topic 3 dq1

Topic 3: Alternatives To The Classical Theories

Objectives:

1. Analyze person-centered, existential, and Gestalt therapies in terms of the role of client and counselor, goals of therapy, and types of counseling techniques employed.

2. Discuss counseling populations for which person-centered, existential, and Gestalt therapies have empirical evidence of their effectiveness.

3. Analyze the key concepts reflected in person-centered, existential, and Gestalt therapies that are important in the development of a counselor. [CACREP 2.F.5.a]

Topic 3 DQ 1 (Obj. 3.1)

Assessment Description

Do you think it is possible to combine client-centered and existential approaches in counseling? Why or why not? Explain what a combined approach might look like.

Box 5.1

Anil is a 48-year-old male who is a second-generation Indian American. He is a college graduate with a business degree and has worked as an insurance salesperson for the past 3 years. Prior to this period, he worked at the management level for a telecommunications company, but left that job because he found it too stressful.

Anil presents with depressed mood that affects his physical, social, and occupational functioning. He reports experiencing this depression for about the past 2 years. During this period, Anil characterizes himself as often fatigued, socially withdrawn, and ineffective at work. His income has dropped significantly during the last 2 years. Anil feels guilty for having to rely on his wife, Sandy (who identifies as White European American), as the primary income provider for their household. According to Anil, Sandy often expresses disapproval of him nonverbally, such as when she is writing checks for the monthly bills. The couple argues quite frequently about financial matters.

Anil and Sandy have two adult children (Natalie and James) who have completed college within the past 5 years. Anil reports that both children currently earn more than his present income. This situation makes him feel inadequate. As a result, Anil feels emotionally distant from Natalie and James and sees them as closer to Sandy.

Anil’s social activities typically involve his wife and are work-related. He spends his spare time with his computer or reading. He reports having no close friends.

During counseling sessions, Anil seems uncomfortable, has difficulty maintaining eye contact, laughs nervously during the shortest periods of silence, and comments on his discomfort with the lack of structure. Although he seems motivated to change, Anil seems to have difficulty discussing his situation.

An Excerpt from “The Necessary and Sufficient Conditions of Therapeutic Personality Change”

The Conditions

As I have considered my own clinical experience and that of my colleagues, together with the pertinent research which is available, I have drawn out several conditions which seem to me to be necessary to initiate constructive personality change, and which, taken together, appear to be sufficient to inaugurate that process. As I have worked on this problem I have found myself surprised at the simplicity of what has emerged. The statement which follows is not offered with any assurance as to its correctness, but with the expectation that it will have the value of any theory, namely that it states or implies a series of hypotheses which are open to proof or disproof, thereby clarifying and extending our knowledge of the field.

Since I am not, in this paper, trying to achieve suspense, I will state at once, in severely rigorous and summarized terms, the six conditions which I have come to feel are basic to the process of personality change. The meaning of a number of the terms is not immediately evident, but will be clarified in the explanatory sections which follow. It is hoped that this brief statement will have much more significance to the reader when he has completed the paper. Without further introduction let me state the basic theoretical position.

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

Two persons are in psychological contact.

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

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

The therapist experiences unconditional positive regard for the client.

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

The communication to the client of the therapist’s empathic understanding and unconditional positive regard is to a minimal degree achieved.

No other conditions are necessary. If these six conditions exist, and continue over a period of time, this is sufficient. The process of constructive personality change will follow.

A Relationship

The first condition specifies that a minimal relationship, a psychological contact, must exist. I am hypothesizing that significant positive personality change does not occur except in a relationship. This is of course a hypothesis, and it may be disproved.

Conditions 2 through 6 define the characteristics of the relationship which are regarded as essential by defining the necessary characteristics of each person in the relationship. All that is intended by this first condition is to specify that the two people are to some degree in contact, that each makes some perceived difference in the experiential field of the other. Probably it is sufficient if each makes some “subceived” difference, even though the individual may not be consciously aware of this impact. Thus it might be difficult to know whether a catatonic patient perceives a therapist’s presence as making a difference to him—a difference of any kind—but it is almost certain that at some organic level he does sense this difference.

Except in such a difficult borderline situation as that just mentioned, it would be relatively easy to define this condition in operational terms and thus determine, from a hard-boiled research point of view, whether the condition does, or does not, exist. The simplest method of determination involves simply the awareness of both client and therapist. If each is aware of being in personal or psychological contact with the other, then this condition is met.

This first condition of therapeutic change is such a simple one that perhaps it should be labeled an assumption or a precondition in order to set it apart from those that follow. Without it, however, the remaining items would have no meaning, and that is the reason for including it.

The State of the Client

It was specified that it is necessary that the client be “in a state of incongruence, being vulnerable or anxious.” What is the meaning of these terms?

Incongruence is a basic construct in the theory we have been developing. It refers to a discrepancy between the actual experience of the organism and the self picture of the individual insofar as it represents that experience. Thus a student may experience, at a total or organismic level, a fear of the university and of examinations which are given on the third floor of a certain building, since these may demonstrate a fundamental inadequacy in him. Since such a fear of his inadequacy is decidedly at odds with his concept of himself, this experience is represented (distortedly) in his awareness as an unreasonable fear of climbing stairs in this building, or any building, and soon an unreasonable fear of crossing the open campus. Thus there is a fundamental discrepancy between the experienced meaning of the situation as it registers in his organism and the symbolic representation of that experience in awareness in such a way that it does not conflict with the picture he has of himself. In this case to admit a fear of inadequacy would contradict the picture he holds of himself; to admit incomprehensible fears does not contradict his self concept.

Another instance would be the mother who develops vague illnesses whenever her only son makes plans to leave home. The actual desire is to hold on to her only source of satisfaction. To perceive this in awareness would be inconsistent with the picture she holds of herself as a good mother. Illness, however, is consistent with herself concept, and the experience is symbolized in this distorted fashion. Thus again there is a basic incongruence between the self as perceived (in this case as an ill mother needing attention) and the actual experience (in this case the desire to hold on to her son).

When the individual has no awareness of such incongruence in himself, then he is merely vulnerable to the possibility of anxiety and disorganization. Some experience might occur so suddenly or so obviously that the incongruence could not be denied. Therefore, the person is vulnerable to such a possibility.

If the individual dimly perceives such an incongruence in himself, then a tension state occurs which is known as anxiety. The incongruence need not be sharply perceived. It is enough that it is subceived—that is, discriminated as threatening to the self without any awareness of the content of that threat. Such anxiety is often seen in therapy as the individual approaches awareness of some element of his experience which is in sharp contradiction to his self concept.

Source: From Rogers, C. R. (1957). The necessary and sufficient conditions of therapeutic personality change. Journal of Consulting Psychology, 21(2), 95–103.

Going beyond individual counseling, Rogers became one of the leaders of the encounter group movement in the late 1960s and 1970s (Kirschenbaum, 2004). In the last years of his life, Rogers led large workshops all over the world aimed at resolving conflict, for which he was nominated for a Nobel Peace Prize in 1987 (D. J. Cain, 2013). The same day he was nominated, Rogers fell and broke his hip and a few weeks later died of a heart attack during surgery to repair it (Weinrach, 1990). Rogers was survived by two children; his wife had died in 1979. His daughter, Natalie, became a therapist, eventually developing her own approach, integrating PC theory with expressive modalities (e.g., art, movement; N. Rogers, 1993; Sommers-Flanagan, 2007).

Carl Rogers was a pioneer in many ways. He was the first to use the term client to refer to someone seeking psychotherapy. In explaining his use of this term, he said, “The client . . . is one who comes actively and voluntarily to gain help on a problem, but without any notion of surrendering his own responsibility for the situation” (1951, p. 7). Perhaps Rogers’s most significant contribution was his willingness to submit the counseling process to the rigors of research. He was the first to record counseling sessions, and he used these recordings to test his ideas. Many times the transcripts or recordings used in research and publications featured Rogers as the counselor. One of these recordings was the basis for the book Counseling and Psychotherapy (1942), which presented the first complete transcription of a counseling case ever printed. Braving the psychotherapeutic unknown, Rogers designed and conducted an extensive study of PC therapy with individuals diagnosed with schizophrenia while he was on the faculty of the psychology and psychiatry departments at the University of Wisconsin (see Box 5.2).

Box 5.2

The Wisconsin Schizophrenia Project

In 1957, Carl Rogers was looking for new challenges. He moved to the University of Wisconsin and became a member of the departments of psychology and psychiatry. He wondered if the client-centered therapeutic approach that was so successful with the college students at the University of Chicago would be as helpful with other kinds of clients. In collaboration with the members of the Psychotherapy Research Group at the University of Wisconsin Psychiatric Institute, he set out to test whether client-centered therapy would work with clients diagnosed with schizophrenia (C. R. Rogers, 1967).

The study took place over a 5-year period. Eight therapists, all of whom were essentially person-centered in their orientations, volunteered to provide counseling. Rogers was one of the therapists. Three groups of participants were identified: acute schizophrenia, chronic schizophrenia, and normal individuals (not hospitalized and reporting no dysfunction). A total of 48 participants entered the study and were randomly assigned to therapy or control groups. Multiple measures were used, including a battery of psychological tests (the Rorschach and the Minnesota Multiphasic Personality Inventory, among others) and measures of the therapeutic relationship. Rating scales were developed to measure the important constructs of PC theory, including empathy, unconditional positive regard, and therapist congruence. Measures of the therapy process included the level of client experiencing and the ability of the client to engage in relationships. Overall, this study was a tremendous undertaking.

Unfortunately, the study did not flow as well as Rogers had planned. One member of the research team committed an ethical violation. It is not absolutely clear what happened from Rogers’s (1967) account, but some of the data apparently disappeared and much of the statistical analysis had to be repeated. Discord was rampant among the research team, and although the study was eventually completed and published, Rogers (1967) characterized the period as “without doubt the most painful and anguished period in my whole professional life” (p. 371).

The results of the study were mixed. Analyses showed some isolated differences between the treatment and control groups (e.g., treated hospitalized clients showed a slightly higher release rate than nontreated hospitalized clients), but overall the therapy group showed no greater improvement when compared to the control group. All hospitalized individuals showed positive change regardless of whether they received PC counseling. Some support for the theory was found in that clients who perceived higher degrees of two of the therapeutic conditions, empathy and congruence, showed better outcomes on two indicators (objective test scores and ratings by clinicians) than did clients who perceived low levels of these conditions. One interesting finding was that clients’ and independent observers’ ratings were similar in their evaluations of the therapeutic relationship, but therapists’ ratings were negatively correlated with the ratings of the other two groups. That is, the therapists’ ratings tended to be high when the clients’ (or the observers’) ratings were low, and vice versa.

Rogers and his colleagues found the results of the study somewhat encouraging. The link between the relationship conditions and outcome seemed promising, and the fact that the researchers were able to develop reliable measures of these indicators was significant. Rogers concluded that the same conditions of good therapy work with clients diagnosed with schizophrenia as well as those categorized as neurotic. In fact, Rogers suggested that one of the most important insights gained from the study might be that generally the clients diagnosed with schizophrenia were more like the typical clients he worked with than they were different (C. R. Rogers et al., 1967, p. 93).

Carl Rogers is one of the most influential American psychologists of all time (D. J. Cain, 2013). His impact on his profession was recognized by the American Psychological Association (APA) when, in 1956, he was chosen as one of the first three individuals awarded the APA award for distinguished scientific contribution. In 1972, he was given the APA award for distinguished professional contribution, becoming the only person ever to receive both awards. He served as president of the APA in 1946.

