic in a cross-cultural context and from a multicultural perspective. This view of the self may reflect a Western cultural bias in valuing individualism. Other cultures, such as those of Asia, value social and family relationships more than Western cultures do, and hence personality theories from Asian cultural perspectives emphasize more the importance of relationships in the development of the individual (Pedersen 1983). For some Asian theories of personality, a focus on self-actualization is viewed as detrimental to a person’s optimal development (see Todd & Bohart 2006, 215).

Fourth, traditional person-centered therapy’s radical emphasis on the therapeutic relationship based on the core conditions of congruence, unconditional positive regard, and empathic understanding, conditions counted as essential healing factors in effective counseling and therapy, is too exclusive and extreme. Although the therapeutic relationship is an important factor in effective therapy, it is not the only factor. In fact, based on earlier research (see, e.g., M. J. Lambert, DeJulio, & Stein 1978; Parloff, Waskow, & Wolfe 1978), even person-centered therapists have acknowledged that the core conditions described by Rogers are not necessary or sufficient, but can be helpful for therapeutic change to occur in clients (see Raskin 1992). More recently, however, an update on research support for psychotherapy relationships that work did list empathy and positive regard (and affirmation) as demonstrably effective, and congruence/genuineness as probably effective, based on recent meta-analyses (see Norcross & Lambert 2019, 632).

Fifth, traditional person-centered therapy’s shunning of specific therapeutic techniques has been questioned. Although techniques are not always the most important factor in effective therapy, they are still important, and in some psychological disorders they are crucial for effective treatment. Examples of specialized therapy techniques that empirical research has found to be more effective in treating specific psychological disorders include exposure treatments for specific phobias, response prevention for obsessive-compulsive disorders, cognitive restructuring and exposure for agoraphobia, gradual practice with some sexual disorders, and use of a more supportive approach in interpretation in short-term psychodynamic therapy, taking client symptom severity into consideration (M. J. Lambert & Barley 2002; M. J. Lambert & Ogles 2004). A related weakness of person-centered therapy is its eschewing of formal diagnosis and psychological assessment and its assumption that it can be effective for all clients and all psychological disorders. Clearly, one size does not fit all in this context; hence, diagnosis and assessment are important, and so are some therapeutic techniques crucial to the effective treatment of specific psychological disorders.

Sixth, the emphasis on the person of the therapist and the need for the therapist to exhibit the core therapeutic conditions in person-centered therapy is a tall order for any therapist. No therapist is perfect; hence, no therapist can experience and express unconditional positive regard and empathic understanding all the time to all clients, with therapist congruence required as well. The other danger is the possibility that a person-centered therapist will try so hard to empathically enter into the client’s internal frame of reference or subjective world of experience that the therapist ends up losing their own sense of self and clinical objectivity. Rogers himself had such an experience with a woman client, as mentioned earlier in this chapter.

Seventh, another closely related weakness of person-centered therapy is its claim to be nondirective and unconditional in the positive regard or valuing of the client. In reality, it is impossible for a therapist to be completely nondirective or value free and unconditional in positive regard for the client. Every therapist, as a person, has values, even if they are not stated explicitly or verbally. Values, of course, should not be imposed on the client, but they must be clarified and shared openly when appropriate. Even Rogers, in his therapy sessions with his clients, was observed to be directive at times, however gently, responding to them with more interest or empathy whenever they expressed their feelings more openly or seemed to be moving in a more actualizing direction.

Eighth, clients with physical disabilities (See 1985), more severe psychological disorders, or more specific symptoms—such as simple phobias, sexual dysfunction, and obsessive-compulsive disorders—may need more than what traditional person-centered therapists can offer in terms of the core therapeutic conditions. In the broader arena of dealing with racial conflicts and political tensions between nations, Rogers still focused on providing the core therapeutic conditions to facilitate group discussion and understanding. Although this practice may be helpful to some extent, it is a rather naive or simplistic approach to peacemaking that does not take into sufficient consideration other powerful historical, political, economic, cultural, tribal, and social forces that may make conflict resolution and constructive change very difficult, if not impossible.

Finally, although Rogers was instrumental in advancing empirical research in the process and outcome of therapy, and specifically of person-centered therapy, methodological weaknesses and flaws appeared in many of the earlier research studies that were conducted on person-centered therapy. Examples of such methodological weaknesses included the absence of no-treatment and attention-placebo control groups, and using assessment that depended on ratings of the client’s subjective experiences rather than the actual functioning or behavior of clients. However, more recent outcome studies on person-centered therapy have been better controlled and methodologically sounder.

A Biblical Perspective on Person-Centered Therapy

Person-centered therapy has several philosophical perspectives, similar to existential therapy, that can be appreciated from a biblical, Christian perspective, including its deep respect and genuine caring for the person and its emphasis on the individual’s freedom to choose and to grow. However, several significant and serious problems with person-centered therapy emerge when it is critiqued from a biblical perspective.

First, Rogers had too optimistic a view of human beings as innately good, with an actualizing or growth tendency. A biblical perspective on human nature will also emphasize the darker side of human nature, which is sinful and fallen (Jer. 17:9; Rom. 3:23). Human beings are therefore also capable of evil and sin. They do not automatically engage in constructive growth because of an innately good actualizing tendency.

Second, person-centered therapy’s supreme regard for the primacy and autonomy of the self or the individual is problematic because it can lead to self-worship and even self-obsession, which is at odds with true worship and love of God and loving community with others (Mark 12:29–31). The eventual result may be allowing and even encouraging the client to “slide into a self-gratifying, narcissistic world,” as Vitz (1994, 110) has pointed out. Hurding drew the following conclusion about Rogers and his person-centered therapy from a Christian perspective: “Francis Schaeffer has described humanity not only as a ruin, but as a glorious ruin. Rogers’ optimistic views, although compatible with the ‘glory,’ do not accord with the ‘ruin’ of mankind. Schaeffer’s ‘glorious ruin’ has become a ‘do-it-yourself’ structure where men and women do not bear the divine image but are made in the image of themselves. Sadly, such an edifice is built on the shaky ground of human autonomy and is doomed to ultimate collapse” (1985, 123).

Third, Rogers also viewed God or biblical authority as secondary, if not unnecessary in an individual’s self-actualization, placing the highest authority instead in the subjective experience of the person. Rogers wrote these strong words: “Experience is, for me, the highest authority. The touchstone of validity is my own experience. No other person’s ideas and none of my own ideas are as authoritative as my experience. It is to experience that I must return again and again; to discover a closer approximation to truth as it is in the process of becoming in me. Neither the bible nor the prophets—neither Freud nor research—neither the revelations of God nor man—can take precedence over my own direct experience” (1961, 23). Such a view of the ultimacy and highest authority of personal experience is seriously flawed from a biblical perspective, which emphasizes the ultimacy of God, and the highest authority in the Bible, God’s inspired Word. Person-centered therapy emphasizes and has a unique and unswerving commitment to the sovereignty of the human person (Raskin, Rogers, & Witty 2019, 149), whereas the Bible emphasizes the sovereignty of God.

Fourth, unconditional positive regard is often equated with agape love as described in Scripture (1 Cor. 13). Rogers himself described unconditional positive regard as a kind of love that is equivalent to agape (C. R. Rogers 1962, 422). Although his therapeutic conditions of congruence, unconditional positive regard, and empathic understanding as a triad come close to agape love, they are not equivalent to agape love (S. L. Jones & Butman 1991, 270). Agape love in Scripture is deeper, purer, divine love (1 Cor. 13), which is truly other centered and focused on the ultimate welfare and well-being of others. It also firmly holds people accountable to ultimate biblical truth, which does not ignore sin and evil. Agape love will therefore caringly and compassionately confront the client when necessary.

Fifth, person-centered therapy’s radical emphasis on the therapeutic relationship and the person of the therapist in effective counseling and therapy is overall a good one and consistent with the Bible’s focus on the importance of the relational dimension in life. However, the need for the Holy Spirit’s power and presence in producing the spiritual fruit or virtue of agape love in the therapist is crucial from a biblical perspective (see Tan 1999b), so that the genuinely caring therapist can maintain a deeply empathic relationship with the client in a healthy and holy way, without losing their sense of self or falling into a more sexualized version of love. The burden is too heavy for the imperfect human therapist to try, on their own strength, to be congruent with unconditional positive regard and empathic understanding all the time with every client.

Sixth, the ultimate human need is not for so-called unconditional positive regard from another human being, but for eternal agape love from God himself, which has been demonstrated through Jesus Christ, who loved us and gave himself for us in his death and resurrection (Gal. 2:20; Rom. 5:8). Furthermore, self-actualization of the deepest kind can only be realized and experienced in a personal relationship with Jesus Christ as our Lord and Savior. We then will discover our true self in Christ, as we surrender to him and his agape love, aligning ourselves with his will and his heart, which always desire the best for us and our ultimate and eternal welfare (see Benner 2003, 2004, 2005a). This is the Christian, biblical answer to unconditional positive regard and self-actualization. It holds in balance sin and grace, as Mark McMinn (2008) has emphasized, whereas Rogers seems to focus solely on grace without adequately dealing with the reality of sin and fallen human nature. In fact, as McMinn has noted, God’s grace is so amazing because our sin is so great.

Finally, agape love includes mutual love for others that involves loving others for their own sake and not for the sole purpose of self-actualization. Mutual love therefore requires a degree of self-transcendence that is not present in person-centered therapy and other humanistic therapies. Person-centered therapy is based on “nonhedonistic ethical egoism,” in which self-actualization is the major goal and regard for others is only a secondary consequence, as Browning and Cooper (2004, 81–82) have pointed out. They thus conclude that if we were to take seriously the humanistic therapies, including person-centered therapy, the eventual result would be more social turmoil and confusion rather than more health (85).

Research: Empirical Status of Person-Centered Therapy

Research on person-centered therapy can be categorized into two main types: empirical studies on the importance of the core conditions of congruence (genuineness), unconditional positive regard (warmth or acceptance), and empathic understanding (empathy) for therapeutic personality change; and empirical studies on the effectiveness of person-centered therapy compared to other therapies and/or control conditions, such as a no-treatment, wait-list control group, or an attention-placebo control group.

Research on the core conditions has included the development of scales to measure them, with subsequent criticisms of the scales and their shortcomings (see Barkham & Shapiro 1990). A more recent measure that may be especially helpful for assessing clients’ perceptions of the core conditions in therapy is the Client Evaluation of Counselor Scale (Hamilton 2000). Empirical evidence has shown a moderate relationship between empathy and positive therapeutic outcome in a meta-analysis of forty-seven studies (Bohart et al. 2002), a moderately positive relationship between unconditional positive regard (warmth) and therapeutic outcome (Farber & Lane 2002; see also W. R. Miller 2000), and a more mixed but still positive relationship between congruence (genuineness) and therapeutic outcome (M. H. Klein et al. 2002). However, such moderate to mixed relationships between these three core conditions and therapeutic outcome are not strong enough to conclude that they are necessary and sufficient conditions for therapeutic personality change (see also Beutler, Crago, & Arezmendi 1986; M. J. Lambert, DeJulio, & Stein 1978; Parloff, Waskow, & Wolfe 1978). They are certainly facilitative or helpful and thus important (Raskin 1992; see also Kirschenbaum & Jourdan 2005), but Rogers’s assertion that these core conditions are necessary and sufficient has not been supported by research to date. Nevertheless, as pointed out earlier, more recent meta-analyses and reviews of the research supporting psychotherapy relationships that work have concluded that empathy and positive regard (and affirmation) are demonstrably effective, and congruence/genuineness is probably effective (see Norcross & Lambert 2019, 632; see also Elliott, Bohart, Watson, & Murphy 2019; Farber, Suzuki, & Lynch 2019; Kolden et al. 2019).

Rogers seems to have overstated his case about the core therapeutic conditions. However, his view that the therapeutic relationship is the essential factor in effective therapy has received more consistent research support from empirical studies that have shown the therapeutic alliance to be more important overall than techniques across different therapies such as psychodynamic, cognitive, and humanistic (M. J. Lambert 1992; see also Elkins 2015; Duncan et al. 2010; Todd & Bohart 2006, 213; Wampold & Imel 2015). Therapist empathy in particular has been found to be an essential factor in effective therapy, regardless of the therapeutic modality; it also appears to be the strongest predictor of client therapeutic progress when client ratings of therapist empathy are used (J. C. Watson 2002). More recently, researchers interested in the neuroscience of empathy have found brain networks and structures, as well as neurochemicals, that are related to empathy or empathic responsiveness (Gonzalez-Liencres, Shamay-Tsoory, & Bruine 2013).

Research on the effectiveness of person-centered therapy, based on earlier meta-analyses, showed it had medium-sized effects (e.g., see Grawe, Donati, & Bernauer 1998; D. A. Shapiro & Shapiro 1982; M. L. Smith, Glass, & Miller 1980) and was as effective as psychodynamic and other therapies that were insight-oriented, but less effective than cognitive-behavioral therapies (see L. Greenberg, Elliott, & Lietaer 1994). More recent reviews have found person-centered therapy with adults to be more effective than no treatment or a placebo treatment, and as effective as cognitive-behavioral treatments, especially when researcher allegiance to their own favored therapy was controlled. In a meta-analysis of seventeen randomized clinical trials and a total of twenty-two comparative studies, person-centered therapy was virtually equivalent to cognitive-behavioral therapies, even with possible researcher allegiance-effects (Elliott, Greenberg, et al. 2013).

In a large, controlled outcome study conducted by theoretically neutral researchers at a National Health Service primary-care center in the United Kingdom over three years, with more than five thousand patients with anxiety and depression, results showed person-centered therapy, cognitive-behavioral therapy, and psychodynamic therapy were all equally effective (Stiles et al. 2008). Similarly, no significant differences were found between cognitive analytic therapy, cognitive-behavioral therapies, and person-centered therapy in another study (Marriott & Kellett 2009). A more recent study found low-intensity cognitive-behavioral therapy and time-limited person-centered therapy to be equally effective for mild depression (Freire et al. 2015). However, meta-analyses have shown that person-centered therapy is less effective than cognitive-behavioral therapies with children (Weisz et al. 1987; Weisz et al. 1995) and in treating anxiety disorders (Elliott, Greenberg, et al. 2013).

Overall, there is strong empirical evidence for the effectiveness of person-centered therapy with adults, with effectiveness comparable to many alternative therapies, but less effective than cognitive-behavioral therapy with children and in the treatment of anxiety (Prochaska & Norcross 2018, 122).

The research on the effectiveness of motivational interviewing has grown tremendously, with over 250 randomized clinical trials, much greater than the controlled outcome studies on person-centered therapy (see Prochaska & Norcross 2018, 122–123). In a large therapy outcome study called Project MATCH, two major randomized clinical trials were conducted in parallel, yet independently, and compared an early, brief version of MI (four sessions) to Cognitive-Behavioral Coping Skill Training (twelve sessions) and to Twelve-Step Facilitation Therapy (twelve sessions); 952 alcohol-dependent clients were seen in outpatient therapy in one study, and 774 clients were seen in aftercare therapy after their alcohol inpatient treatment in the other study (Project MATCH Research Group 1993, 1997). Of the four sessions, MI was a significant component of the first two sessions, with the last two sessions serving mainly as booster sessions (W. R. Miller, Zweben, et al. 1992). The brief form of MI was found to be as effective as the two longer treatments at each follow-up period.

Motivational interviewing has been found to have large effects even with the use of small or brief interventions (B. L. Burke, Arkowitz, & Dunn 2002). In fact, MI was as effective as longer and active treatments for a variety of target behaviors, but especially for substance or alcohol abuse, according to the results of a meta-analysis of seventy-two controlled clinical trials (Hettema, Steele, & Miller 2005; see also B. L. Burke, Arkowitz, & Menchola 2003). Ethnic-minority clients and resistant clients did especially well with MI and its supportive and nonconfrontational style (Hettema, Steele, & Miller 2005). MI can also be successfully taught to licensed substance-abuse professionals or counselors through systematic training, especially if it involves a clinical workshop plus feedback and coaching (W. R. Miller, Yahne, et al. 2004).

Empirical support from meta-analyses for the effectiveness of MI has been strongest for treating substance abuse among both adolescents and adults (Jensen et al. 2011; Smedslund et al. 2011), including significantly reducing drinking in clients (Hettema, Steele, & Miller 2005), as well as reducing or stopping smoking but not as substantially as with drinking (Lai et al. 2010). As pointed out earlier, MI has made a tremendous impact, being effectively applied to a broadening range of problems or disorders as well as populations and settings. There is research support for the effectiveness of MI in facilitating constructive health changes in medical care settings, for both children and adults, particularly in enhancing dental outcomes and dealing with HIV-related behaviors, body weight, and sedentary behaviors, but not eating disorders (Lundahl et al. 2013). MI is also effective in helping children with health issues such as asthma and diabetes, especially when both child and parent are involved in MI sessions and there is a cultural match between the therapist and the family (Gayes & Steele 2014).

Meta-analyses have also found that MI is effective for decreasing disordered gambling behaviors (Yakovenko et al. 2015), enhancing health behaviors of adolescents (Cushing et al. 2014), and decreasing consumption of alcohol in young people seen in emergency care settings (Kohler & Hofmann 2015; see Prochaska & Norcross 2018, 122–123; also J. Sommers-Flanagan & Sommers-Flanagan 2018, 137). MI is therefore a widely used and well-known empirically supported treatment for a broad range of problems and disorders, a contemporary adaptation and extension of person-centered therapy that has now received more empirical support than person-centered therapy itself.

The long-term effects of MI, however, have not endured over time, especially in follow-up evaluations of longer than twelve months. The effect sizes of MI compared to control groups significantly and quickly decreased over time in a meta-analysis of seventy-two clinical trials covering several different problems, except when MI was combined with another treatment such as cognitive-behavioral therapy (Hettema, Steele, & Miller 2005). MI may need to be combined with another empirically supported treatment for its effects to last over time (e.g., see Naar & Safren 2017).

Future Directions

On the one hand, person-centered therapy and its emphasis on the core therapeutic conditions and the therapeutic relationship as well as on the person of the therapist, rather than on technique, have been incorporated into many other approaches to counseling and therapy. On the other hand, person-centered therapy has also been challenged to adapt and integrate other approaches to therapy into its own practice, especially focusing-oriented, experiential, and existential therapies that share much in common with person-centered therapy (P. Sanders 2012). Although person-centered therapy in its traditional practice generally shuns techniques, there have been attempts to integrate behavioral interventions, such as relaxation techniques (Tausch 1990) and cognitive-behavioral therapy (Keijsers, Schaap, & Hoogduin 2000), with person-centered therapy.

Motivational interviewing has been an especially powerful and effective integration of person-centered therapy with techniques to help clients change behavior to enhance their physical and mental health or to overcome addictions. MI is a relatively brief or short-term approach that has recently shown afresh how therapist empathy and the autonomy of the client are crucial factors in effective counseling and therapy. More recently, Sylvie Naar and Steven Safren (2017) have integrated MI and cognitive-behavioral therapy in combining strategies for maximum effectiveness.

Rogers has thus often been ranked as the psychologist who has most greatly impacted the field of counseling and psychotherapy (D. Smith 1982) because of the pervasive way in which person-centered therapy has been incorporated into virtually every major approach to therapy. However, only a small percentage of clinical psychologists (2 percent), counseling psychologists (3 percent), social workers (1 percent), and counselors (10 percent) in the United States identified themselves as person-centered therapists in recent surveys (Prochaska & Norcross 2018, 3). Nevertheless, the development of person-centered therapy has progressed, despite Rogers’s own reluctance to form a formal association or school of person-centered therapy. The Association for the Development of the Person-Centered Approach (ADPCA) was inaugurated in September 1986 with a meeting at International House, University of Chicago, which Rogers attended five months before his death. The first workshop on the person-centered approach was held February 11–15, 1987, in Warm Springs, Georgia, a week after the death of Rogers, and it has been held annually in Warm Springs since 1987. The ADPCA also holds annual meetings; further information can be found at the organization’s website (www.adpca.org) (Raskin, Rogers, & Witty 2019, 115).