Seeman (1990) argued that a theory is by necessity the theorist’s autobiography. Sollod et al. (2009) commented that Rogers’s emphasis on personal freedom likely had its roots in reaction to his strict early environment. The comparability between Rogers’s theory and his life was quite evident in his increasing willingness to reveal his person in both his writings and his work with clients. Over his professional career, he became more and more convinced that the genuineness of the therapist is critical to the therapeutic process, and he applied this assertion to his life as well. At least four times (in 1961, 1972, 1980, and 1987; see Kirschenbaum & Henderson, 1989), he wrote accounts of his personal experiences, which are excellent demonstrations of the PC philosophy in action. Here we should pause to note that PC theory was developed in the late 1950s and 1960s, from the perspective of a White male, which could introduce some biases as a function of the cultural context and the person of the theorist. In fact, PC theory has been criticized for being too individualistic, and the nondirectiveness of the PC approach, it has been suggested, is not appropriate for all clients. The failure to take societal oppression of women, people of color, and of diverse gender identity and sexual orientation into account is an issue with PC theory, as you will discover in the section on diversity at the end of the chapter. However, many writers have also noted that unconditional positive regard, an essential element of PC counseling, provides space for its use with a wide range of individuals, given a sensitive counselor.

Carl Rogers applied PC concepts in areas beyond counseling and psychotherapy, coming to see his theory as more of an approach to interpersonal relations and learning than simply as a theory of client change. For instance, he wrote about marriage (C. R. Rogers, 1972) and education (C. R. Rogers & Freiberg, 1994) and conducted encounter groups all over the world in the interests of contributing to world peace (C. R. Rogers, 1980). Rogers lives on in the Three Approaches to Psychotherapy videos, in which he demonstrated PC therapy with a client named Gloria (Shostrom, 1965). The session with Gloria is considered a classic demonstration of the ideal therapeutic relationship and is still avidly watched by counseling students today. Box 5.3 describes a controversy associated with the video.

Box 5.3

The Meaning of the Missing 249 Words

In 1965, a film series was presented that changed the world of counseling and psychotherapy. In the Three Approaches to Psychotherapy (Shostrom, 1965), a courageous woman named Gloria served as a client for three therapists, Carl Rogers, Fritz Perls, and Albert Ellis. Each of the three segments begins with the theorist explaining his views, proceeds to a 20-minute counseling session with Gloria, and concludes with the theorist’s evaluation of his work. At the end of the third interview, Gloria presents her reactions to the three theorists. Gloria’s interaction with Rogers has been characterized as exemplifying his incredible ability to form intense, satisfying relationships with people, a demonstration of his almost uncanny therapeutic ability (Weinrach, 1990). Gloria and Carl corresponded for 15 years after the interview until her death at age 45, and met once during this period.

One section of the Gloria–Carl interaction has been the subject of controversy. Toward the end of the film, Gloria tells Carl, “I’d like you for my father.” Carl responds, “You look to me like a pretty nice daughter.” In his taped discussion after the session, Rogers mentions that this interaction might be labeled transference and countertransference, but dismisses that conceptualization as intellectualizing and a disservice to the value of the relationship.

As a result of a rather surprising discovery, the meaning of Gloria and Carl’s interchange was the topic of a hot debate in the journal Psychotherapy (Bohart, 1991; Weinrach, 1990). Six months after Carl Rogers’s death, Weinrach (1990) located a 249-word segment of the interview that was not included in the film. Evidently the film ran out, but a separate audio recording of the session continued. In the segment, Gloria and Carl had continued their conversation, and Gloria indicated that her search for a loving father figure was a “neurosis.” Weinrach (1990) suggested that, if it had been known that Gloria’s longing was, for her, a typical pattern, “or worse yet, a long-standing neurotic need” (p. 283), Rogers would have lost the therapist-guru status that he gained from the film. Instead, Rogers would have been seen as merely a human therapist who missed the boat in failing to interpret Gloria’s transference reaction. Even more problematic, in Weinrach’s view, was the fact that Rogers appeared to be bound up in countertransference feelings for Gloria, which was what caused his failure to respond to her transference. Also, Weinrach maintained that if Rogers had acknowledged these dynamics he would have been supporting a theory against which he had argued for a long time (psychoanalysis), thereby questioning his own theory. In essence, Weinrach implied that had the missing 249 words been included in the film, Rogers would have been discredited.

Bohart (1991) defended Rogers, contending that Weinrach’s views are based in a theoretical perspective (psychoanalytic), not absolute truth. Agreeing with Rogers that reference to transference processes is not productive, Bohart (1991) maintained that “what Weinrach is really saying is that he prefers a transferential interpretation of the Rogers–Gloria interaction” (p. 497). Further, he wrote, “To accuse Rogers of making a therapeutic mistake because he did not deal with transference is equivalent to saying that Rogers made a mistake because he did not operate in terms of the theoretical constructs that Weinrach . . . ascribe[s] to” (p. 497). Pointing out that Gloria tends to discount her experience (when she calls her wish for an accepting male figure neurotic), Bohart noted that classifying Gloria’s feelings as transferential would validate her mistrust of her person, a damaging event from a PC perspective. With regard to Rogers’s responses to Gloria, Bohart questioned if it is “‘countertransferential’ to like and respect one’s client, or (heaven forbid) to actually express such sentiments” (p. 501; emphasis in original).

In responding to Bohart, Weinrach (1991) defended his conceptualization of the transferential nature of the Gloria–Carl interaction. He acknowledged that Rogers had always elicited in him a wish to have such a grandfather and wondered “what feelings Rogers’ persona has evoked in Bohart that influenced him to write such an impassioned defense of Rogers” (1991, p. 505). Further, Weinrach (1991) wrote, “Bohart appears to be applying the therapeutic principle of unconditional positive regard to everything Rogers did, including Rogers’ demonstration with Gloria” (pp. 505–506). Weinrach concluded by suggesting that the film be regarded only as a historical artifact at best and as a negative example at worst. Evidently, Bohart chose not to respond to Weinrach’s rebuttal.

This entertaining interchange is probably best viewed as a good demonstration of the way theoretical lenses can influence the interpretation of events. Working from a psychoanalytically influenced view, Weinrach saw Gloria and Carl’s interaction as transference and countertransference. This perspective, with its attention to client–counselor interaction as a recapitulation of early experience, would evaluate the interchange as a negative therapeutic event because Rogers did not recognize the processes and intervene. In contrast, Bohart endorsed a PC approach, seeing the Gloria–Carl interaction as an authentic exchange of intimate feelings, a positive event from this perspective. Until the unlikely time that one of these two theories is elected as the “truth” of psychotherapy, the lesson to be learned is that what we know as “reality” can be viewed from multiple perspectives.

The Center for Studies of the Person continues Rogers’s work and has a website, www.centerfortheperson.org. Other Internet sites of interest are the World Association for Person-Centered and Experiential Psychotherapy and Counseling (WAPCEPC; www.pce-world.org), the Association for the Development of the Person Centered Approach (ADPCA; http://adpca.org), and the webpage of Person-Centered Expressive Arts, the organization founded by Rogers’s daughter, Natalie Rogers (http://personcenteredexpressivearts.com), who characterizes herself as an arts therapist philosophically grounded in her father’s ideas. The scholarly journal Person-Centered Review, launched in 1986 as a result of the first meeting of ADPCA, became the Person-Centered Journal in 1992 (Raskin et al., 2019). WAPCEPC currently publishes Person-Centered and Experiential Psychotherapies.

It appears that the prominence of the PC approach has decreased in the United States in recent years, but in Europe there is still lots of interest in PC theory and in the United Kingdom, a version of PC counseling is recognized by the National Health Services as an approved approach used in primary care (Barkham et al., 2021; Cooper et al., 2013). Lively programs of research and intervention continue in other countries, and there are PC organizations around the world (Kirschenbaum & Jourdan, 2005, presented a list of 18). Elements of Rogers’s approach can also be clearly seen in contemporary programs of training for interpersonal and counseling skills (C. A. Hill, 2020; Ivey et al., 2016).

Basic Philosophy

The hallmark of PC theory is the basic premise that given a supportive environment, humans have a tendency to be good. Carl Rogers (1961) was quite clear about this conviction, writing that “the basic nature of the human being, when functioning freely, is constructive and trustworthy. . . . We do not need to ask who will control his aggressive impulses; for as he becomes more open to all of his impulses, his need to be liked by others and his tendency to give affection will be as strong as his impulses to strike out or to seize for himself. He will be aggressive in situations in which aggression is realistically appropriate, but there will be no runaway need for aggression” (p. 194). Statements such as these provoked accusations of an overly positive view of humans, most famously a debate between Rogers and Rollo May concerning the potential for evil in human nature (see May, 1982; C. R. Rogers, 1982). Discussions of this issue persisted, with Bohart (2013) and Schmid (2013a) pointing out that Rogers never denied the human capacity for bad behavior. What Rogers meant, they argued, was that if the conditions in which an individual functions are not destructive, the actualizing tendency will push the person in a positive, constructive direction.

In Rogers’s (1980) view, human behavior is the result of an innate need to grow and develop that is common to all living organisms. If left alone, the person will follow the road to full human potential, showing none of the negative tendencies postulated by other theorists (e.g., Freud’s aggressive instinct). Rogers (1966) wrote, “Contrary to those therapists who see depravity at men’s core, who see men’s deepest instincts as destructive, I have found that when man is truly free to become what he most deeply is, free to actualize his nature as an organism capable of awareness, then he clearly appears to move toward wholeness and integration” (p. 193). The PC therapist recognizes that humans sometimes act in destructive or antisocial ways, but maintains that these tendencies are a product of experience in the environment, not built into the human psyche (Bohart, 2013).

Daryl, Anil’s PC therapist, begins with the assumption that Anil is inherently a positive, forward-moving individual. Even though Anil is exhibiting some emotion and behavior that might be labeled by others as dysfunctional, Daryl is sure that within Anil is the potential to grow and actualize, establish meaningful and productive relationships with others, and work effectively. He sees glimmers of this in Anil’s evident willingness to engage in counseling and small sparks of hope that appear when Daryl responds supportively to him. Daryl, who is White, gay, and cisgender, takes note of Anil’s Indian descent and will strive to be aware of aspects of Anil’s heritage that may influence his perspective on his situation. At the same time, Daryl attends to his own identities and how those might influence the counseling process with Anil.

PC counselors are committed to the notion that clients are self-directing and able to accept full responsibility for their actions (Bohart, 2013). Each person has within them the resources and strengths to grow and become a better person. This respect for the individual’s autonomy leads to an attitude of equality in the therapeutic interaction, and this mutuality of involvement is critical in any context to which PC theory is applied (Raskin et al., 2019). Rogers spoke of freedom as an important element of the counseling relationship. He believed that the client (and the counselor as well) should be free to explore every aspect of the self within the therapeutic environment. “There is also a complete freedom from any type of moral or diagnostic evaluation, since all such evaluations are, I believe, always threatening” (C. R. Rogers, 1961, p. 34).

PC therapy is characterized as humanistic and phenomenological (Ruthven, 1992). Proponents of humanistic approaches trust the individual, viewing people as oriented toward growth and harmony with others. Rogers’s approach is phenomenological in that he argued that the most important factor in understanding a given individual is their (the individual’s) perceptions of reality, because for the person, perception is reality.

Daryl approaches Anil as an equal and encourages him to determine the nature and content of the counseling relationship. He relies on Anil to provide the basic material of counseling, asking Anil what he wants to discuss. Although this attitude seems somewhat surprising to Anil and tends to make him a little uncomfortable, Daryl persists in his gentle support of Anil’s choices and decisions within the counseling session. In no way does Daryl assess, diagnose, or evaluate Anil; he simply does his best to understand Anil’s world.

Human Motivation

PC theorists believe that the only motivation of human behavior is the tendency to grow to full potential in constructive, positive ways (Raskin et al., 2019). Living beings strive to maximize the organism (a term used by Rogers to mean the whole person or other living entity) and avoid experiences that are detrimental to it. PC theorists see no inherent aggressive or destructive tendencies in people, although aggression or assertion may sometimes be used as a means to grow, such as when an individual asserts themself to obtain something that enhances their existence. For example, killing animals for food might be seen as an aggressive act directed toward the actualization of the organism.

Daryl knows that Anil is motivated to grow and enhance himself and live in harmony with his environment, which includes other people. At the beginning of counseling, Anil’s behavior may not seem to consistently stem from this tendency—he seems somewhat stuck at present—but Daryl knows that it is there and needs only to be released from interference. Daryl will constantly look for and respect Anil’s growth tendencies throughout the counseling interaction.