David Cain founded the Person-Centered Review in 1986; in 1992 it was renamed the Person-Centered Journal, with Jerold Bozarth and Fred Zimring serving as coeditors. The World Association for Person-Centered and Experiential Psychotherapy and Counseling was formed in 2000 in Lisbon, Portugal, at the International Forum for the Person-Centered Approach (for more information, visit www.pce-world.org). A peer-reviewed journal, Person-Centered and Experiential Psychotherapies, publishes theoretical, qualitative, and empirical articles that are of interest to humanistic researchers and practitioners (Raskin, Rogers, & Witty 2019, 115; see also Kirschenbaum & Jourdan 2005).

Person-centered therapy has not been as popular in the United States, but it is still going strong in Europe. Formal training in person-centered therapy in the United States is available only at Chicago Counseling Center, which currently offers a formal training program. More training programs in person-centered therapy are available in Europe and Great Britain. For example, the University of Strathclyde in Scotland has a well-developed model for training in person-centered therapy and uses a person-centered approach (Mearns 1997a, 1997b). There are approximately thirty-five training programs available in Great Britain; formal training programs are also offered in other countries, including France, Germany, Greece, Switzerland, and the Slovak Republic (Sharf 2016, 233–234).

Person-centered therapy, formerly client-centered therapy, has made and will continue to make significant contributions to the development and training of paraprofessionals or lay counselors, such as students doing peer counseling in schools and colleges, or lay counselors running self-help groups (e.g., Truax & Carkhuff 1967; C. E. Hill 2020). Paraprofessionals or lay counselors are often trained in Rogerian or person-centered therapy skills emphasizing empathy, unconditional positive regard, and genuineness (see also Tan & Scalise 2016).

A final trend concerns the continued work on using person-centered therapy principles with large groups to deal with political tensions, international conflict, and racial problems. Some successful work has been done in South Africa with governmental groups (Cilliers 2004) and with racially mixed South Africans in exile (Saley & Holdstock 1993). The Carl Rogers Institute for Peace in La Jolla, California, has continued to sponsor such work in conflict resolution and peacemaking (Sharf 2016, 232–233).

Person-centered therapy will continue to be a significant part of contemporary counseling and psychotherapy (see Cain 2010; Cain, Keenan, & Rubin 2016), but its distinctiveness may ironically be reduced as its influence on other approaches to counseling and therapy becomes even more pervasive and widespread. However, books on person-centered therapy and the person-centered approach continue to appear, reflecting a strong interest in person-centered therapy and Carl Rogers (e.g., see M. Cooper et al. 2013; Cornelius-White, Motschnig-Pitrick, & Lux 2013; Joseph 2017; Lago & Charura 2016; P. Sanders 2012).

Recommended Readings

· Cain, D. J. (2010). Person-centered psychotherapies. Washington, DC: American Psychological Association.

· Cooper, M., O’Hara, M., Schmid, P. F., & Bohart, A. C. (Eds.). (2013). The handbook of person-centred psychotherapy and counseling (2nd ed.). New York: Palgrave MacMillan.

· Joseph, S. (Ed.). (2017). The handbook of person-centred therapy and mental health: Theory, research and practice. (2nd ed.). Ross-on-Wye, UK: PCCS Books.

· Levitt, B. E. (Ed.). (2005). Embracing non-directivity: Reassessing person-centered theory and practice in the 21st century. Ross-on-Wye, UK: PCCS Books.

· Rogers, C. R. (1951). Client-centered therapy. Boston: Houghton Mifflin.

· Rogers, C. R. (1961). On becoming a person. Boston: Houghton Mifflin.

· Rogers, C. R. (1980). A way of being. Boston: Houghton Mifflin.

· Sanders, P. (Ed.). (2012). The tribes of the person-centred nation (2nd ed.). Ross-on-Wye, UK: PCCS Books.

· Thorne, B. (2003). Carl Rogers (2nd ed.). London: Sage.

Chapter 9

Gestalt Therapy

Frederick Solomon “Fritz” Perls (1893–1970) is often credited as the founder of Gestalt therapy. However, in a more recent account of the historical development of Gestalt therapy, Charles Bowman notes that two other names are crucial in the founding and establishing of Gestalt therapy: Laura Perls (Fritz’s wife, whose maiden name was Lore Posner) and Isadore From. Bowman emphasizes that “if Frederick Perls was the father of Gestalt therapy, Laura Perls was certainly the first lady and Isadore From the dean of the school” (2005, 11). From played an important role in the historical development of Gestalt therapy not only because of his deep commitment to Gestalt therapy and his articulate teaching of it, but also because Paul Goodman, another key figure in early Gestalt therapy, abandoned Gestalt therapy and had an untimely death at age sixty-one in 1972 (Bowman 2005, 11–12).

Gestalt therapy has roots in psychoanalysis but developed into a unique and independent approach to therapy that is grounded in the experiential and humanistic perspectives. It focuses especially on enhancing the client’s awareness, with the Gestalt therapist taking a very active role, fully engaging in authentic dialogue and relationship with the client. Gestalt therapy is a holistic, integrative approach to therapy that uses a variety of therapeutic techniques or interventions to help the client develop greater awareness in order to more freely choose their own direction in life (see Yontef, Jacobs, & Bowman 2019, 310).

Gestalt therapy focuses on experiential methods more than on merely verbal ones. Examples of well-known Gestalt therapy techniques include the empty chair, converting questions into statements, and experiential dream work (Parrott 2003).

Biographical Sketch of Fritz Perls

Fritz Perls, the main developer of Gestalt therapy, was born in 1893 in Berlin, the only son and middle child of lower middle-class German Jewish parents. His parents had frequent and intense arguments. Perls was close to his mother but did not respect his father, who was a heavy drinker and a traveling wine salesperson. He was also closer to Grete, his younger sister, but disliked Elsie, his older sister, who later died in a concentration camp (Shepard 1975).

Perls was difficult to manage as a child, creating trouble at school and at home. He failed seventh grade twice and even had to leave school for a while, during which time he briefly worked for a merchant. He returned to school when he was fourteen years old. Perls eventually managed to attend medical school and obtained his medical degree. He served as a medic in the German army during World War I.

After the war, Perls spent time working as an assistant with Kurt Goldstein in Frankfurt at the Institute for Brain Injured Soldiers. Perls learned a Gestalt psychology, or holistic perspective, from Goldstein, viewing the soldiers’ perceptions of themselves and their environment as crucial, with the whole consisting of more than merely the sum of its parts. Perls also met other people who later greatly influenced him, including Laura, whom he married in 1930.

Perls received psychoanalytic training at the Vienna and Berlin Institutes of Psychoanalysis. He was especially affected by Wilhelm Reich, his training analyst. Other psychoanalysts who influenced Perls at this time include Otto Fenichel, Karen Horney, and Helene Deutsch. Perls also came into personal contact with Carl Jung, Alfred Adler, and Sigmund Freud.

Due to the rise of Nazism and Hitler’s anti-Semitic policies in Germany in the 1930s, Perls, with his wife and their two-year-old daughter, fled to Amsterdam, where they lived for a year under miserable conditions. In 1934 they left Amsterdam for South Africa, where Perls accepted a psychoanalytic position in Johannesburg that Ernst Jones had announced. Perls established his psychoanalytic practice, and in 1935 founded the South African Institute for Psychoanalysis. He and Laura had a thriving psychoanalytic practice in Johannesburg for over a decade and enjoyed an affluent lifestyle. Perls was exposed to the holistic ideas of South African prime minister Jan Christian Smuts, who wrote an influential book, Holism and Evolution (Smuts 1926/1996), which strongly impressed Perls (Bowman 2005, 9).

Perls met Freud in 1936 at an international psychoanalytic conference for just a few minutes. Yet Perls described it as a negative experience in which he felt shock and disappointment at being so badly treated by Freud, who seemed to have brushed him off (F. Perls 1969c, 56). This was a significant experience for Perls, who then felt free to let go of traditional Freudian psychoanalytic thinking and begin developing his own unique approach to psychotherapy and counseling (with significant help from his wife, Laura): Gestalt therapy.

After living in South Africa for twelve years, Perls left in 1946 because of the rise of apartheid and moved to New York City. In 1952 he eventually established the New York Institute for Gestalt Therapy, together with Laura Perls and Paul Goodman. Perls lived in New York for nine years, after which he moved and traveled extensively, setting up Gestalt therapy training centers in US cities such as Los Angeles, San Francisco, and Miami, as well as in Canada, Japan, Israel, and other countries. He also separated from his wife during this time.

Perls then became involved with the Esalen Institute in Big Sur, California, and worked as an associate psychiatrist there from 1964 to 1969. In 1969 he moved to Cowichan Lake on Vancouver Island, in British Columbia, where he set up a therapeutic community, a special “Gestalt community,” as a training center where therapists could study with him for longer periods of time (e.g., for a few months). Perls died shortly thereafter, in 1970.

Some of the important books that Perls authored or coauthored in developing Gestalt therapy include Ego, Hunger, and Aggression, first published in 1947 (F. Perls 1969a), with Laura Perls contributing a couple of chapters, but her significant work was not sufficiently acknowledged, due partly to Fritz Perls’s own flamboyant and somewhat egotistical style (see Rosenfeld 1978); Gestalt Therapy: Excitement and Growth in the Human Personality, coauthored with Ralph F. Hefferline and Paul Goodman in 1951 (F. Perls, Hefferline, & Goodman 1994); Gestalt Therapy Verbatim (F. Perls 1969b); and In and Out of the Garbage Pail (F. Perls 1969c), which includes much autobiographical material summarized in this biographical sketch of Fritz Perls (see also Sharf 2016, 248–250; Parrott 2003, 202–203). Two other books were published posthumously: The Gestalt Approach (F. Perls 1973) and Legacy from Fritz (Baumgardner 1975).

Laura Posner Perls (1905–1990), wife of Fritz Perls, deserves recognition as a cofounder and developer of Gestalt therapy. She was born in Pforzheim, Germany. Music and modern dance were crucial parts of her life, both as a child and as an adult. She was a gifted pianist, with a varied and rich educational background, having studied law, Gestalt psychology, philosophy, and psychoanalysis. She cofounded the New York Institute for Gestalt Therapy in 1952, with Fritz Perls and Paul Goodman, and made significant contributions in the development of Gestalt therapy and in training Gestalt therapists. In fact, at the twenty-fifth anniversary of the New York Institute for Gestalt Therapy, she insisted that without the support and help of her and other friends, Fritz Perls would not have written or founded anything (see L. Perls 1990, 18).

Laura focused on relationships and the importance of support and contact, in contrast to Fritz’s emphasis on awareness and the individual. She also underscored the need for each Gestalt therapist to develop a unique personal style in therapy (Humphrey 1986; see also Corey 2021, 210).

Major Theoretical Ideas of Gestalt Therapy

Perspective on Human Nature

Gestalt therapy is an experiential therapy that seeks to increase the client’s awareness, especially of the here and now as well as the holistic and balanced integration of mind and body. Fritz Perls focused on helping clients to be self-sufficient so that they themselves could deal with their problems in living (F. Perls 1969b). To achieve this autonomy, Perls worked with clients in a directive, active, and even confrontational style to move them from depending on others or their environment (environmental support) to depending on themselves (self-support) and to facilitate the reintegration of disowned or blocked-off parts of their personalities.

Gestalt therapy assumes that clients have an inherent capacity to become more aware and in contact with their internal and external worlds, so that they are able to solve their problems in their own way and time and engage in self-regulation. It therefore has a somewhat positive perspective on human nature and its potential for change and growth and hence is rooted in existential and humanistic worldviews. Gestalt therapy’s emphasis on self-sufficiency and self-support in the self-actualization of the individual person, however, reflects a harshly realistic and somewhat pessimistic view of human relationships (S. L. Jones & Butman 1991, 307). This is more true of Fritz Perls’s original views, whereas contemporary Gestalt therapists emphasize more the importance of the interpersonal dimensions and a more mutual and dialogical relationship between the Gestalt therapist and the client.

Basic Theoretical Principles of Gestalt Therapy

Gerald Corey has summarized the basic theoretical principles and key concepts of Gestalt therapy as “Holism, Field Theory, the Figure-Formation Process, Organismic Self-Regulation, Contact and Resistances to Contact, The Now, Unfinished Business, Energy and Blocks to Energy” (2021, 201–205).

Holism

Gestalt therapists focus on the whole person, emphasizing that the whole is more than the sum of its parts. Thus, they do not regard any one part of a client’s experiences as more important than other parts. A client’s feelings, behaviors, thoughts, bodily sensations, dreams, and other experiences are all considered by the Gestalt therapist with equal weight. Gestalt is a German word meaning a complete whole that cannot be broken down into its parts without losing its essential nature, and Gestalt therapy is rooted in such holism.

Sidebar 9.1: Principles and Key Concepts of Gestalt Therapy

(see Corey 2021, 201–205)

1. Holism

2. Field theory

3. The figure-formation process

4. Organismic self-regulation

5. Contact and resistances to contact

6. The now

7. Unfinished business

8. Energy and blocks to energy

Field Theory

Field theory is closely related to holism. It emphasizes that one’s experience is influenced by one’s environment or context, that is, one’s field, with interconnected parts or elements. According to Gary Yontef, Lynne Jacobs, and Charles Bowman, “Holism asserts that humans are inherently self-regulating, that they are growth-oriented, and that persons and their symptoms cannot be understood apart from their environment. Holism and field theory are interrelated in gestalt theory. Field theory is a way of understanding how one’s context influences one’s experiences” (2019, 310).

The Figure-Formation Process

The notion of figure-formation process is based on the work of Gestalt psychologists with visual perception; it refers to how a person organizes their experience, moment by moment, depending on what comes to the foreground, that is, the figure; and what stays or recedes into the background, that is, the ground. This process is strongly influenced by the specific needs of a person at a specific moment of experience.

Organismic Self-Regulation

Organismic self-regulation is an individual’s capacity to move in the direction of growth and wholeness, by being consciously aware of or in touch with their present experience and needs or wants and working toward equilibrium. Organisms or individuals regulate themselves so that they experience equilibrium, growth, and change as urgent needs in the foreground are met. As Yontef, Jacobs, and Bowman emphasize, organismic self-regulation “means that people are inherently self-regulating, context sensitive, and motivated to solve problems. Needs and desires are organized hierarchically so that in health the most urgent need takes precedence. . . . When this need is met, the next need or interest becomes the center of attention” (2019, 320).

Contact and Resistances to Contact

Contact refers to the connection or relationship between a person and others and between a person and their environment. Contact involves moving and using the senses such as hearing, touching, seeing, and smelling. In Gestalt therapy, contact is viewed as crucial for growth and change. The Gestalt therapist therefore helps the client to have constructive and authentic contact with people and the environment, without the client losing a sense of self, so that the client does not become fused with others or the environment (Polster & Polster 1973). Appropriate healthy boundaries must be maintained for two main reasons: boundaries help people to be in contact, and they help people to separate so that fusion with others or the environment does not take place.

Fritz Perls (1969b, 1969c, 1970) described various levels of contact as five layers of neuroses that people must remove so that they can grow into psychological maturity by being in greater contact with others and their environment. These five layers are (1) the phony layer, which involves interacting with others in patterned or inauthentic ways, for example, being nice to others to get something from them; (2) the phobic layer, which avoids or denies emotional pain, for example, not admitting that a close relationship with someone has ended; (3) the impasse layer, that is, the point where a person feels stuck and afraid to make a move or change, for example, no longer being in love with one’s spouse and feeling stuck in the marriage; (4) the implosive layer, where one begins to be aware of one’s real self and experiences feelings more, but may still not do much about them; and (5) the explosive layer, where the person is more authentic and real, without pretense, and experiences feelings fully. A person will be in more authentic contact with self, others, and the environment if all five layers of neuroses are experienced and eventually stripped away, so that the person can experience the present more fully (see Sharf 2016, 254–255).

Contact boundaries are processes by which a person connects with or separates from others or the environment. Erving Polster and Miriam Polster (1973) have described the following types of contact boundaries: (1) body boundaries, which make certain bodily sensations off-limits or at least restricts them; (2) value boundaries, values that people hold strongly or rigidly and thus are difficult to change; (3) familiarity boundaries, which involve behaviors or events that occur frequently and routinely, without much thought or challenge, such as driving the same route to work every day for many years; and (4) expressive boundaries, which involve behaviors learned early in life, such as not yelling or whining, and—especially for men in American culture—not crying (see Sharf 2016, 255).

Contact boundaries can be broken, resulting in resistances to contact, so that one’s experiences of the present are curtailed. Erving Polster and Miriam Polster (1973) have described five types of contact boundary disturbances (see Sharf 2016, 256):

1. Introjection is the wholesale or uncritical acceptance of the views and values of others by an individual without further reflection or integration (e.g., a child introjecting or taking in all of the parents’ values and standards without questioning their validity).

2. Projection is the disowning of certain aspects of oneself by assigning them to others or the environment (e.g., blaming others for one’s own faults or mistakes).

3. Retroflection occurs when an individual does to oneself something that they actually want to do to someone else or does for oneself something that they actually want someone else to do for them (e.g., a man who engages in self-injurious behavior because he directs aggression at himself instead of outward toward others). Such self-directed retroflection can lead to depression and other psychosomatic symptoms (Corey 2021, 203).

4. Deflection involves different degrees of avoiding contact with others or the environment, as in talking incessantly about details and beating around the bush, talking constantly, and being extremely polite, all of which enable a person to avoid authentic contact with others or the environment.

5. Confluence happens when the boundary between oneself and others or the environment is lessened and blurred, so that the demarcation between inner experiences or feelings of oneself and the experiences and feelings of others in external reality is no longer clear (e.g., when the people involved in interpersonal relationships perceive that they all share exactly the same feelings and thoughts, and there is no conflict or anger whatsoever). Individuals who engage in confluence usually have an extreme need to be liked and accepted, and they therefore allow enmeshment and blurred boundaries to occur between themselves and others. Genuine contact with such persons is very difficult.

Gestalt therapists try to help their clients become aware of such contact boundary disturbances or resistances to authentic contact because they regard contact as crucial for genuine growth and self-actualization to take place.

The Now

Gestalt therapists emphasize the power of the now, the present, to help clients not become mired in the past or preoccupied with the future. This emphasis on the now is also evident in Gestalt therapy’s focus on the what and how, not on the why. Gestalt therapists engage in phenomenological inquiry, in which they ask clients what and how questions to help clients be in touch with the present moment and their immediate experience; they do not ask why questions, which often result in intellectualizing or cognitive reasoning that may impede the awareness of current experience. Gestalt therapists use a variety of therapeutic interventions to help clients focus on the here and now, and on the what and how. These therapeutic interventions are described later in this chapter.

Unfinished Business

Clients experience unfinished business when unexpressed feelings or unresolved issues from the past affect their present experience, for example, having unexpressed feelings, such as anger, hatred, fear, guilt, grief, and abandonment, of which they are not fully aware. Unfinished business can also be manifested in obsessions with sex or money or in problematic physical sensations and blockages within one’s body.

Gestalt therapists help their clients deal with unfinished business by encouraging them to stay with the impasse, or point where they are stuck; to fully experience their impasse and be in touch with their frustrations; and to accept themselves and their experiences more fully. As clients do this, without being rescued or too frustrated by the Gestalt therapist, they are better able to complete the Gestalt, that is, resolve the unfinished business from the past by feeling, thinking, and acting in new ways that are more self-actualizing. Gestalt therapy assumes that individuals have inherent self-actualization or growth-oriented tendencies and capacities.

Energy and Blocks to Energy

The Gestalt therapist pays special attention to the location of energy in the client, where and how it may be blocked, and how it may be better used by the client. Blocked energy is viewed as another manifestation of defensive behavior on the part of the client. Examples of blocked energy include tension in certain parts of the body, shallow breathing, not looking at people when interacting with them, cutting off certain sensations or feelings, and closing off or tightening one’s body.

The Gestalt therapist will help clients become more aware of where and how they are blocking their energy so that they can release their energy and use it in more constructive ways to facilitate growth and self-actualization. One way of doing this involves the Gestalt therapist encouraging clients to more fully experience tension in their bodies by exaggerating tension states such as tightened jaws and shaking legs rather than ignoring them (Corey 2021, 205).

Therapeutic Process and Relationship

Gestalt therapists do not have preset goals for clients. However, they do have a fundamental aim or goal of helping clients achieve deeper awareness and hence more freedom to choose (Corey 2021, 206) so that clients can grow toward self-actualization and personal integration. A good and meaningful therapeutic relationship is seen as essential in this process of helping clients (see Sharf 2016, 260).