Central Constructs

Experience

Rogers (1959) used the term experience in two ways. Experience as a noun refers to everything that is going on in the individual at a given moment. Of particular importance in experience are emotions, because we tend to suppress, deny, or distort these in the service of social rules. Although Rogers (1959) recognized that unconscious processes might exist, they are not considered in the definition of experience because they cannot be studied objectively; thus, experience is confined to events that are potentially available to consciousness.

The use of the term experience as a verb means the process of the person receiving what is going on around and within them, the “sensory or physiological events which are happening at the moment” (C. R. Rogers, 1959, p. 197). This term is special to PC theory because in order to grow, humans must experience accurately, discriminating between events that contribute to the organism’s well-being and those that are harmful. The degree to which experience is perceived without distortion or disruption determines the level of the individual’s functioning.

Daryl is aware that accurate perception and symbolization of experience are critical to Anil’s psychological well-being. Anil is clearly attending to what is going on in the environment around him as well as his psychological experience (he can report feelings of depression). However, Anil’s desire to come to counseling and his admission that he is depressed suggest that Anil’s experiencing is derailed in some way.

Actualizing Tendency

The most basic human process is the actualizing tendency, which is the “inherent tendency of the organism to develop all its capacities in ways which serve to maintain or enhance the organism” (C. R. Rogers, 1959, p. 196). This process involves both the person’s biological and psychological growth. Growth is always in the direction of autonomy and thus leads to internal regulation of the individual’s existence. Growth is also toward greater levels of complexity (C. R. Rogers, 1980).

Daryl looks for signs of the actualizing tendency in Anil. Even though Anil’s uncomfortable presence and evident depression seem to suggest that he is stuck somehow, when Anil talks about his struggles Daryl can sense the presence of a tendency to grow in Anil’s desire to live a better, less isolated life.

Organismic Valuing Process

Rogers thought that humans engage in an ongoing process of evaluating experience, measuring it event by event to determine if it contributes to one’s growth or detracts from it. Humans move toward growth-producing experiences and away from those that do not contribute to or that interfere with growth. In the healthy person, the basis for this constant evaluation of experience is the actualizing tendency. To take a simple example, when 3-year-old Sasha touches a hot stove, she snatches her hand away because it does not promote the growth of her organism to get burned!

Ideally, Daryl would look for signs of the operation of the organismic valuing process in Anil’s behavior. Signs of this process are observable at times, but at other times Anil’s behavior might seem to be motivated by other influences. For example, Anil seems to fully enjoy his leisure pursuits (reading and working on his computer), but he avoids his family and other social relationships. Because healthy interpersonal relationships are growth-enhancing, Daryl hypothesizes that in those situations Anil is not acting in accordance with his organismic valuing process. Daryl knows that fluctuations of this type are natural—and perhaps even more pronounced in individuals coming to counseling because the need for counseling suggests that some processes are awry.

Self

As humans grow and experience the world, a portion of this experience becomes labeled as the self. All experiences that the person recognizes as “me” and the values that are attached to them become the self-concept (C. R. Rogers, 1959). For instance, if I discover that I am good at doing the tango, this experience becomes a part of my self-concept. If I value tango dancing, then this experience contributes to a positive self-concept.

Rogers thought that, if experiences are inconsistent with our self-concepts, or negatively valued, we will have difficulty allowing ourselves to perceive them. For example, if it is difficult for me to get up in the morning, then my self-concept could include the construct that I am not a morning person. If there are negative values associated with not being a morning person, this experience will contribute to a negative self-concept to the degree to which I allow myself to acknowledge it. I could, in fact, insist that I always get up at 5:00 a.m., but none of my friends would believe me! A third self-construct important in PC theory is the ideal self, the self the person would like to be. My ideal self may contain the characteristics “tango dancer” and “morning person,” only one of which is consistent with my actual experience.

Anil probably has a negative self-concept. He is able to recognize and reveal several “negative” aspects of himself—he is socially withdrawn and ineffective at work. Because he unfavorably compares himself with his children, Anil feels inadequate. Very little in Anil’s self-description seems positive, and Daryl also guesses that Anil’s ideal self is so close to perfection as to be unobtainable by a human being.

Self-Actualizing Tendency

An aspect of the general actualization tendency, the self-actualizing tendency, refers to the propensity of the self to grow and maximize. When the individual is functioning well, the actualizing and self-actualizing tendencies function in concert. What is good for the organism is also perceived as good for the self; what is bad for the organism is therefore bad for the self. Hugging another person is good for me both physically and in terms of self needs.

No matter how gloomy or rigid he seems, Daryl is convinced that Anil has within him the potential to self-actualize. Given the right support, Anil’s organismic and self-actualizing tendencies can align so that he functions at the top of his game.

Need for Positive Regard and Self-Regard

All human beings have a need for positive regard, and this need extends to the self-system. We value the love of others and also have a need to positively value ourselves. Rogers (1959) was not clear whether the need for regard is innate or learned, but he was quite specific in saying that the need for positive regard of the self is learned through experiencing it from others important to the individual.

Anil’s need for positive regard is evident in his reactions to his wife’s disapproval. He is falling short in the area of positive self-regard, as seen in his feelings of inadequacy when he compares his achievements to those of his children.

Conditions of Worth

The need for positive regard motivates individuals to seek love from important others around them (C. R. Rogers, 1959). When the individual perceives that some aspect of the self (whether it is perception, feeling, or behavior) is evaluated positively by someone important to them and other aspects are not, conditions of worth arise. The need for love is so intense that we will deny parts of our experience that are deemed unacceptable (unlovable) by significant others. A classic example of this dynamic is when Toni becomes frustrated and angry. From a PC perspective, anger is a natural part of human existence; it does not detract from the growth of the organism. If her parents consistently display negative reactions to Toni’s anger, she will tend to deny or distort the experience of anger in the future. She will begin to feel anxious or “bad” when she begins to get angry, and in an attempt to align her perceived and ideal selves, she may even start to view herself as someone who never gets angry. In contrast, if Toni’s parents accept her anger nonjudgmentally, she will have no need to distort or disown the experience. She can experience the anger and then go about her business.

Initially, conditions of worth are external; that is, they are the reactions of others (such as parents) who value behaviors differentially, often based on societal norms (e.g., boys don’t cry, girls don’t shout). What happens quite often, however, is that individuals repeatedly gain the approval of important others for displaying behaviors that are consistent with conditions of worth, and after a while the conditions are internalized as parts of the self (C. R. Rogers, 1959). When this transformation happens, the individual is not evaluating experiences through the organismic valuing process; rather, they are valuing experiences based on whether they are consistent with the internalized conditions of worth. The person is said to be operating on an external locus of evaluation (because his values are not self-generated) rather than an internal locus of evaluation (the organismic valuing process). Because conditions of worth are based on societal rules, they are not always consistent with the actualizing tendency. In fact, they are often at odds with the actualizing tendency.

Daryl knows that Anil’s self is conditional. His guilt and depression are likely the result of aspects of his experience that are inconsistent with his internalized conditions of worth. For example, Anil apparently holds the value that to be worthwhile, he should earn a certain amount of money—specifically, that he should be the primary provider for his family. He is not fulfilling the condition that men are strong and provide for their families. This condition may be magnified by Indian cultural values that position the man as the primary provider and head of the family, which may have permeated his early experiences in his family. Daryl, who is White and of Western European descent, is aware that he needs to be sensitive to this possibility and how it might differ from his own experiences, values, and perception. That Anil’s children make more money than he does only confirms his negative perceptions of self. Daryl also guesses that Anil’s decision to change occupations was inconsistent with his conditional self, which dictates that men don’t buckle under stress and do not show “weak” emotions. He is just not good enough.

Theory of the Person and Development of the Individual

Life is an active process (C. R. Rogers, 1980, p. 118). “In short, organisms are always seeking, always initiating, always ‘up to something’” (p. 123; quotes in original). Even in the worst conditions, all organisms strive to grow in positive directions. So begins the journey of the infant.

The infant, motivated by the actualizing tendency, evaluates experience based on the organismic valuing process. “Experiences which are perceived as maintaining or enhancing the organism are valued positively. Those which are perceived as negating such maintenance or enhancement are valued negatively” (C. R. Rogers, 1959, p. 222). Babies naturally move toward the positive and away from the negative.

As the child grows, part of the experience becomes defined as the self. The differentiation of self is an offshoot of the actualizing tendency—that is, reaching full human potential involves developing a sense of who one is. Further experience leads to establishing a defined self-concept. With the development of the self, the need for positive regard from others emerges along with the need for positive self-regard.

Gradually, the child becomes aware that certain self-experiences are valued positively or negatively by others around them. Parents, teachers, and other important figures in the child’s life have reactions to the child’s behaviors that are verbally or nonverbally labelled as good or bad. Because the need for positive regard is so compelling, these evaluations are internalized, and conditions of worth are established. The child begins to seek self-experiences that are consistent with the conditional self and avoid or deny those that are inconsistent. For example, Margarita might initially find the experience of playing in squishy mud pleasurable (i.e., consistent with the organismic valuing tendency). However, Margarita’s mom berates her for messing up her beautiful white dress and shoes. The pleasurable experience of mud-playing then becomes a negative one because Margarita experienced negative regard from her mother. Eventually, Margarita internalizes this condition of worth and can never again be dirty; in fact, she might even develop a compulsive tendency to wash her hands.

In a perfect world, individuals could develop in an atmosphere of unconditional positive regard. Rogers (1959) was careful to say that unconditional positive regard does not mean positively valuing all of a child’s behaviors, writing that “a parent ‘prizes’ his child, though he may not value equally all of his behaviors” (p. 208). Given an accepting environment, children could develop unfettered by conditions of worth, and the needs for positive regard and positive self-regard would not be at odds with the organismic valuing process.

Anil is clearly conditional in his self-regard. Daryl does not have much information about Anil’s early experiences, but Daryl speculates that people important to Anil early in his life were conditional in their evaluation of him. For example, Anil’s current discomfort with his occupational situation (the change in jobs and income) probably results from his early internalization of the value that work is an important definition of who he is as a man. The change of jobs, which could be perceived as taking care of himself, is probably viewed as inconsistent with traditional U.S. values of “never give up” and “tough it out” along with those stemming from his family’s Indian cultural background, and may be particularly powerful for men. Daryl guesses that Anil might have been raised in an environment in which feelings were off limits, and therefore he is hesitant and uncomfortable disclosing them to those close to him, including Daryl.

Health and Dysfunction

The “good life,” according to Rogers (1961), is a process, not a destination. The healthy person is a congruent person; put simply, their perception of self is consistent with what they experiences. Healthy individuals are open to experiences and have an internal locus of evaluation (the organismic valuing process). The individual trusts themself to follow the right paths, guided by their organismic valuing process (C. R. Rogers, 1961). Because the individual has no internalized conditions of worth, experiences can be accepted freely into awareness and evaluated on the basis of the needs of the organism. The individual has a positive self-concept and unconditional self-regard. All experience is perceived accurately, without distortion; the person naturally orients toward experiences that actualize and away from those that do not contribute to the maximization of potential (Raskin et al., 2019).

Healthy individuals are creative and take risks in life. Rogers wrote that the healthy person “would not necessarily be ‘adjusted’ to his culture, and he would almost certainly not be a conformist. But at any time and in any culture he would live constructively, in as much harmony with his culture as a balanced satisfaction of needs demanded” (C. R. Rogers, 1961, p. 194; quotes in original). An important part of accepting all of one’s experience is the authentic expression of the self, with all of the feelings that accompany being human.

In PC theory, dysfunction is defined as incongruence between self and experience. The individual’s self is conditional; some experiences are inconsistent with internalized conditions of worth. The actualizing and self-actualizing tendencies are in conflict because the individual is busily trying to evaluate self-relevant experiences according to conditions of worth rather than via the organismic valuing process. The conditional self and the organismic experience are inconsistent, and therefore the actualizing and self-actualizing tendencies are divorced from each other.

When a person encounters experiences that are inconsistent with the conditional self, the experiences are generally “subceived”—that is, only dimly perceived. A clear recognition of the incongruent thought, emotion, or perception could cause a change in the self-concept, and people who are conditional do not welcome such changes. Experiences such as these are threatening to the self because they endanger the person’s ability to obtain positive regard from others (and to positively regard the self). The incongruent information results in anxiety. As a result, the individual becomes defensive and rigid, either denying or distorting the experience. Defensiveness is the hallmark of the person traditionally described as “neurotic” (C. R. Rogers, 1959). The incongruent person’s behavior is inconsistent; sometimes their behavior is guided by the conditional self and sometimes by the organismic valuing process. The individual is vulnerable because they are constantly defending against experiences deemed unacceptable. They are anxious, rigidly protecting the self-concept. The locus of evaluation is external (paradoxically, because it resides in internalized conditions of worth) rather than internal (i.e., the organismic valuing process; C. R. Rogers, 1959).

If the person is very incongruent (i.e., a lot of experiences are unacceptable to the self) and if incongruent experiences are very powerful or sudden, the individual’s defenses can become overwhelmed, and the experience is symbolized in awareness (C. R. Rogers, 1959). The self-structure is damaged, so the individual becomes disorganized. Similar to the neurotic, sometimes their behavior is guided by the conditional self, and at other times the “real” self (i.e., the organismic valuing process) rallies and directs behavior, but these swings are much more severe. The result looks much like what we typically describe as psychosis. Rogers (1959) gave the example of the person labelled an acute psychotic exhibiting sexual behavior that is typically deemed inappropriate in social situations. Such a person is simply following their actualizing tendency (i.e., sex is good for the organism), but conditions of worth have led them to deny their sexuality. When the self is shattered by too much incongruence, these behaviors are expressed because the need for sexual experience is symbolized in awareness (C. R. Rogers, 1959).

Despite his use of terms such as neurotic and psychotic, Rogers did not have much use for traditional diagnostic procedures and systems. Referring to the previously discussed categorization of individuals into defensive versus disorganized, Rogers (1959) said, “This seems to be a more fundamental classification than those usually employed, and perhaps more fruitful in considering treatment. It also avoids any concept of neurosis and psychosis as entities in themselves, which we believe has been an unfortunate and misleading conception” (p. 228).

Translating a bit, then, in PC theory, the roots of all dysfunction are found in incongruence. We all experience incongruence from time to time but if our self-concepts are not rigidly held, we can accept and integrate different aspects of ourselves (Bohart & Watson, 2020). Depression, for example, would be seen as probably involving a negative self-concept that resulted from an excess of conditions of worth. Experiences inconsistent with the conditions would be subceived, and the extent of the depression would depend on the type and nature of the experiences perceived. Anxiety would be seen as resulting from the subception of incongruence and the need to defend the conditional self.

Anil is incongruent. In his session with Daryl, he behaves uncomfortably, showing signs of anxiety in his nervous laugh. He seems unwilling to reveal himself, possibly because his internalized conditions of worth disallow the authentic expression of feelings. He dares not talk about his anxiety or the feelings behind it because they are contrary to his conditional view of himself, which probably involves being strong. He is fearful of showing Daryl who he really is because he fears conditional reactions from others and as yet has no reason to believe that Daryl is different. He reports being depressed, and Daryl sees this sadness as resulting from Anil’s inability to realize his conditional self. Daryl understands the power of the stereotypic views of men in both U.S. and Indian cultures, which may have echoed and reinforced the conditions of worth that Anil experienced early in his life.

Nature of Therapy

Assessment

PC counselors do not use any form of assessment. Many are adamantly antidiagnosis. Rogers thought that assessing and diagnosing clients turned them into objects and distanced the counselor from the therapeutic interaction.

After welcoming Anil to counseling, Daryl asks how he can help. Daryl does not conduct an “interview” or direct the flow of Anil’s conversation in any way.

Overview of the Therapeutic Atmosphere

Rogers saw therapy as an encounter between two individuals. He vehemently rejected the idea that the counselor was an expert and argued that the therapist’s attitude, or philosophy, was critical to the success of the relationship. PC counselors emphasize the freedom and autonomy of the client in counseling, “with the therapist’s person playing a real but primarily catalytic part in that relationship” (Rogers, 1977, p. 21). The client is in the driver’s seat, choosing the frequency and length of sessions, the type of therapist, and ultimately whether to engage in therapy at all. As you might expect, PC therapists dislike the term treatment because of the medical connotations the term brings (Raskin et al., 2019).

Roles of Client and Counselor

In PC counseling, the counselor and client are equals, with the therapist serving as a companion in the client’s search for their authentic self (C. R. Rogers, 1986a). Describing his experience, Rogers (1986a) said, “As a therapist, I do not want to lead the client, since she knows, better than I, the pathway to the sources of her pain. . . . What I wish is to be at her side, occasionally falling a step behind, occasionally a step ahead when I can see more clearly the path we are on, and taking a leap ahead only when guided by my intuition” (pp. 207–208).

The counselor’s job in PC theory is to provide the climate that will release the client’s potential. Two tasks of the therapist—struggling to understand the experience of the client while at the same time being open to their own experience in the therapeutic relationship—are critical. Raskin et al. (2011) commented that “to be a client-centered therapist is to risk meeting the client as a person, to be of service in an authentic, collaborative relationship. It is the difference between using techniques . . . and being oneself in relation to another person” (p. 149; emphasis in original).

The role of the client is to be who they are. They are expected to be in contact with their experience as much as possible and serve as the guide in the therapeutic journey. Initially, the degree to which the client is able to experience and express is directly related to the level of incongruence present. Clients who are in extreme incongruence will be less comfortable verbalizing their experiences than will those who are more congruent.

Daryl approaches Anil as a partner in an interpersonal encounter. In no way does Daryl take a teaching, evaluating stance or offer any advice to Anil. Instead, Daryl attempts to engage with Anil in a personal, authentic way and to understand Anil’s experience as much as possible. Anil is expected to reveal himself to the extent he feels comfortable.

Goals

The goal of PC therapy is to facilitate the client’s journey toward full potential. If the right conditions are achieved, the client experiences the counselor’s acceptance and is in turn able to accept their experience more fully and thereby become more in touch with their actualizing tendency. A narrower version of the goal of PC counseling is for the client to move from being incongruent to being congruent. Successful PC counseling should result in diminishing or eliminating conditions of worth—and thus incongruence between self and experience. The locus of evaluation, rather than being external (i.e., based on internalized conditions of worth), becomes internal.

Daryl hopes that Anil can become aware of the experiences that are incongruent with his conditional self and accept these experiences as valuable aspects of himself. If counseling is successful, Anil will embrace all aspects of himself, freely living aspects of himself that he subceives and denies or distorts, such as his “failure” to live up to the ideal of the strong, supportive male. Getting in touch with his natural organismic valuing process will allow Anil to evaluate his experiences as negative or positive based on whether they contribute to his actualization. For example, Anil would value his taking care of himself by changing jobs to reduce stress rather than feeling bad about it. Once Anil is able to experience and express his feelings to others authentically (because he is not rejecting them to achieve positive self-regard in concert with his internalized conditions of worth), he will be able to relate in more unconditional and open ways with others, including his wife and kids.

Process of Therapy

Dryden and Mytton (1999) identified three historical stages in the evolution of PC theory. The earliest stage (in the 1940s and 1950s) emphasized the nondirective nature of the counseling interaction. In a cathartic model, the client expresses and releases emotion, and the therapist is prohibited from offering any advice or interpretation. Insight is to be achieved by the client on their own. The counselor, through their reflection of the client’s feelings, conveys understanding and acceptance of the client.

The attitude of the therapist was the emphasis of the second stage in the development of PC theory (in the late 1950s and early 1960s). During this stage, Rogers decided that the “techniques” of the nondirective approach (e.g., repeating the client’s words, avoiding giving advice) were becoming the approach. Dissatisfied with this characterization of his system as mechanical and passive, Rogers began to focus on the attitude of the counselor in relation to the client—and particularly the belief that the impetus for change was within the client. The counselor needed only to accurately understand and support the client in their journey inward.

Dryden and Mytton maintained that the spark for the third transformation of PC theory (in the mid- to late 1960s) came out of Rogers’s experience as a therapist. They explained that Rogers was working with a very disturbed client that he did not like; he felt “trapped by her dependence upon him” (1999, p. 64). Eventually, Rogers realized that he felt so immersed in the relationship that he could not separate himself from the client. The crisis was so severe that he referred the client and found a temporary geographic cure. After literally fleeing with his wife for a period of time, Rogers then entered therapy with a colleague. This incident led to his recognition that it was critical to be honest in the therapy relationship. He believed that, if he had been honest with his client, the relationship might not have become so destructive. Rogers’s later versions of PC theory therefore placed great emphasis on the congruence, or genuineness, of the therapist.

For Rogers, all that was needed to release the innate growth tendencies of the client was for the therapist to provide the optimum atmosphere and for the client to perceive it. The counselor creates this environment by holding the right attitudes toward the client and the counseling venture. Simply put, the counselor works to create the facilitative climate for the client’s growth by providing what Rogers (1957) called the necessary and sufficient conditions for change: congruence, unconditional positive regard, and empathic understanding (also called the core conditions). Because these concepts are so vital to the theory, they will be discussed separately.

Before discussing the conditions of therapy, however, it is necessary to note that the precursor to counseling is that the client and the counselor must be in psychological contact. When two individuals “make a difference” (C. R. Rogers, 1959, p. 207) in each other’s experiential field, they are in contact. If you have read the excerpt from Rogers’s writing at the beginning of this chapter, you will also know that it is critical that the client perceive the unconditional positive regard and empathy of the therapist.

Congruence

Also called genuineness, transparence, and realness (C. R. Rogers, 1980), congruence refers to the counselor’s freely flowing awareness of their experience in the therapeutic moment. “The more the therapist is himself or herself in the relationship, putting up no professional front or personal façade, the greater is the likelihood that the client will change and grow in a constructive manner” (C. R. Rogers, 1980, p. 115). Not only is the therapist aware of their own experience, but also this awareness is apparent in both verbal and nonverbal expression; feelings and reactions can be communicated to the client if this seems helpful. As his theory developed, Rogers became convinced that congruence is the key to good therapy, writing that “for more than a decade I have been trying to state that genuineness, or congruence, and the expression of such genuineness, is probably the most important part of the therapeutic relationship” (C. R. Rogers et al., 1967, p. 511).

Rogers attempted to clarify what he meant by congruence, writing

It might be well to state some of the things that it does not imply. It does not mean that the therapist burdens his client with the overt expression of all of his feelings. It does not mean that he blurts out impulsively anything which comes to mind. It does not mean that the therapist discloses his total self to the client. It does mean, however, that he does not deny to himself the feelings that he is experiencing, and that he is willing transparently to be any persistent feelings which exist in the relationship and to let these be known to the client if appropriate. It means avoiding the temptation to present a façade or hide behind a mask of professionalism to adopt a confessional-professional relationship. (Rogers, 1967, p. 101; emphasis in original)

Although Rogers (1966, p. 185) thought it would be best if the therapist did not experience any persistent negative feelings about the client, if they happen these, too, should be expressed, because negative feelings would be more harmful if they were hidden. To hide negative feelings would be to put up a false front, which would surely be picked up by the client. Contemporary PC theorists have developed guidelines for expressing the therapist’s negative feelings: The therapist must be clear, tentative, own the feelings as a personal reaction and the helpful, affirming attitude behind the expression of them must be clearly conveyed (Elliott, 2013a).

Rogers (1959, 1980) did recognize that it is impossible to be congruent every minute of one’s life. He said, “Indeed if this were a necessary condition there would be no therapy” (1959, p. 215) because no one can be completely aware of their experience all of the time. What is critical is that the therapist be present and aware of their experience in the moment of interaction with the client: “[T]hus it is that imperfect human beings can be of therapeutic assistance to other imperfect human beings” (p. 215).

Daryl strives to be fully himself in his sessions with Anil. He attends to what Anil is communicating, both verbally and nonverbally, but is also aware of his own experience in the relationship with Anil. At times Daryl reveals to Anil what he is feeling in the interaction as, for example, when he tells Anil that he feels distant from him.