Fritz Perls (1969b, 16) believed that awareness in and of itself can be curative for clients. Gestalt therapists therefore focus on enhancing clients’ awareness of both themselves and their environments. Joseph Zinker (1978, 96–97) has provided the following specific examples of increased awareness in clients: experiencing deeper awareness of their emotions, physical sensations, and environment; owning their experiences rather than making others responsible for them; learning to be conscious of their needs and having the skills to fulfill such needs without violating the rights of others; having more contact with all their senses (sight, hearing, smell, touch, and taste) so that they more fully experience themselves in every aspect; being able to support themselves rather than blaming others, complaining, or making others feel guilty; becoming more sensitive to their environments but with appropriate protection from what may be dangerous to them; and developing responsibility for their behaviors and consequences.

Richard Sharf (2016, 260) has noted that Gestalt therapy may be especially helpful for clients who are inhibited or overly socialized and constricted, such as phobic, depressed, or perfectionistic individuals.

The process of therapeutic change and growth in clients undergoing Gestalt therapy has been described by Miriam Polster (1987) as a three-stage integration sequence. The first stage, discovery, involves clients achieving a new view of themselves or a new perspective on an old situation. The second stage, accommodation, involves clients realizing that they have choices, and therefore they can experiment with new or different behaviors, especially with therapeutic support that is crucial at this stage. Finally, the third stage, assimilation, involves clients in learning how to impact their environment, including being more assertive in expressing and obtaining what they want from others or from their environment.

The therapeutic relationship is crucial in effective Gestalt therapy, which emphasizes an existential approach to the client. Gestalt therapy has been influenced by Carl Rogers and his emphasis on empathy and the need for the therapist to be sensitively attuned to the client’s subjective experience. It has also been influenced by Martin Buber’s emphasis on an authentic I-Thou relationship between the therapist and the client. More recently, Gestalt therapy has also been affected by intersubjectivity theory, which has stressed a more mutually respectful and interactional relationship between client and therapist in psychoanalytic therapy. A meaningful relationship with the therapist is therefore essential for facilitating growth in the client through deepened awareness (see Yontef, Jacobs, & Bowman 2019, 314–315). This therapeutic relationship has been described as dialogic, focusing on an authentic meeting and understanding of the other person, and not on any specific outcomes (see Hycner & Jacobs 1995).

Gestalt therapy has developed several unique therapeutic techniques to help clients develop deeper awareness. However, it is important to emphasize that the therapeutic relationship is seen as the crucial factor in effective Gestalt therapy, rather than simply the techniques (e.g., see Brownell 2016; Jacobs & Hycner 2009; G. Wheeler & Axelsson 2015; Yontef, Jacobs, & Bowman 2019). As Corey has observed, “Many contemporary Gestalt therapists place increasing emphasis on factors such as presence, authentic dialogue, gentleness, more direct self-expression by the therapist, decreased use of stereotypic exercises, and greater trust in the client’s experiencing” (2021, 210). Thus, Gestalt therapy today has gone beyond the therapeutic practices of its earlier history, when Fritz Perls emphasized confrontation and more-specific techniques.

Major Therapeutic Techniques and Interventions

Gestalt therapy emphasizes the experiential rather than the verbal, doing more than talking. It focuses especially on the here and now, the present moment. It has developed some of the most creative and innovative therapeutic techniques and interventions available (Parrott 2003). Before we examine the major Gestalt therapy techniques, it may be helpful to clarify the difference between experiments and exercises (or techniques). Exercises refer to set techniques that can be used to produce specific outcomes during a therapy session or to attain a therapeutic goal. Experiments are more spontaneous and emerge from the dialogic interaction between the Gestalt therapist and the client. They help to facilitate experiential learning for clients and are one-of-a-kind interventions creatively tailored for specific clients. Experiments have often been confused with exercises (Melnick & Nevis 2005).

The experiment is a crucial and foundational part of Gestalt therapy as it is practiced today (Brownell 2016; G. Wheeler & Axelsson 2015). In full collaboration with the client, the Gestalt therapist creatively develops experiments to help the client experience deeper levels of awareness and emotions in order to gain fresh insight (Strümpfel & Goldman 2002). Miriam Polster (1987) has specifically focused on how an experiment can help a client work through their sticking points, by encouraging spontaneous and innovative ways of dramatizing an internal conflict or sticking point, in the safety and immediacy of the therapy session. Examples of such Gestalt therapy experiments include visualizing a future event that may be threatening, role-playing an interaction between the client and another important person, playing out the experience of a painful memory, role-playing one’s father or mother, and creating a dialogue between two parts of an individual that are in conflict. Experiments must be implemented in a supportive, timely, and customized way for a specific client. They should challenge a client without overwhelming them (see Corey 2021, 212–213).

Important therapeutic techniques or interventions often used in Gestalt therapy (see Mann 2021) include experiential dream work; converting questions to statements; using personal pronouns; assuming responsibility; playing the projection; the empty-chair technique; making the rounds; exaggeration; confrontation; asking, “May I feed you a sentence?” (see Parrott 2003, 213–217); and staying with the feeling (see J. Sommers-Flanagan & Sommers-Flanagan 2018, 156).

Sidebar 9.2: Techniques of Gestalt Therapy

(see Parrott 2003, 213–217; J. Sommers-Flanagan & Sommers-Flanagan 2018, 156)

1. Experiential dream work

2. Converting questions to statements

3. Using personal pronouns

4. Assuming responsibility

5. Playing the projection

6. The empty-chair technique

7. Making the rounds

8. Exaggeration

9. Confrontation

10. “May I feed you a sentence?”

11. Staying with the feeling

12. Experiential Dream Work

Dream work is a crucial part of Gestalt therapy. Fritz Perls believed that the dream is “the royal road to integration” (F. Perls 1969a, 66) and the mainstay of Gestalt therapy. However, Gestalt therapists do not engage in the interpretation of dreams. Instead, they believe that dreams are to be experienced; hence, Gestalt dream work is experiential and not analytical. The client is fully responsible for their dreams and shares them with the Gestalt therapist, who then encourages the client to identify with every aspect of each dream. Every character and detail of each dream is viewed as representing some part of the client that the client needs to own in fully experiencing the dream.

Gestalt experiential dream work involves four steps. First, the client describes the dream to the therapist. Second, the client is asked by the therapist to talk about the dream in the present tense instead of the past tense. Third, the client is encouraged to play the role of a director, organizing the dream like a play and describing its details and sequence, including its characters and objects. Finally, in the fourth step, the client acts out the dream as fully as possible, identifying with each character or object by using “I” language to personalize the identification and more deeply experience the dream. Perls also often asked his clients to add the following repetitive statement after each brief phrase describing a dream (or fantasy or image): “and this is my existence,” even though this may initially feel fake or silly to the client. He did this to help facilitate deeper client insight and experience of the dream (see J. Sommers-Flanagan & Sommers-Flanagan 2004, 163–164).

Gestalt experiential dream work is meant to help clients be more in touch with themselves, especially parts of themselves that they may have blocked from awareness, by identifying personally with different characters or objects and details in their dreams. Clients can then become more integrated persons as they grow in their self-awareness and take more responsibility for themselves and their experiences.

Converting Questions to Statements

The Gestalt therapist, following Perls, often asks clients to change their questions into statements, so that clients cannot hide behind questions that may reflect manipulation, denial of personal responsibility, passivity, and so forth. For example, when a client asks a question like “Do you really feel that?” the Gestalt therapist will ask the client to convert this question into a statement, so that the client says: “I don’t think you really feel that.” This technique of asking clients to convert questions to statements is meant to help clients acknowledge their own beliefs and feelings and take responsibility for them.

Using Personal Pronouns

Clients tend to talk about themselves by using words such as “you,” “we,” or “it,” thereby distancing themselves from fully experiencing what they are describing about themselves. For example, a client might say: “It’s so boring to attend this meeting.” The Gestalt therapist will then ask the client to use the personal pronoun “I” instead of the word “it,” and say instead: “I find it is so boring to attend this meeting,” thus owning their own experience or behavior and taking responsibility for it.

Assuming Responsibility

Employing a method similar to using personal pronouns, the Gestalt therapist also often instructs clients to add the following statement at the end of every expression of feelings or thoughts: “And I take responsibility for it.” To use the previous example again, the client will now say: “I find it so boring to attend this meeting, and I take responsibility for it.” Another method for helping clients to assume responsibility is to ask them to change the word “can’t” to “won’t,” and the word “but” to “and.” For example, a client might say: “I can’t do that!” The Gestalt therapist will ask the client to say instead: “I won’t do that!” As another example, a client might say: “I want to attend the concert, but I haven’t purchased a ticket for it yet.” The Gestalt therapist will instruct the client to say instead: “I want to attend the concert, and I have not purchased a ticket for it yet.” These techniques for helping clients assume responsibility are important because clients eventually realize that they do not have to depend so much on others or the environment.

Playing the Projection

Clients often project onto others what they themselves are experiencing or struggling with, but at an unconscious level. Gestalt therapists will ask clients to role-play or act out a specific quality they don’t like in someone else, that is, “play the projection.” For example, if a client says, “My friend is a really loud and aggressive person,” the Gestalt therapist will ask the client to take on the role of the friend and act in a loud and aggressive way. Perls believed that projection frequently occurs in interpersonal relationships. Playing the projection is an important Gestalt intervention to help clients acknowledge their projections and gain deeper awareness of their own experience and behavior, including their tendency to project onto others.

The Empty-Chair Technique

The empty-chair technique is the best-known and best-researched Gestalt therapy intervention (L. S. Greenberg & Foerster 1996; L. S. Greenberg & Malcolm 2002; Paivio & Greenberg 1995). It has been used not only in Gestalt therapy but also in other approaches to therapy (e.g., see N. E. Carpenter et al. 2016; J. C. Watson et al. 2011). Gestalt therapy uses the empty-chair technique in two ways to help clients become more aware of and reclaim parts of themselves that they may have blocked from consciousness. The first way involves instructing the client to role-play two polarized parts of their personality that are in conflict with each other: the “top dog,” representing the legalistic side or the righteous conscience or superego of one’s personality, and the “underdog,” representing the side that is weak and often frustrating to the person (F. Perls 1973, 125). The top dog is therefore the moralistic, demanding, and critical side of the client; the underdog is the passive, weak, and needy side (Strümpfel & Goldman 2002). In the empty-chair technique, the Gestalt therapist asks the client to sit in one chair and assume the role of the top dog talking to the empty chair in front of the client. The client is then asked to move to the previously empty chair and assume the role of the underdog talking to the chair that is now empty. The client moves from chair to chair, repeating this process several times while guided by the Gestalt therapist. Eventually, the client experiences both sides or polarities of their personality that are often in conflict and begins to better integrate the top dog and underdog parts within, finding more-effective compromise solutions to unfinished business (L. S. Greenberg & Malcolm 2002; see also Elliott, Watson, et al. 2004).