Unconditional Positive Regard

The counselor approaches the client with complete acceptance and caring (C. R. Rogers, 1980). Rogers spoke often of “prizing” to describe this attitude and added that it is risky to experience these feelings because we fear being trapped by them. It is scary to invest such feeling in others because they could disappoint us or they could become demanding. In fact, Rogers (1961, p. 52) thought that these fears were primarily responsible for our adoption of the “professional attitude” toward clients, which creates distance between counselor and client and protects against hurt. He said, “It is a real achievement when we can learn, even in certain relationships or at certain times in those relationships, that it is safe to care, that it is safe to relate to the other as a person for whom we have positive feelings” (1961, p. 52). Rogers (1966) did note one exception to the rule of unconditional positive regard: In working with the “extremely immature or regressed individual, a conditional regard may be more effective in getting a relationship under way . . . than an unconditional positive regard” (p. 186).

In order to be effective, Daryl must accept Anil without any conditions or evaluations. He finds himself prizing Anil as another human being and communicates this to Anil in a genuine, caring way.

Empathy

Empathy is achieved when one individual perceives the internal experience of another as if they were that person, “without ever losing the ‘as if ’ condition” (C. R. Rogers, 1959, p. 210; quotes in original). Rogers (1980) conceived of empathy as a process, rather than a state, saying that it meant “temporarily living in the other’s life, moving about in it delicately without making judgements” (p. 142). If the counselor achieves truly accurate empathy, they can even perceive meanings and feelings with which the client is not totally in touch.

The counselor must communicate empathic understanding to the client. However, Rogers (1980, p. 142) warned against trying to make the client aware of totally unconscious feelings because that would be too threatening. Instead, the counselor “aims to dip from the pool of implicit meanings just at the edge of the client’s awareness” (C. R. Rogers, 1966, p. 190).

Unfortunately, according to Rogers (1980) the early concept of accurate empathy grew into a rigid focus on the counselor’s responses. “Reflecting the client’s feelings” became synonymous with the PC approach. Teaching reflection of feelings as a skill became popular, and Rogers (1986b) thought that this approach often led to robot responses; when I was in graduate school, “I hear you saying . . .” was a kind of joke phrase. Rogers (1980) said, “I was so shocked by these complete distortions of our approach that for a number of years, I said almost nothing about empathic listening, and when I did it was to stress an empathic attitude, with little comment as to how this might be implemented” (p. 139). Instead, Rogers (1986b) emphasized that when he appeared to be “reflecting feelings,” what he was really doing was trying to check whether his “understanding of the client’s inner world [was] correct” (p. 376). Merry and Tudor (2006) further clarified that the PC counselor would never focus on feelings to the exclusion of other aspects of the client’s experience, such as thoughts, physical sensations, or fantasies.

Daryl strives to fully understand what it is like to be Anil. He attempts to “walk in Anil’s shoes” as much as possible without losing the boundaries between himself and Anil. At times, Daryl finds himself wanting to mention to Anil something he is not quite sure Anil has recognized—feelings that Anil has denied or distorted. For instance, Daryl senses Anil’s feelings of inadequacy around his role as husband and provider. Anil becomes anxious if these feelings and their meaning start to surface. In the supportive atmosphere of their relationship, Daryl tries to help Anil move toward experiencing these feelings. He does not, however, push Anil into experiencing these feelings or in any way insist that Anil acknowledge them if Anil is not ready.

A Fourth Condition?

In his last writings, Rogers (1986a) began to discuss a fourth characteristic of helping relationships. Acknowledging that he had no scientific basis for his idea, Rogers (1986a) maintained that when he was at his best as a therapist, he believed that he entered a “slightly altered state of consciousness . . . full of healing” (p. 198). This transcendent state leads to behaviors that are impulsive, but they almost magically fit with the client’s experience. “At those moments it seems that my inner spirit has reached out and touched the inner spirit of the other” (p. 199). Despite Rogers’s discussion of this transcendent state, subsequent treatments of his theory have paid little attention to this fourth condition.

Stages of the Therapeutic Process

Rogers saw the counseling process as a gradual progression from incongruence to congruence and observed stages through which clients passed on this journey. An interesting side note is that Rogers (1958) developed this “process conception” (p. 142) at a time when he was preparing his address to be given when he was awarded the APA award for distinguished scientific contributions. He did not want to discuss his previous work; instead, he wanted to take a new look at personality change, and what emerged was a view of the change process from an observer’s perspective (C. R. Rogers, 1961). Spending numerous hours reviewing audiotapes of counseling sessions, Rogers (1958) said that he was “trying to listen as naively as possible. I have endeavored to soak up all the clues I could capture as to the process, as to what elements are significant in change” (p. 142). Through this study, Rogers (1958) identified seven stages of the change process. As I describe these in the following sections, I quote liberally from Rogers’s (1958) writing in an attempt to convey the rich and vivid description for which he was known.

Stage 1

The individual in this stage is not likely to show up in the counselor’s office voluntarily. Change is not on the agenda because they typically do not see that any problems exist. “Feelings and personal meanings are neither recognized nor owned” (p. 143), and the person is afraid of intimate relationships. They tend to talk about externals, not themselves, and have a rigid self-structure.

Stage 2

“When a person in the first stage can experience himself as fully received then the second stage follows” (p. 144). Rogers was not certain about how this contact is made, but once it is the individual moves a little further along the continuum of experiencing. They begin to talk about subjects that are not related to the self, but display no sense of responsibility for problems—they are external. Although people do come to counseling when they are in this stage, Rogers considered them very tough customers.

Stage 3

Many clients who come to counseling on their own power are in this stage. If the person continues on the path established in stage 2, they take small steps toward more fluid experiencing and expression. In stage 3, the client discusses self-experiences and feelings, but in a largely distant and objectified manner; they do not experience them fully. Feelings are perceived, but as bad things. Although the self is still rigid, it is dimly recognized. The client also recognizes contradictions in experience.

Stage 4

In this stage, the individual begins to express more intense feelings, but they are still largely from past experience. The client begins to become aware of incongruence between the self and experience and to take some responsibility for their difficulties. Sometimes feelings even sneak into the present, but this experience is scary and the person has difficulty accepting them.

Stage 5

If the proper climate of acceptance is established, the fourth stage then “sets in motion still further loosenings, and the freedom of organismic flow is increased” (p. 144). Stage 5 clients experience feelings and express them freely as they experience them. This experiencing is not completely without fear, and the feelings that sneak through are sometimes surprising to the client. The person more frequently expresses “ownership of self feelings” (p. 145) and an accompanying urge to be authentic in accepting the feelings. The client begins to sense an internal frame of reference (the organismic valuing process) for experience. Rogers characterized this stage as “several hundred psychological miles from the first stage described” (p. 145).

Stage 6

Rogers described stage 6 as a “very distinctive and often dramatic phase” (p. 146). The client experiences “with immediacy and richness” a feeling that has been previously “stuck” (p. 146). The feeling is fully accepted by the client. In this moment, the self is no longer an object—it “is this feeling. This is a being in the moment, with little self-conscious awareness” (p. 146; emphasis in original). Incongruence between self and experience is dramatically symbolized in awareness and is thereby transformed to congruence. In essence, the client becomes the aspect of the self that was denied because of conditions of worth. According to Rogers, once the client experiences this process it is irreversible.

Stage 7

The last stage identified by Rogers is seen both within and outside of the counseling relationship. “There is a growing and continuing sense of acceptant ownership of . . . changing feelings, a basic trust in his own process” (p. 148). The client, having learned to trust themself, consistently uses the organismic valuing process as the basis for living. The self becomes the process of experiencing rather than a perceived object. Conditions of worth are replaced by values and constructs loosely held, generated from within. “The client has now incorporated the quality of motion, of flow, of changingness into every aspect of his psychological life” (p. 149). Genuineness and free, consistent, and clear communication characterize relationships.

Not every client will reach the final stage of change (C. R. Rogers, 1961). In fact, Rogers was aware that some people do not value fluidity and would disagree with his ideas altogether. If a client started at stage 1, Rogers indicated that it could take years to get to stage 7 and that this progression would be a rare event. More likely, clients would come to counseling at stage 2 and end at stage 4, with both parties in the relationship being justifiably satisfied with this outcome.

Rogers (1987) recognized two kinds of client resistance to the therapy process. First, there is the natural reluctance to undergo the painful experience of divulging to one’s self and to the counselor feelings previously denied. After all, these feelings have been denied for a reason. The second type of resistance, however, is created by the counselor and arises as a result of “offering interpretations, making diagnoses and other judgments” (C. R. Rogers, 1987, p. 186). If the counselor creates a safe relationship through providing the core conditions, the client will have no need to protect themself by resisting.

Anil appears to be in stage 3. He experiences depression and feelings of inadequacy, “bad” feelings. Uncomfortable with the lack of structure and apparently avoiding self-relevant topics, Anil seems hesitant to make real contact with Daryl. If Daryl is able to remain accepting, genuine, and empathic, Anil will begin to lose the rigid structure that protects him from experiences not allowed into his conditional self. He will begin to experience feelings in the present (such as pain or anger) and will begin to accept these experiences into himself.

Therapeutic Techniques

There are no techniques in PC therapy! The therapist must simply provide the right (core) conditions, empathy, unconditional positive regard, and congruence; if the client perceives them, the actualizing tendency will be freed. Or to put it another way, establishing the facilitative relationship is the only technique (Bohart & Watson, 2020). Techniques as we typically view them (things such as challenging the client, interpretation, and so forth) are seen as guiding and objectifying the client instead of allowing them to find their own experience—and thus solutions. As noted earlier, when the professional world began to focus on “reflection of feeling” as the primary technique in PC counseling, Rogers objected, seeing the attitude conveyed by the counselor as what was truly important.

Over the years, the lack of specific techniques connected to the nondirectiveness of PC theory has been perceived as a significant weakness of this approach. Variants of PC theory have evolved that include the use of directive, active interventions by the counselor that are intended to increase clients’ levels of experiencing (e.g., Gendlin, 1996; Bohart & Watson, 2020). Josefowitz and Myran (2005) discussed the role of activity in PC counseling and identified two general “types” of PC therapists. They called the first “experientialists” and include here those interested in Gendlin’s (1996) focusing approach and proponents of emotion-focused therapy (L. S. Greenberg, 2019; S. M. Johnson, 2004). These therapists are likely to allow for greater therapist activity and directiveness as compared to the “non-directive client-centred group,” which, as the name implies, emphasizes the need to give the client control of the direction of therapy (Josefowitz & Myran, 2005, p. 330). Emotion-focused therapy weaves together and draws techniques from the PC, Gestalt, and existential approaches, including interventions such as empty-chair dialogues (L. S. Greenberg, 2019; Goldman & Greenberg, 2022; see Chapter 7, Box 7.3 for a brief description of this approach). Gendlin (1990, 1996) emphasized the experience of the client, developing a technique called focusing, which directs the client’s attention to the physical sense of their problems (the “felt sense”; D. J. Cain, 2013, p. 172). Again, all of these techniques are aimed at intensifying client experiencing within counseling sessions with the goal of loosening up “stuck” feelings.

Another identified strain of contemporary PC theory is the relational view, which like relational psychoanalysis emphasizes the joint construction of therapy, the two-way nature of the therapeutic alliance (Schmid, 2013b). However, I should note that there are arguments within the PC community whether approaches that are more directive or integrate techniques from other systems are “true” PC approaches, resembling the antics of the psychoanalytic camp’s proponents as they debated what is proper and what is “not psychoanalytic” (Bohart, 2012). Some of the current leaders of the PC community, who knew Carl Rogers well, opine that he would have been fine with such integration, as long as the key attitudes of the PC therapist remained and there was not too much directivity (Bohart, 2012; Kirschenbaum, 2012). It could be noted that Natalie Rogers’s expressive therapy is directive by nature, and according to Kirschenbaum (2012) Carl Rogers approved of her efforts.

On the other end of the spectrum is Prouty’s pre-therapy (Prouty, 1998; Werde & Prouty, 2013). Noting that the first problem of PC counseling is to establish psychological contact, Prouty focused on this process in individuals who are “contact impaired” (p. 389)—those who are labeled schizophrenic and mentally challenged. This interesting theory includes a detailed description of the very concrete types of reflections that are helpful in establishing contact (e.g., situational, facial, word for word, body). An example of such a reflection might be “You are sitting on the floor with your arms wrapped tightly around your body.”

Another interesting approach that situates itself within the PC camp is motivational interviewing (MI; Rollnick et al., 2023). Developed primarily for use with individuals who misuse substances, MI combines the unconditional acceptance and empathic stance of PC with a sort of Socratic questioning designed to help individuals become motivated to change. Oddly enough, MI also sounds a little like solution-focused therapy (see Chapter 14), for, in exploring the client’s thoughts and feelings, the MI counselor “seeks to evoke . . .‘change talk’—expressions of the client’s desire, ability, reasons, and need for change—and responds with reflective listening” (Hettema et al., 2005, p. 92; quotes in original). It is a short-term approach designed to enhance commitment to change, and it usually consists of one to two sessions.

The PC approach has also proven quite useful in play therapy with young children (Raskin et al., 2019). First developed by one of Rogers’s students, Virginia Axline (1947), child-centered play therapy is based on the notion of the positive potential residing in the actualizing tendency. Through play, children are able to express difficult feelings, such as anger and fear, and of course happy feelings are always welcome, too. The accepting therapist then recognizes the feelings and reflects them to the child (Bratton et al., 2009). The child’s experience in the nondirective, accepting, safe relationship is expected to help the child gain knowledge about and acceptance of self.

Daryl is a traditional PC therapist and will simply try to provide the right conditions for Anil. He will unconditionally accept Anil and strive to understand Anil’s experience and communicate this to him. Therapist congruence is also important to Daryl, so he will attempt to be genuine and in the moment with Anil.

Evaluation of the Theory

PC theory has been one of the most influential theories in the profession of counseling and psychotherapy. It can be seen as forming the basis for most approaches to counseling because almost every approach to therapy acknowledges the impact of the therapeutic relationship on counseling outcome. Beginning counselors are taught good listening skills and are often drilled in responses that convey active listening and empathy (e.g., C. A. Hill, 2020; Ivey et al., 2016).

Despite his impact on the profession, Rogers has also been criticized for wearing “rose colored glasses”; his view of people is characterized as overly positive and ignorant of the “darker side of human nature” (Coleman, 1988, p. 23). Bohart (2007) responded that this is a misunderstanding of the theory: the tendency to self-actualization is directed at enhancing the self and can, unfortunately, be directed to the growth of a destructive self. A related issue for some is Rogers’s neglect of unconscious motivations and dynamics (Cooper, 2007).

Seager (2003) argued that “unconditional positive regard is impossible in any human relationship” (p. 401), and the current view seems to be that this attitude is an ideal that will never be attained by any counselor (D. J. Cain, 2010). Weaver (2008) discussed using PC theory with men who are perpetrators of domestic violence and argued that seeing unconditional positive regard as equivalent to accepting such behavior is a simplistic view. She makes two arguments about this issue: First, unconditional positive regard does not mean that the counselor unconditionally accepts the client’s behaviors. Second, the therapeutic principle of congruence would allow the counselor to express their discomfort with the client’s behavior.

Some writers have been concerned that the PC approach is not effective with clients who display severe levels of psychopathology (van Blarikom, 2008). However, efforts such as Prouty’s pre-therapy and a recent relational turn in PC theory, which emphasizes the interpersonal aspects of the PC therapy relationship, would suggest that PC theorists are extending the theory in ways that would be applicable to these clients (Cooper, 2005; Cox, 2009; Mearns & Cooper, 2005). In addition, recent evidence does indeed support the use of PC counseling with individuals who have been diagnosed with schizophrenia (Elliot et al., 2021). Quinn (2011) pointed to the results of several empirical studies of PC therapy with individuals diagnosed with borderline personality disorder that demonstrated that PC therapy produced favorable outcomes as evidence of the effectiveness of PC counseling, despite the fact that two out of three of these studies classified PC therapy as “supportive” therapy. He noted that the client centeredness of PC therapy allows for the therapist to use directive or teaching techniques if the client requests these and that the principle of genuineness requires that the therapist feed back to the client their experience of persistent negative reactions, both of which are qualities in common with well-known approaches to borderline personality disorder (such as dialectical behavior therapy and transference-focused therapy; see Chapters 16 and 3, respectively).

As noted earlier, some find a weakness in the nondirective approach emphasized in classic PC counseling. In my experience teaching this approach, I have similarly found that students struggle with the concept of trusting the client’s growth tendencies; instead, they want to “do something.” These kinds of questions (don’t I need techniques?) are directly tied to arguments about whether PC theory’s necessary and sufficient conditions are really that: “Sufficient” implies that all one has to do is be empathic, be congruent, and provide unconditional positive regard and the client will get better. Although there are likely PC advocates who maintain this stance, other contemporary PC therapist concede that PC therapists, although rarely, sometimes tentatively suggest techniques, but only in the spirit of furthering the process of exploration (Bohart & Watson, 2020). This offering is definitely not in the interests of “doing something” or making some therapist-desired outcome happen. Also, some PC advocates allow that if the client asks for a specific technique (e.g., learning a mindfulness technique) and the therapist is competent in it, they can share with the client as a form of empathy (Ong et al., 2020).

Qualities of the Theory

Precision and Testability

Rogers was a pioneer of research on the psychotherapy process, and he and his associates generated many studies testing PC theory. Despite this legacy, disagreements abound over how to measure PC constructs, which bears directly on the testability of the theory (Beutler et al., 1994; C. E. Hill & Corbett, 1993). In early research, congruence, for instance, was measured by differentials in adjective sorts of clients and experts (e.g., the client description was assumed to be of the distorted, incongruent self, whereas the observing expert could discern the more realistic self-experience of the client). However, it could be argued that this approach does not adequately capture the internal processes that create incongruence; observation by others, even experts, will not yield an accurate picture of an individual’s self-experience because this can be experienced only by the individual. Other early efforts to measure empathy, unconditional regard, and congruence seemed successful because raters could generally agree on what they were observing (C. R. Rogers et al., 1967). However, the reports of observers, clients, and therapists were sometimes found to be discrepant, as they were in the Wisconsin Schizophrenia Project (Rogers et al., 1967; see Box 5.2).

PC theory provides clear and simple predictions. For example, PC theory predicts that, if clients receive empathy and unconditional positive regard from a congruent therapist, they will change in favorable directions. However, the theory has been criticized as imprecise because the predictions derived are too general (Lietaer, 1990). For instance, it is possible that the core conditions are differentially effective depending on the stage of counseling—they might be much more important in the early rather than the later stages (Lietaer, 1990). Few predictions are offered about the other constructs of the theory except in general ways (e.g., if parents are not accepting of children, children will develop conditions of worth).

Empirical Support

PC theory has received a good deal of research attention. Most of these efforts have focused on the predictions about therapy rather than those derived from the personality theory. In general, research has supported the effectiveness of PC therapy, but Rogers’s core conditions are considered necessary but not sufficient.

Research Support

Outcome Research

Over the years, many reviews of the outcomes of PC therapy have appeared. For instance, Bozarth et al. (2001) presented a traditional summary review of PC research, breaking it into four time periods and describing the research within each. They maintained that common factors research that emphasizes the power of the therapeutic relationship and the resources of the client in producing positive outcomes (see Chapter 1) supports PC theory’s basic assumptions. Bozarth et al. concluded that “the clear message of five decades of research identifies the relationship of the client and therapist in combination with the resources of the client (extratherapeutic variables) . . . [which] respectively account for 30% and 40% of the variance in successful psychotherapy” (p. 168).

More recent reviews tend to show that PC therapy is effective in helping clients change, with results comparable to other therapeutic approaches. However, in some analyses, cognitive-behavioral therapy (CBT) shows somewhat better results. It is important to note that many times, PC therapy is being used as a comparison group (i.e., Rogerian supportive therapy or nondirective therapy; Elliot et al., 2013) and is often facilitated by therapists not particularly trained in the PC approach. Meta-analyses also find strong allegiance effects—the “home” therapy of the researchers—tends to do better than the comparison intervention. As you keep these factors in mind, I’ll now summarize three major meta-analyses and one large clinical trial of PC therapy.

Elliott et al. (2013) conducted a meta-analysis of 195 studies of humanistic/experiential therapies and reported that overall clients demonstrated significant amounts of change. These gains were found to be maintained for up to a year. This analysis was of a set of studies that included a number of approaches, such as classic or “pure” PC therapy, variants of it (e.g., Gendlin’s focusing approach), and emotion-focused therapy. Therefore, these positive conclusions cannot be taken as specific to PC theory. However, Elliot (2013b) separated out a subset of studies that tested PC counseling and found comparable effect sizes, indicating that clients improved from pretest to post-test, and outcomes were more favorable than those of clients who received no treatment. Comparisons in 43 studies of PC and other forms of therapy showed no differences in outcomes. However, in 22 studies that compared PC therapy and cognitive-behavioral therapy (CBT), a slight advantage was found in favor of CBT. Elliott argued that the advantage was small enough to be insignificant for practical purposes. Elliott et al. (2013) further looked at the meta-analytic evidence for the effectiveness of humanistic/experiential therapies across various diagnostic categories, finding strong support for pre- to post-test change, including, interestingly, for psychosis (a set of studies that included several of Prouty’s pre-therapy).

Elliot et al. (2021) followed up on the earlier research, meta-analyzing 91 studies that appeared between 2009 and 2018, again including a number of tests of approaches labelled humanistic-experiential therapies. A diversity of clients were included in these studies, along with a large list of presenting problems. Their results were very similar to the earlier review, except that PC therapy, while effective overall, was less effective in comparison to CBT. Elliot et al. speculated that the difference could be a result of the increased allegiance effects they documented in the review, or that the studies involved client populations that were more complex and challenging than the previous ones, perhaps beyond PC therapy’s range of impact.

One large, careful trial that was not included in Elliot et al.’s analysis was conducted in England (Barkham et al., 2021). Called the PRaCTICED trial, the effort was a true RCT in which 510 clients experiencing moderate or severe depression were randomly assigned to CBT or Counselling for depression—a type of PC therapy approved by the UK government. Most of the clients were White (88%) and female (57%). Six months after starting treatment, the two groups of clients had equivalent outcomes but the CBT group was better off at 12 months. It appeared that the PC clients maintained their improvement at 12 months, but the CBT group had continued to improve (Elliot et al., 2021). Interestingly, there were no differences in client satisfaction between the two groups.

In a smaller RCT, Artiran and DiGiuseppe (2022) compared rational emotive behavior therapy (REBT; see Chapter 9) to humanistic client-centered therapy (HCCT) both pre and post treatment, with a 3-month follow up. Thirty-six clients who sought counseling at an agency in Istanbul, Turkey, were randomly assigned to REBT or HCCT, but only 31 completed the full 12 weeks of treatment (2 participants dropped out of the REBT condition, 3 in the HCCT condition). The sample comprised 14 women and 17 men—other identities were not described (e.g., race/ethnicity, sexual orientation)—who met criteria for mild depression and reported symptoms of anxiety. One therapist, who had 10 years of experience practicing REBT, provided that treatment; three therapists, who had one year of training in HCCT (and 5–8 years of overall experience) provided HCCT. Primary analyses showed no differences between the two groups at post test and at 3 months after therapy, and significant changes over time in all participants on all measures. Artiran and DiGiuseppe then executed post-hoc analyses for clinically significant change, finding more of it in the REBT group. This led them to declare that “REBT treatment was more successful than the HCCT group” (p. 226). However, close inspection of the results and other factors showed that these results need to be viewed cautiously. First, the differences in the therapists providing the two treatments was significant—the one providing REBT seemed to be an advocate of REBT, having 10 years of experience providing it, whereas the therapists for the HCCT groups were very different. It is difficult to tell, but it is not clear whether these therapists were strong advocates of HCCT. Also, of the two indices used post hoc, the reliable change indices of the two groups appeared similar across the two groups (and indicating reliable change across all measures for both groups); it was only when individual clients were classified via a clinical significance index that differences appeared. I would also note that the second author is a well-known proponent of REBT, the study was published in the Journal of Rational-Emotive & Cognitive Behavioral Therapy, and the HCCT group is referred to as the “comparison” group whereas the REBT group was the “experimental” group. So, in all, this study seems to be a good example of how careful examination of the details of a study may tell a different story than what is reported in the article abstract.