The second way of using the empty-chair technique in Gestalt therapy involves asking a client who is experiencing a real-life conflict with a significant other to role-play the two people involved in the conflict (i.e., the client and someone else) by using two chairs facing each other. For example, if a woman client is having a conflict with a rude brother, with feelings of hurt and anger toward this brother, she is first asked to assume the role of herself and express those feelings to the brother, whom she imagines to be sitting in the empty chair across from her. She is then instructed to move into the previously empty chair, take on the role of the brother, and speak to the client now imagined to be sitting in the opposite chair. This process is repeated several times with the guidance of the Gestalt therapist, so that the client is helped to more fully experience the conflict, with deeper awareness of her own feelings as well as more empathy for the feelings of her brother. This can help the client to reintegrate parts of herself that may have been blocked before.

The empty-chair technique seems to be more effective in helping clients resolve unfinished business when it involves highly emotional experiencing and processing by the client (L. S. Greenberg & Malcolm 2002).

Making the Rounds

This Gestalt therapy technique is often used in the context of group therapy. For example, if a client says, “Everyone is so cold in this group,” the Gestalt therapist will ask the client to go around and say this to each member of the group: “You are so cold.” The client thus engages in “making the rounds” with each member of the group and thereby more fully experiences their own inner feelings and becomes more aware of what is happening within. Making the rounds can also be used with positive feelings, not just with negative feelings.

Exaggeration

This Gestalt therapy technique involves the therapist asking the client to exaggerate, act out more intensively and expansively, a specific behavior, usually nonverbal, to help the client become more in touch with underlying feelings and thus increase self-awareness. For example, a client may start biting their fingernails while talking about the harsh boss at work. The Gestalt therapist, in using exaggeration as an intervention, will ask the client to bite their fingernails even more while continuing to talk about the boss, and to focus more attention on what this exaggerated behavior of fingernail biting feels like and may mean to the client. Previously blocked feelings of fear and anger toward the boss may surface into the client’s awareness.

Confrontation

When clients show discrepancies in their feelings and behaviors, the Gestalt therapist will often use the technique of confrontation, by pointing out these contradictions to the client. The therapist will use how and what questions rather than why to avoid intellectualization or rationalization. For example, a client may say very softly, “I don’t like it when my mother criticizes me for little, petty things.” The Gestalt therapist will then point out the discrepancy between the very soft voice and the strong feeling of dislike and possibly even anger at the mother by asking the client, “What are you experiencing deep inside when you state your dislike of your mother’s criticism of you in such a soft voice? How are you really feeling?” This gentle confrontation can help the client become more aware of inner feelings and better integrate them.

May I Feed You a Sentence?

A Gestalt therapist may suggest a sentence for the client to repeat, to help the client verbalize an underlying, implicit message or attitude that is unclear. The therapist will then say to the client, “May I feed you a sentence?” and ask the client to repeat that sentence. For example, if the therapist senses that the client is having some trouble verbalizing feelings of being hurt by a friend, the therapist may say to the client: “May I feed you a sentence?” and “Here’s the sentence I want you to repeat after me: ‘I feel deeply hurt and disappointed by my friend Joan, who is very precious to me.’” The client will repeat this sentence aloud and, in doing so, may become more aware of their own inner feelings and grow in insight as well.

Staying with the Feeling

Gestalt therapists use this general strategy with all clients to help them stay with and experience their immediate feelings in the present, instead of blocking them or avoiding them.

Several specific techniques can be used in Gestalt therapy to help clients stay with the feeling. First, specific questions can be used repeatedly, such as “What are you experiencing now?” or “What are you aware of at this very moment?” Second, the therapist can instruct clients to let their feelings speak for themselves or to give “voice” to their feelings (e.g., “Let your depression have a voice and speak now”). Third, the therapist can encourage clients to act out or role-play their feelings right in the session at the moment of experiencing them. Finally, the therapist may simply tell the client to “stay with that,” referring to whatever the client may be feeling or experiencing at that moment (see J. Sommers-Flanagan & Sommers-Flanagan 2018, 156).

Staying with the feeling helps clients to be more in touch with their previously blocked feelings and to own them and reintegrate them into their current awareness and functioning.

Gestalt Therapy in Practice

This hypothetical transcript of a small part of a Gestalt therapy session demonstrates the Gestalt therapist’s use of assuming responsibility as well as the empty-chair technique to help the client take more responsibility and also to be more aware of the top dog and underdog parts that are in conflict and need to be more integrated (e.g., by coming up with compromise solutions).

Client: I have an article to write for a scientific journal, with a deadline in a few days. I’ve tried to write it, but I get stuck. . . . I just can’t do it!

Gestalt Therapist: Please change the word “but” to “and,” and the word “can’t” to “won’t,” and make your statement again!

Client: OK . . . I’ve tried to write it, and I get stuck. . . . I just won’t do it!

Gestalt Therapist: I would like you to repeat your statement but this time add “And I take responsibility for it” at the end of the statement.

Client: Well, I’ll try again. . . . I have tried to write it, and I get stuck. . . . I just won’t do it! And I take responsibility for it!

Gestalt Therapist: How do you feel now? What’s going on within you at this moment?

Client: I’m feeling my stuckness more and also that I’m responsible for it, . . . that I’ve somehow chosen not to write the article instead of that I cannot write it, . . . that maybe I can do something about it, . . . and yet I still struggle inside me with a part of me that says, “Come on, you have to do it!” and another part of me that says, “Yes, I’ll try, but I don’t think I can make it!” It’s a real conflict!

Gestalt Therapist: It’s tough to have these two sides or parts of you fighting each other, like a top dog demanding that you get the article done and an underdog helplessly pleading weakness and inability to do so. Let me suggest an experiment for you to try that may help you deal with these two sides of yourself. You’re now sitting in one chair, and I would like you to speak and express the part of you that is harshly demanding that you finish writing the article by the deadline, the top dog in you, in this chair. Then move to the empty chair across from you, and in this second chair I would like you to speak and express the part of you that is weak and helpless, feeling that you can’t make it by the deadline, the underdog in you. I would like you to continue this dialogue or interaction between the two parts of you by switching back and forth between the two chairs, and let’s see what happens. OK?

Client: OK, I’ll try.

Gestalt Therapist: OK, go ahead and speak to the other part of you in the empty chair as you look at the empty chair.

Client: (sitting in the first chair) You really need to pull yourself together and get this article written on time. You’re wasting a lot of time worrying about it, and then watching a lot of TV as an escape. You’re being lazy and flaky again. You will really blow it if you don’t get this article done! Your chances of getting promoted to associate professor will be badly affected! So, come on and get going and just do it!

Gestalt Therapist: Good! Now move into the empty chair and express the other part of you while looking at the first chair you sat in.

Client: (moves to the empty chair and sits in it) OK, OK . . . I know I have to finish writing the article by the deadline, . . . but it’s too much work and too much pressure for me! I don’t think that I can finish it on time. . . . I only have a few days left before the deadline, and this is driving me crazy! I need a break, and that’s why I watch TV. I’m not flaky or lazy, and I do want to get promoted in my department!

Gestalt Therapist: OK, now move back to the first chair and switch back to the harsh, demanding part of you again, and see what happens. . . .

Critique of Gestalt Therapy: Strengths and Weaknesses

Gestalt therapy has several strengths. First, it emphasizes focusing on the here and now and experiencing the present moment. Many clients are stuck in the past and its pain and regrets or are preoccupied with worry about the future and its concerns. The Gestalt therapist’s focus on helping clients experience the now, in the present moment, is a good corrective and balance. It is also consistent with the contemporary emphasis on mindfulness, attending to present experience, with gentle acceptance in various approaches to therapy (see, e.g., Baer 2006; K. W. Brown, Creswell, & Ryan 2015; C. K. Germer, Siegel, & Fulton 2013; see also chap. 13 of this book on mindfulness and acceptance-based cognitive-behavioral therapies). Second, Gestalt therapy highly values awareness and being in touch with one’s feelings and present experience. This is a good corrective to therapeutic approaches that tend to overemphasize the cognitive processes of thinking, which can lead to the client intellectualizing and rationalizing as defenses against painful experiences that they may want to deny, distort, or disown.

Third, Gestalt therapy attempts to facilitate self-actualization or self-regulation in the client, who is assumed to have an inherent capacity toward integration and self-actualization. The client therefore ultimately depends much less on others or the environment to fulfill their needs and becomes more self-reliant and self-sufficient. However, while growing to be more mature and less dependent on external sources of support can be a healthy development for a person, there is a danger of falling into gross individualism and self-centeredness.

Fourth, Gestalt therapy focuses on helping clients finish or resolve unfinished business in their lives. The Gestalt therapist will thus confront clients (even if more gently in contemporary Gestalt therapy than Fritz Perls did) with their self-deceptions, layers of neuroses, and other discrepancies; the purpose is to frustrate their neuroses so that they can face reality and grow toward self-actualization. Authenticity is crucial in Gestalt therapy, which is also a form of existential therapy that is humanistic and experiential. Clients are therefore helped to stop playing games with themselves and others.

Fifth, Gestalt therapy has more recently emphasized the importance of the therapeutic relationship and a more reciprocal, gentle, and dialogical interaction between the therapist and the client. This is a good balance and a corrective to the often flamboyant, authoritarian, and even abrasive style of Fritz Perls and his earlier followers in their practice of Gestalt therapy, which was more confrontational and less relational.

Sixth, Gestalt therapy has developed several helpful and creative therapy interventions or methods, including the widely known and researched empty-chair technique. As an existential and experiential therapy, it has more concrete and specific therapy interventions than other existential therapies. However, this is both a strength and a potential weakness since Gestalt therapy techniques can be misused when they are insensitively applied to clients, without appropriate understanding or training.