Taking all of this evidence into account, it seems clear that PC therapy has empirical support but it is possible that it is somewhat less effective than CBT, to which it is often compared. However, it is not clear whether the difference is a function of the two approaches, or related to methodological issues.

Empirical studies of play therapy support the effectiveness of PC counseling with kids. Several meta-analyses have been performed, yielding positive results (Bratton et al., 2005; Lin & Bratton, 2015; Ray et al., 2015). Notably, Post et al. (2019) specifically reviewed research on child-centered play therapy (CCPT), attempting to focus on students from low-income families and of non-White backgrounds, who are more likely to experience adverse childhood experiences. They found one meta-analysis that included ethnicity, and it showed that CCPT produced a stronger effect size in studies in which the majority of participants were non-White compared to those in which the samples were majority White (Lin & Bratton, 2015). Reviews of individual studies also demonstrated that CCPT led to positive results in low income and non-White students.

Theory-Testing Research

Much energy has been devoted to testing the theoretical propositions of PC theory, at least those pertaining to the necessary and sufficient conditions. Rogers was the first investigator to systematically use recordings and transcripts of counseling sessions to understand the counseling process. Although this research is, of course, dated, I will briefly summarize a few examples of Rogers’s and his colleagues’ early efforts.

At the University of Chicago Counseling Center, Rogers and his colleagues designed an intensive study of clients in counseling that exemplified some of the most important tenets of experimental design. Twenty-nine clients and a matched control group (no treatment) were assessed, and audio recordings and other measures were gathered. Raskin (1952) reported his test of the locus of evaluation hypothesis on 10 of these cases. PC theory predicts that the locus of evaluation should shift from external (based on others’ perceptions) to internal (based on the client’s own perceptions) over the course of therapy. Using ratings made of client statements of evaluation, Raskin demonstrated that the shift along the internal–external dimension among the clients was significant and in the predicted direction. That is, clients were rated as having made judgments based more on their own values at the end of counseling compared to the beginning. Using the same 10 cases, Bergman (1951) studied counselors’ responses to client requests for evaluation by the counselor (e.g., requests for advice, evaluation of progress). After classifying counselor responses to these requests, Bergman demonstrated that when the counselor responded with reflection of feeling, clients were more likely to continue significant self-exploration than when counselors chose other responses.

Rogers and his associates conducted many other studies of the process of counseling over the years, and most supported the basic tenets of PC theory. Of particular interest are Barrett-Lennard’s efforts to operationalize the core conditions by creating the Barrett-Lennard Relationship Inventory (BLRI; Barrett-Lennard, 1959). This study was Barrett-Lennard’s doctoral dissertation and produced a measure of therapist congruence, empathic understanding, and unconditional positive regard that is still used in research today. In fact, a short form of the BLRI was recently developed, and it demonstrated good psychometric properties (Chen, Liao et al., 2021). Rogers argued, with some justification, that the fact that these conditions could be reliably measured was, in itself, support for the theory (C. R. Rogers, 1967).

Early studies conducted by other investigators also supported PC theory. Truax and Carkhuff (1965) experimentally manipulated levels of empathy and unconditional positive regard in a small sample (three clients) case study (this type of investigation would likely not be sanctioned by an institutional review board today). Their examinations of levels of client experiencing supported PC predictions—clients’ levels of experiencing appeared to decrease in tandem with the decrease in therapist conditions. The Wisconsin Project (see Box 5.2) provided a wealth of data on PC theory and supported the contention that the level of the PC therapeutic conditions (i.e., empathy, congruence, and unconditioned positive regard) was related to client outcome (C. R. Rogers, 1967; van der Veen, 1967).

Later research focusing on Rogers’s statement of the necessary and sufficient conditions generally finds that these conditions are correlated with client outcome, but are not sufficient. Tudor and Worrall (2006), PC proponents, stated flatly that “Rogers’ therapeutic conditions are neither necessary nor sufficient” (p. 10). Citing empirical data that suggest that many variables, and most especially the resources of the client, influence the outcome of therapy, they concluded that “the [therapeutic] conditions are intrinsically helpful and often implicated in therapeutic growth” (p. 20). However, most research does not test the three conditions simultaneously, which would be necessary to clearly address Rogers’s necessary and sufficient hypothesis, and most of the research uses methods that are insufficient to establish causal statements (e.g., Do facilitative conditions lead to good outcome, or vice versa?). On the other hand, meta-analytic findings have consistently demonstrated that the working alliance is at least moderately related to outcome in psychotherapy (Crits-Cristoph & Gibbons, 2021). The support for the impact of the therapeutic relationship, however, can also be seen as only weak support for PC theory because this effect is seen across theoretical orientations.

Arguments about how to operationally define the constructs in PC theory further weaken the empirical support for the theory—that is, researchers have disagreed about how best to define and measure empathy, unconditional positive regard, and congruence (Elliot et al., 2018; C. E. Hill & Corbett, 1993). Nonetheless, relatively recent meta-analyses of research relevant to all three PC constructs are available. Farber et al. (2018) meta-analyzed 64 studies of positive regard and therapy outcome, finding an effect size of 0.36, a moderate relationship. Likewise, Kolden et al. (2018) documented a moderate relationship between congruence or genuineness and counseling outcome.

Elliot et al. (2018) discussed the controversy over defining empathy and identifying different types of empathy (e.g., rapport building, exploratory empathy). They also meta-analyzed data from 80 studies testing the relation between empathy and counseling outcomes, finding an effect size of .28, a medium effect size. Comparing the relationships between various perspectives of measurement (e.g., client, counselor, observer-rated), they replicated an earlier finding that client-rated empathy had the strongest relationship with outcomes (Elliot et al., 2011). Acknowledging that there is little research in the area, they addressed diversity concerns, pointing out that part of being empathic involves sensitivity to the various identities of our clients and to social forces such as oppression and microaggression. They concluded that “empathy is best offered with humility and held lightly, ready to be corrected” (p. 406).

Recall that Rogers said that it was of utmost importance that clients perceive the core conditions—the stronger correlation between client rated empathy and outcome would be consistent with this contention. Finally, Elliot et al. (2018) further documented that the relationship between empathy and outcome did not differ across theoretical orientations or client presentations. Carl Rogers would probably agree that therapists of other orientations who have strong empathy would be effective, but the generality of this result across them would tend to raise questions again, about the degree to which they provide specific support for PC theory.

An interesting study was performed by Murphy and Cramer (2014) in which clients and therapists in 62 dyads rated each other on empathy, unconditional positive regard, and genuineness after the first and third sessions of therapy. Client distress decreased over the three sessions and progress was even more pronounced when clients and therapists rated each other as offering high levels of the three conditions. These results suggest that therapy may be a two-way street—that clients’ progress is better when they are empathic, unconditionally positive, and genuine, too.

Of interest to those who work with clients who are diagnosed with serious mental health conditions would be Mallonee et al.’s (2022) study of the factors that influence these clients’ engagement in therapy. An anonymous survey of 131 adults showed that the strongest predictors of engagement were the working alliance and empathy. The degree to which the client felt coerced into treatment was, interestingly, not a predictor of engagement.

In conclusion, it seems that Carl Rogers pointed us to some powerful factors in client response to counseling, and the data support their influences. On the other hand, the very clear theoretically derived prediction that empathy, congruence, and unconditional positive regard are necessary and sufficient for client change has not been supported.

Issues of Diversity

PC theory has been both villainized and praised in addressing its utility with individuals from diverse backgrounds. Like many theories of counseling, PC theory can be criticized for placing too much emphasis on the individual and paying relatively little attention to family and cultural effects on people’s lives and behaviors (Bohart & Watson, 2020). Sue et al. (1996) noted that “many psychologists fail to realize that the majority of societies and cultures in the world have a more collectivistic notion of identity; they do not define the psychosocial unit of operation as the individual” (p. 5). Values such as duty to family and cultural groups are largely neglected, given the strong emphasis on the internal locus of evaluation prized by PC therapists (Usher, 1989). However, Bohart and Watson (2020) explained that Rogers placed a good deal of emphasis on interconnectedness and decried the western emphasis on self-sufficiency. They maintained that that PC therapists’ respect for client autonomy and prizing of the client’s reality allows them to respect the client’s various identities, avoiding acting on stereotypes or imposing some standard of being that would clash with the client’s reality.

Although many writers find PC theory’s tilt toward individuality, prioritizing emotional expression, and failure to recognize the power of the family and collectives beyond it as problematic with clients who are diverse in culture and other identities, most cite the utility of the core conditions proposed by Rogers. Starting with some relatively dated writings, Poyrazli (2003) flatly stated that “despite its popularity, Rogerian therapy clashes with and is inappropriate for Turkish culture” (p. 111). She cited most of the major problems noticed by others in PC theory: the emphasis on individualism and emotional expression, the disregard of the power of the family, and the lack of structure and authoritative stance on the part of the counselor. However, Poyrazli cited the utility of the core conditions in working with Turkish clients. Spangenberg (2003) agreed that these conditions are useful in working with South African clients and noted that successful PC counseling with these clients would focus on the client in the context of family, community, and culture. In contrast to Poyrazli, Spangenberg saw the nondirectiveness of the PC counselor as respectful to the client and cautioned therapists not to succumb to the temptation to give advice and suggestions without providing the opportunity to process them. Oyama (2014) described the transformation of PC theory in Japan. Since its introduction after World War II, the approach has gradually mutated to one that is more culturally consistent with less emphasis on individuation. More recently, Ioane and Tudor (2022) similarly discussed modified views of spirituality, individuality, and relationality needed in working with individuals of South Pacific heritage (e.g., Samoan, New Zealand, Australia).

The stress on individualism in PC theory can lead to an attitude that the person must change, not the environment, organization, or society in which they exist. The notion that an individual can actualize without the recognition that social structures sometimes oppress is seen as detrimental to women, racial and ethnic minorities, and individuals who are gay, lesbian, or bisexual or of nonbinary gender identity (Sue et al., 2022).

Chantler (2005, 2006) joined in these kinds of criticisms of PC theory and suggested an extension of the concept of conditions of worth to include “gender, class or race dimensions of conditions of worth” (2006, p. 51). In doing so, the internalization of societal stereotypes and the often negative impact that they have would be recognized. Chantler also advised counselors who are of White backgrounds working in an enlightened PC mode to examine their own lives for the effects of privilege and how these factors influence their work with clients. Consistent with feminist theory, Chantler emphasized the issue of socially conferred power, particularly when counseling those of other than White backgrounds. She pointed out that, although PC therapists attempt to create a symmetrical therapeutic relationship, “the desire to equalize counseling relationships does not mean that they will be equal” (2005, p. 253).

Gillon (2008) called for an examination of how PC theory works for men. Exploring traditional male sex-role stereotypes, he argued that, because of the PC emphasis on vulnerability, experiencing, and relationship, men who are strongly socialized into traditional masculine roles may not fully engage in therapy. He noted that, because men are encouraged to “think and do, rather than feel” (p. 127), the empathic, emotion-focused atmosphere of PC counseling is inconsistent with traditional masculine ways of relating. The PC therapist’s congruence may be perceived as weakness, according to masculine stereotypes, leading to decreases in trust and therapist credibility for male clients. However, Gillon did think that PC therapy can be saved, noting that PC counseling can provide an environment in which men are not required to perform behavior that is consistent with masculine stereotypes. Other suggestions involve educating male clients at the start of therapy, using language that is characteristic of masculine tendencies (e.g., distancing or objectifying) in pinpointing clients’ meanings, and empathizing with any difficulties in expressing and experiencing that men might experience.

Clients from cultures other than White European cultures may expect and desire more guidance from the counselor than is provided by traditional PC therapists. MacDougall (2002) suggested that this lack of direction may produce frustration for these clients and recommended that PC counselors consider alternative behaviors, such as giving advice and making suggestions. Quinn (2013) argued that two adaptations are needed when using a PC approach with clients from non-White cultures. First, the therapist needs to understand the client’s culturally based understanding of illness (in the broadest sense). Second, the counselor needs to be very attentive to how the client is perceiving them, to make sure that the facilitative conditions are being received.