Seventh, Gestalt therapy is a flexible, open, and creative approach to therapy, and it can be adapted for use with different ethnic groups and cultures, nationally and internationally, especially in group work and group therapy contexts (see Corey 2021, 218–220; see also P. Cole & Reese 2018; Feder 2013).

Finally, Gestalt therapy has recently been subjected to more empirical research evaluating its effectiveness or efficacy in terms of therapeutic outcomes (see, e.g., Strümpfel 2006; see also Elliott, Greenberg, & Lietaer 2004; Elliott, Greenberg, et al. 2013; Roubal 2016). Fritz Perls was not interested in conducting such research in the earlier years of Gestalt therapy, instead emphasizing individual cases with subjective reports of therapeutic growth. However, the empirical evidence related to Gestalt therapy has grown in recent years, including more research on specific therapeutic interventions such as the empty-chair technique.

Gestalt therapy also has several weaknesses. First, as a humanistic and existential therapy, it tends to overrate human nature and an individual’s inherent capacity to grow toward self-actualization or self-regulation. Its focus on helping a client become more self-sufficient can easily lead to narcissistic self-centeredness and gross individualism. Gestalt therapy does not sufficiently consider the darker side of human nature, which is capable of evil and destructive behavior such as crime and war (Parrott 2003). However, it does confront clients with their self-deception, layers of neuroses, and discrepancies that reflect efforts at denying, disowning, or distorting reality in their lives.

Second, Gestalt therapy’s emphasis on focusing on the here and now and one’s experience in the present moment may result in a client not adequately dealing with the past or the future. Clients are motivated or affected by future goals and concerns as well as by past issues. Although Gestalt therapists do work with clients on resolving or completing unfinished business from the past, their emphasis is still on the present experience of the client. Such a focus can overemphasize present experience, resulting in therapy that is imbalanced or insufficiently holistic.

Third, Gestalt therapy’s focus on enhancing the client’s awareness and helping the client more fully experience feelings can also be imbalanced, since this focus usually ignores or even negates rational thinking. One’s thoughts can affect one’s feelings and behaviors, as the cognitive-behavioral therapists have emphasized. Gestalt therapy’s eschewing of rational thinking or cognition is a weakness. Reasonable or rational thinking is not always equivalent to rationalization or intellectualization as a defense, as Fritz Perls assumed and asserted in his anti-intellectual stance (F. Perls 1969a). Another related weakness is the “philosophical sloppiness” of Gestalt therapy’s theoretical views, which are not rigorously systematic or comprehensive and are philosophically weak. Gestalt therapy is primarily a pragmatic approach to therapy that combines ideas and methods from various sources but not always in a coherent way (see Day 2004, 230). Some of the terms Gestalt therapy uses, borrowed from Gestalt psychology and other existential schools, are also sometimes loosely used with meanings that may be somewhat different from their original sources.

Fourth, Gestalt therapy, although more gentle and relational now than in its earlier years, is still a somewhat confrontational and directive therapy. Clients are confronted with their unfinished business, defenses, and layers of neuroses and self-deception. There is a danger of such confrontation being overwhelming for some clients and therefore potentially harmful. This is a potential danger for all confrontational, intensely emotional types of therapy (Lilienfeld 2007; see also D. McKay & Jensen-Doss 2021; Tan 2008c).

Fifth, Gestalt therapy may be helpful to clients who are inhibited and out of touch with their deeper feelings and impulses, but it may not be appropriate for those who are impulsive, reckless, and insensitive to others’ feelings and needs, such as sociopaths, delinquents, and individuals who lack empathy for others (see Day 2004, 221–222; Shepherd 1970).

Sixth, Gestalt therapy, unlike some other approaches to existential therapy such as logotherapy (see, e.g., Wong et al. 2007), does not adequately address the larger questions of life concerning meaning and purpose in life. Gestalt therapists do not ask “Why?” but pose how and what questions. However, many clients do struggle with the existential questions of life that are related to fear of death and meaning in life. Asking the bigger why questions may therefore be crucial at times for some clients, and Gestalt therapy is weak in dealing with such questions (see S. L. Jones & Butman 1991, 313).

Seventh, although Gestalt therapy has developed some useful specific techniques such as the empty-chair technique, a weakness lies in therapists’ misusing or abusing them. Inexperienced or inadequately trained therapists can apply such Gestalt techniques in a simplistic and mechanical manner, without being sufficiently sensitive to clients and their actual needs and struggles. The appropriate and ethical use of Gestalt therapy interventions must be safeguarded (see R. G. Lee 2004) because of the potential harm clients can suffer when these techniques are misused or abused.

Eighth, although Gestalt therapy can be flexibly adapted for use with other ethnic groups or cultures, it nonetheless tends to be saturated with middle-class North American culture and values, focusing on self-actualization, self-sufficiency, and even self-centeredness. Clients from countries with more collectivistic and collaborative cultures may value family and social relationships more highly. In fact, some Asian cultures view an emphasis on self-actualization negatively because it is seen as being detrimental to a person’s healthy development (Todd & Bohart 2006, 215). A related weakness in Gestalt therapy’s focus on the individual is the tendency to neglect other influential factors that can also contribute to the development of psychopathology in people, such as social, cultural, political, economic, spiritual, and biological forces.

Finally, while empirical research has increased in recent years on the effectiveness or efficacy of Gestalt therapy, it is still limited. Although more research has been done on specific Gestalt interventions such as the empty-chair technique, additional controlled outcome research is needed to evaluate the effectiveness of Gestalt therapy as a whole for various clients with different disorders (see Barber 2006; Brownell 2008).

A Biblical Perspective on Gestalt Therapy

Gestalt therapy has several strengths that have already been mentioned, some of which are consistent with a biblical perspective or worldview. For example, the emphasis on being real and authentic, confronting and overcoming self-deception and layers of neuroses, and taking responsibility for oneself and one’s growth can be appreciated from a biblical, Christian perspective, which also affirms the need to face and experience truth in order to be set free (John 8:32) and to take responsibility for one’s choices and behaviors. The focus on the here and now and present experience, in the moment, is also a good corrective to being stuck in the past or preoccupied with worries about the future. It is somewhat consistent with a biblical, Christian view of attending to the “sacrament of the present moment” (Caussade 1989), focusing on one day at a time and not worrying about tomorrow, as Jesus taught in the Sermon on the Mount (Matt. 6:34). However, Gestalt therapy also presents several significant problems when it is critiqued from a biblical perspective.

First, the focus of Gestalt therapy on the here and now, popularized even more by Eckhart Tolle (2005) with the support of Oprah Winfrey, can be overemphasized to the point of negating a biblical hope for the future, including eternity in heaven because of what Jesus Christ has done for those of us who believe in him. True and eternal hope encourages an appropriate and biblical focus on the future to help us live more faithful and obedient lives now on earth for God and his kingdom (see Matt. 6:33; Rom. 8:18; 2 Cor. 4:16–18). There are other serious problems with Tolle’s views from a biblical perspective (see Abanes 2008).

Second, another serious problem from a biblical perspective is Gestalt therapy’s emphasis on present experience to deepen awareness, valuing intense emotional processing, and negating the importance of thinking, including rational and intellectual processing. The Bible instead emphasizes the whole person and values the importance of thinking (as well as feelings and behaviors) in the transformation of the person. We are transformed by the renewing of our minds (Rom. 12:2), and we are set free through knowing and experiencing the truth (John 8:32). Biblical thinking and sound doctrine are crucial to true Christian spirituality and personal transformation into deeper Christlikeness, which is God’s ultimate will for us (Rom. 8:29).

Third, Gestalt therapy holds too positive a view of human nature, with its assumption that individuals have an inherent capacity to grow toward self-regulation or self-actualization. A biblical perspective on human nature will also consider the darker side of human nature, which is sinful, fallen, and capable of evil (Jer. 17:9; Rom. 3:23). As human beings, we are not simply inclined toward growth and self-actualization. We also have a tendency toward sin and evil, from which only Jesus Christ can adequately redeem and heal us.

Fourth, Gestalt therapy, as advocated by Fritz Perls, emphasizes individual self-actualization or self-regulation so much that it can easily deteriorate into gross individualism and even sinful self-worship (Vitz 1994). The well-known Gestalt prayer written and popularized by Fritz Perls in the 1960s captures this attitude well:

I do my thing and you do your thing.

I am not in this world to live up to your expectations,

And you are not in this world to live up to mine.

You are you and I am I. If by chance we find each other, it’s beautiful.

If not, it can’t be helped. (see Day 2004, 229)

A biblical perspective instead emphasizes agape love (1 Cor. 13), loving God and loving others (Mark 12:29–31). The interdependent and community aspects of human interpersonal interaction and functioning are therefore viewed as essential to human fulfillment and harmony (see 1 Cor. 12), needed in overcoming the sinful tendency toward selfishness and gross individualism (see also Phil. 2:3–4), which ultimately lead to isolation and moral decay. Similar to person-centered therapy, Gestalt therapy is based on “nonhedonistic ethical egoism” (Browning & Cooper 2004, 81), with its ultimate value of self-actualization or self-regulation, which reduces caring or concern for others to only a secondary consequence. True agape love, however, is characterized by self-transcendence and mutual love for others that involves loving others for their own welfare, and not for self-actualization itself. Such a degree of self-transcendence is not present in Gestalt therapy and the other humanistic therapies, which can eventually lead to more confusion and social turmoil rather than health (see Browning & Cooper 2004, 81–85).

Fifth, Gestalt therapy does not adequately deal with the larger existential and spiritual or religious questions about death and the ultimate meaning of life: the why questions (see S. L. Jones & Butman 1991, 313). A biblical perspective will seriously and authentically deal with these larger-meaning questions (see Wong et al. 2007), and it will center the answers ultimately in Jesus Christ as the way, the truth, and the life (John 14:6). Recent developments in Gestalt therapy, however, have included attempts to integrate generic or personal spirituality with Gestalt therapy (see, e.g., Ingersoll 2005).

Sixth, Gestalt therapy’s focus on subjective experience as the foundation of one’s life and growth toward self-actualization negates moral absolutes of right and wrong, thus resulting in a radical “situational ethics.” There is no ultimate truth or meaning in life and there are no moral absolutes to follow (see Hurding 1985, 206–207). A biblical perspective will uphold the absolute truth and moral absolutes revealed in the Bible, the inspired Word of God (Matt. 24:35; 2 Tim. 3:16), yet with careful interpretation of Scripture.

Gestalt therapy therefore presents several serious problems from a biblical perspective. However, as Stanton L. Jones and Richard Butman have commented, “Perhaps Gestalt therapy has something to teach us about what it means to love one another in truth and honesty” (1991, 321), in what Clinton McLemore (1984) has called “honest Christianity,” because of its emphasis on being real and authentic and confronting and overcoming self-deception or layers of deceit. Yet the Bible’s balanced teaching is that truth should always be spoken in love, so that we will grow up into Christ and deeper spiritual maturity (Eph. 4:15). A recent book on Christianity and Gestalt therapy focuses on the presence of God in human relationships from a more phenomenological perspective (Brownell 2020).

Research: Empirical Status of Gestalt Therapy

Mary Lee Smith, Gene Glass, and Thomas Miller (1980), in an earlier quantitative review of research on the outcomes of various approaches to therapy, found that Gestalt therapy had an average effect size of .64, which is in the moderate effect range. Such an effect size means that Gestalt therapy is better than no treatment but not much better than placebo interventions. More-recent reviews of the limited number of outcome studies on Gestalt therapy have concluded that it is significantly better than no-treatment and wait-list control groups, with no direct comparisons to an “active” placebo group (Elliott, Greenberg, & Lietaer 2004; Elliott, Greenberg, et al. 2013). Gestalt therapy has been evaluated with other forms of therapy in five direct comparisons, with Gestalt therapy showing slightly inferior outcomes in four of them (L. Greenberg, Elliott, & Lietaer 1994; Elliott, Greenberg, et al. 2013). Gestalt therapy is therefore more effective than no treatment, but it is not more effective than other forms of therapy with adult clients and may be a bit less effective than cognitive-behavioral therapies. Its effectiveness with children and adolescents has not been adequately researched to date (see Prochaska & Norcross 2018, 148–149).

In the comparisons of Gestalt therapy and other experiential therapies with cognitive-behavioral therapies, the slight statistical superiority of cognitive-behavioral therapies may have been partly due to methodological problems, especially what has been called the researcher-allegiance effect (L. Luborsky et al. 1999). Robert Elliott, Leslie Greenberg, and Germain Lietaer (2004) have noted that a researcher-allegiance effect occurs when advocates of experiential therapies, including Gestalt therapy, find significantly better outcomes of these therapies compared to cognitive-behavioral therapies. Similarly, this effect occurs when proponents of nonexperiential therapies, including cognitive-behavioral therapies, report significantly better outcomes for such therapies compared to experiential therapies, including Gestalt therapy. When such researcher-allegiance effects were controlled, the slight superiority of cognitive-behavioral therapies over Gestalt therapy and other experiential therapies was no longer present, with equivalent outcomes found for these therapies (Elliott, Greenberg, et al. 2013).

Research on experiential therapies includes more than just Gestalt therapy; hence, conclusions based on such research cannot be overgeneralized to Gestalt therapy. For example, Larry Beutler, Andres Consoli, and Geoffrey Lane (2005) reported the results of several studies that compared a Gestalt-based group treatment called focused expressive psychotherapy (Daldrup et al. 1988) with cognitive therapy and supportive self-directed therapy in group therapy with depressed outpatients, meeting weekly for twenty weeks. There were no significant differences in overall effectiveness of the three group treatments. However, overly socialized, low-resistant, internalizing clients did better with Gestalt-based therapy. The Gestalt-based therapy was an experiential-focused expressive therapy that went beyond standard Gestalt therapy. It intensified emotional arousal by enhancing awareness and the processing of unwanted feelings. The important work of Leslie Greenberg and his colleagues on process-experiential therapy, recently developed into a more integrative approach called emotion-focused therapy (see Elliott, Watson, et al. 2004), is another example of an experiential therapy that is not synonymous with Gestalt therapy. It includes elements of Gestalt therapy and person-centered therapy, as well as other experiential therapies, and therefore goes beyond Gestalt therapy (see Sharf 2016, 278; see also Pos, Greenberg, & Elliott 2008, 87).

In an earlier review of outcome research on Gestalt therapy, Uwe Strümpfel and Rhonda Goldman (2002) optimistically reported the following significant results: (1) Gestalt therapy is equal to or better than other therapies for a number of disorders; (2) Gestalt therapy is effective with personality disorders, substance addictions, psychosomatic problems, and various other psychological disorders; and (3) Gestalt therapy has lasting therapeutic effects, according to follow-up evaluations conducted from one to three years after the end of treatment (see also Strümpfel & Courtney 2004). Some of these conclusions may be too positive in light of more-nuanced conclusions from other more-recent reviews already mentioned.

Some recent research on the effectiveness of Gestalt therapy include these promising or positive findings (see J. Sommers-Flanagan & Sommers-Flanagan 2018, 163): (1) In a practice-based and large-scale study in the United Kingdom, Gestalt therapy was found to be as effective as cognitive-behavioral, person-centered, and psychodynamic therapies, with large effect sizes (C. Stevens et al. 2011). (2) In a study in Iran, Gestalt therapy was found to be as effective as logotherapy in the treatment of college students with aggression and anxiety (Yousefi et al. 2009).

More research has also been done to evaluate the effectiveness of specific Gestalt therapy techniques, especially the empty-chair technique (L. S. Greenberg & Foerster 1996; L. S. Greenberg & Malcolm 2002; Paivio & Greenberg 1995), not only in Gestalt therapy but also in other therapy approaches (e.g., N. E. Carpenter et al. 2016; J. C. Watson et al. 2011). For example, the empty-chair technique has been found to be effective in helping clients resolve conflictual feelings. It has also helped clients to be experientially involved in the therapeutic process more quickly than the technique of reflecting feelings as developed in person-centered therapy. Although more empirical research on the effectiveness of Gestalt therapy has been conducted in recent years, the number of controlled outcome studies available is still relatively small (see Elliott, Greenberg, & Lietaer 2004; Elliott, Greenberg, et al. 2013; Roubal 2016; Strümpfel 2006; see also Barber 2006; Brownell 2008). More and better controlled outcome research is needed to expand and strengthen the empirical base for the efficacy of Gestalt therapy.

Future Directions

Only 1 percent of clinical psychologists and social workers and 2 percent of counseling psychologists and counselors surveyed in the United States indicate Gestalt/experiential therapy as their primary theoretical orientation (see Prochaska & Norcross 2018, 3). The number of “purist” Gestalt therapists is therefore small in the United States. However, the influence of Gestalt therapy as an experiential and humanistic therapeutic approach in the field of counseling and psychotherapy in general has recently increased again. Emotion has become a major focus in psychotherapy, whereas behavior was predominant in the 1970s and 1980s and cognition through the early 2000s (Prochaska & Norcross 2018, 153). Gestalt therapy is therefore being incorporated in various ways, large and small, into other therapeutic approaches that are essentially experiential (e.g., emotion-focused therapy) as well as those that are not (e.g., cognitive-behavioral therapies that utilize some Gestalt methods such as the empty-chair technique to help clients access emotionally laden or “hot” cognitions).

However, one must be cautious with the use of Gestalt therapy and other experiential therapies that focus on evoking intense emotional experiences and thus may not be appropriate for certain types of vulnerable clients who can be negatively affected by such therapies (see Lilienfeld 2007; D. McKay & Jensen-Doss 2021; Tan 2008c). Overcontrolled and inhibited clients with relatively low resistance may nevertheless respond well to Gestalt therapy.

Gestalt therapy has undergone some significant shifts in its view of personality and therapy. For example, a greater appreciation of interdependence and a deeper understanding of shame processes have led Gestalt therapists to become less confrontational and more self-disclosing, gentle, and supportive in their therapeutic style with their clients (Corey 2021, 210; see also Brownell 2016; Jacobs & Hycner 2009; G. Wheeler & Axelsson 2015; Yontef, Jacobs, & Bowman 2019).

Gary Yontef, Lynne Jacobs, and Charles Bowman (2019) also describe the significant growth or proliferation of Gestalt therapy training institutes or centers and literature available all over the world. There are many Gestalt therapy training institutes in the United States, with at least one in every major US city, and more than two hundred Gestalt therapy training institutes worldwide (see Yontef, Jacobs, & Bowman 2019, 319). Well-known professional organizations include the Association for the Advancement of Gestalt Therapy (www.AAGT.org), the European Association for Gestalt Therapy (www.EAGT.org), and Gestalt Australia and New Zealand (www.ganz.org.au).

Two major English language Gestalt therapy journals available today are the Gestalt Review and the British Gestalt Journal (www.britishgestaltjournal.com). The Gestalt Directory, containing information about Gestalt therapists and training programs worldwide, can be obtained at no cost from the Center for Gestalt Development Inc. (www.gestalt.org). The center also offers audiotapes, videotapes, and books on Gestalt therapy (Corey 2021, 227–228).

As previously noted, Gestalt therapy has recently experienced renewed interest and growth that will likely continue into the near future.

Recommended Readings

· Brownell, P. (2008). Handbook for theory, research and practice in Gestalt therapy. Newcastle, UK: Cambridge Scholar Publishing.

· Cain, D. J., Keenan, K., & Rubin, S. (Eds.). (2016). Humanistic psychotherapies: Handbook of research and practice (2nd ed.). Washington DC: American Psychological Association.

· Passons, W. R. (1975). Gestalt approaches in counseling. New York: Holt, Rinehart & Winston.

· Perls, F. (1969). Gestalt therapy verbatim. Moab, UT: Real People Press.

· Perls, F. (1969). In and out of the garbage pail. Moab, UT: Real People Press.

· Polster, E., & Polster, M. (1973). Gestalt therapy integrated: Contours of theory and practice. New York: Brunner/Mazel.

· Wheeler, G., & Axelsson, L. S. (2015). Gestalt therapy. Washington, DC: American Psychological Association.

· Woldt, A. S., & Toman, S. M. (Eds.). (2005). Gestalt therapy: History, theory, and practice. Thousand Oaks, CA: Sage.

Reference

Tan, S. (2022). Counseling and Psychotherapy, 2nd Edition. [[VitalSource Bookshelf version]]. Retrieved from vbk://9781493435074