Sue et al. (2022) noted that the emphasis on self-disclosure in psychotherapy approaches can be problematic for clients from cultures other than White Western European. Clearly, self-disclosure is a cornerstone of PC theory, and clients from cultures that do not value such disclosure (such as Asian individuals) may not respond well to this approach. Also, clients who for good reasons mistrust “majority” individuals may be reluctant to invest in PC counseling. Insight is highly valued in the PC approach; individuals from cultures or groups other than European and of lower socioeconomic status (SES) may not share this value. The latter clients, particularly, may be more concerned with concrete life problems (Sue et al., 2022).

PC theory does have some strengths that are relevant to working with clients who are of diverse origins and identities (D. J. Cain, 2010). The assumption that the client, rather than the therapist, determines the goals of counseling avoids the imposition of culturally based notions of the healthy personality (Usher, 1989). In fact, Rogers probably would have argued that the PC credo of trusting the individual would create an atmosphere of respect for clients’ culturally based values and personal history. Essentially, the PC counselor wants to walk in the client’s world. Freire et al. (2005) provided an example of such work in their description of the process and outcomes of using a PC approach with 98 lower SES, neglected children and adolescents in Brazil. At the publication of their report, 98 clients had participated in this ongoing program, attending a range of 1–39 sessions (the average was 12). Initially, the clients in this project were puzzled by the nondirective approach, but Freire et al. reported that they quickly began to learn to use the unique relationship to their benefit. Improvements in interpersonal, emotional, and academic functioning were noted by these authors. However, no data are presented to support these contentions, and it should be noted that this study in no way approached the standards of controlled outcome studies.

The valuing of real, egalitarian relationships in this approach is consistent with the values of a feminist approach to counseling (Waterhouse, 1993). Although these analyses are dated, they still mostly ring true in the present. However, feminists point out that PC theory can be seen as ignoring the social and political context in which women reside (Chantler, 2005; Waterhouse, 1993). The emphasis on autonomy and individual responsibility for change ignores the fact that social roles and norms often prevent women from realizing their potential and can result in blaming women for their problems. According to Waterhouse (1993), “There is within the Rogerian perspective a strong faith in the transformative powers of counselling which is at best overambitious and at worst reckless and irresponsible” (p. 62). Further, the construct of empathy is problematic—to empathize with women or members of other historically oppressed groups requires not just awareness in the here and now, but also an understanding of the historical influences on current social contexts.

From an

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perspective, many of the criticisms and strengths elaborated here apply. The total acceptance of the client by the counselor would be a positive. However,

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advocates would also criticize the theory for ignoring cultural and historical influences that contribute to discrimination and prejudice, including the practice of psychological diagnosis (Livingstone, 2008). The conditions of worth construct might need to be broadened to include societal conditions of worth. Lemoire and Chen (2005) emphasized this latter idea in their discussion of the use of PC counseling with

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adolescents. While allowing that the core conditions provided by the therapist create a safe situation in which the adolescent can explore their sexual identity, Lemoire and Chen also noted that at least three elements need to be added to PC counseling when working with this group: deliberate validation of the adolescent’s sexual identity, discussion of risks and benefits associated with the disclosure of sexual identity, and socialization into the

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community in ways appropriate to the ages of clients.

Crowter (2022) wrote about wrote about a PC perspective on trans experience. Emphasizing the PC value of authenticity, Crowter asserted that the transitioning experience is another form of being oneself in a true way, yet in the midst of dominant cultural narratives that characterize transness as wrong. This view brings forth a new view of incongruence, one that explores the internalized negative evaluations of trans as conditions of worth that must, according to PC theory, be released in favor of an internal locus of evaluation. This banishing of the conditions in favor of trust in the self is difficult, and indeed can be dangerous, both physically and through the loss of friends, family, and jobs. Crowter admonished therapists to create an environment that emphasizes freedom, and the therapist should “not pursue self-acceptance, gender euphoria or authenticity for their client . . . .these types of aspirations are directive and diminish freedom” (p. 12). Although these outcomes might be held to be healthy outcomes, what’s most important is to trust the individual and their actualizing tendency. Likewise, Knutson and Koch (2021), in their presentation of a case study of a gender fluid client, emphasized the value of a collaborative, affirmative PC approach.

In a way, Rogers was ahead of the professional psychology community of his time in terms of considering issues of diversity and oppression. Toward the end of his life, he became involved politically, conducting large encounter groups with individuals from conflicting social groups (such as in South Africa and South America), suggesting a greater awareness of group and social factors in human behavior. In his book On Personal Power (1977), Rogers discussed the utility of the PC approach with a wide variety of people, including African Americans; gay, lesbian, and bisexual individuals; Chicanos; Filipinos; and many others. He acknowledged that “minority group members feel tremendous rage and bitterness towards whites. . . . Rage needs to be heard. This does not mean that it simply needs to be listened to. It needs to be accepted, taken within and understood empathically. . . . To achieve this kind of empathic listening the white needs to listen to his own feelings too, his feelings of anger and resentment at ‘unjust’ accusations” (pp. 133–134; quotes and emphasis in original). However, some writers maintained that these experiences with diverse cultures had little influence on Rogers’s thinking because he did not fully recognize the implications of cultural norms of interdependence and community (Holdstock, 1990).

Long-time PC advocate Patterson (2000) opined that the emphasis on cultural diversity leads to an excessively technique-oriented position in which counselors modify what they do on the basis of the client’s background. Counterpoints to Patterson’s arguments are offered by other PC advocates, who argue that attention to issues of diversity is essential so that PC therapists do not continue the historical patterns of oppression and discrimination seen in many areas of social service (Lago & Hirai, 2013).

Cooper and McLeod (2011) argued that the ultimate PC stance with clients from diverse backgrounds and identities would be a personalized one, based on clients’ stated goals and needs, which should be privileged over generalized theory. This led them to advocate a pluralistic approach they called the goal-task-method in which client input is solicited on goals, tasks, and methods. Ong et al. (2020) challenged Cooper and McLeod, claiming that they promoted theoretical and technical eclecticism, which Ong et al. saw as incompatible with a truly PC approach. Citing the proper PC therapist’s role as “non-manipulative, non-evaluative and non-expert,” Ong et al. asserted that “person-centered therapists do not take the expert role and offer interpretations, advice, or analyze the client simply because in any given moment the client expresses a want for it” (p. 172). They see the PC approach as having distinct philosophical and theoretical roots that cannot be abandoned in favor of theory switching according to clients’ desires. Noting that true PC counseling exists when the therapist is fully present and experiencing, Ong et al. contend that what Cooper and McLeod suggested is essentially asking the PC therapist to be incongruent. Furthermore, PC theory assumes that clients don’t trust themselves (i.e., their organismic valuing process) and often expect the therapist to be in line with the conditions of worth they are carrying with them (e.g., you should be more x or y). Directing the client to talk about goals, wants, and needs is taking an expert stance and so is contrary to the values of the PC counselor, who strives to be in the moment with the client, providing unconditional positive regard. If the client wants to talk about goals and methods, then the therapist surely follows that lead, but there is no reason to direct discussion to those if the client doesn’t bring it up. In essence, the client is always the best expert and the therapist trust this and the client’s emerging actualizing tendency.

The Case Study

Anil presents with depressive and anxiety symptoms, probably very common among the clients with whom Rogers worked as he was developing his theory. The theory accounts particularly well for anxiety and is generally useful in understanding individuals who have difficulty processing and expressing emotion. Anil is a member of a culture traditionally characterized as collectivistic, emphasizing the importance of family (Baptiste, 2005), so the emphasis on values such as individual choice and striving for the betterment of the person in the PC approach may be less than a good fit for him. On the other hand, traditional Indian culture sets the man as the head of the family, responsible for critical decisions and rules, and support of the family. It would be important that a counselor working with him be aware of this emphasis, and how it may tempt the counselor to label these values simply as conditions of worth, potentially pathologizing them. Fully exploring traditional Indian values and how they played out in Anil’s family of origin as well as in his current situation in an accepting way would be a critical aspect of working with Anil. Once Anil gets past his hesitance to discuss and experience emotion, he might be quite comfortable with this approach and its goals.

Summary

PC therapy begins with an optimistic view of people. Humans are seen as growthful beings that attempt to maximize their potential. We inherently move toward experiences that contribute to our growth and away from those that don’t, following our actualizing tendency, which is in turn guided by the organismic valuing process.

Part of actualization of the organism is the development of the self, which adopts part of the actualizing tendency. The urge to self-actualize can create problems, however, when it runs into the need for positive regard. In wanting the love of others, we may internalize conditions that brand aspects of the self as worthy or bad; these conditions of worth may be counter to the self-actualizing tendency. Once an individual internalizes conditions of worth, they are incongruent—they have a discrepancy between self and experience. They deny or distort aspects of their experience that do not fit the conditions of worth.

PC counselors do not diagnose or assess. They simply provide the right atmosphere and trust the client to lead the way. Therapist congruence, empathy, and unconditional positive regard are the necessary and sufficient conditions for client change. Given these conditions, the client will progress from a state of incongruence to one of congruence and become fully functioning.

PC theory has been criticized for being simplistic and oblivious to the true qualities of human nature. Outcome research supports the theory, but theory-testing research is less convincing. The core conditions are likely to be necessary, but not sufficient, according to the data.

The individualistic emphasis within PC theory can be detrimental to clients who have experienced oppression. The lack of attention to familial and cultural factors in PC theory may be problematic in working with clients from other cultures. On the other hand, PC theory’s trust in the individual to know what is needed can be helpful in working with clients from diverse backgrounds and identities.

Box 6.1

Helen is a 43-year-old White lesbian woman who presents for counseling due to problems in her marriage. Helen holds a Master of Fine Arts degree in playwriting from Yale University. She and her wife, Adele, have three children—a 10-year-old boy named Luke, a 12-year-old girl named Grace, and a 14-year-old boy named Charlie. Helen met Adele, 48, while she was attending Yale and Adele was working in New York City as a bond trader.

Helen grew up in suburban Chicago, the third of five children. Helen’s family had the appearance of the “perfect” family. Her father was a very successful surgeon, but not involved in the children’s lives on a daily basis. Mom was loving and steady, yet also somewhat reserved; she was perhaps more concerned with what others thought than she would have liked to admit. In some ways, the family environment was one of benign neglect—the children behaved well, so no one thought there could possibly be anything wrong. In fact, two of Helen’s sisters had eating disorders, and her brother has battled an alcohol addiction off and on. Helen struggled when she decided to come out to her parents, but discovered that her parents, although a little uncomfortable at first, eventually became supportive of her.

Adele and Helen lived in New York City after they married. Helen had an administrative job with a theater and wrote a bit at night, although she stopped writing when they had their son Charlie. They had plenty of money, but Adele began to gamble during a period when her work was not going as well as she would have liked. Helen was 8 months pregnant when she learned that Adele had gambled away large amounts of money, including most of their savings.

Helen was devastated, but having grown up in a family where you stick it out no matter what, she immediately began looking for treatment for Adele and housing options for their young family. Unable to deal with the strain, Helen called on her parents for assistance in spite of the fact that she believes that they never truly accepted Adele. They suggested she look in the Chicago area because it would have job options for Adele and perhaps less pressure than New York City. Helen’s parents offered financial assistance in the form of a down payment on a house, and although it was never stated, it was understood that it was for a house in Chicago. The family moved and has lived in the same house now for 10 years.

On a recent trip to New York with some friends, Helen ran into a former professor from Yale. He asked about her work. She was pleased, but also embarrassed that she’s done nothing, although in her mind this is no great loss because she isn’t all that talented. He reminded her that she won a competition during graduate school and shared a couple of things faculty members said about her in which they praised her talent and insight. He is divorced, 8 years older than Helen, and very handsome.

He asked her to meet him for a drink and gave her his business card. She didn’t call him, but kept the card and did not tell Adele about the encounter. Having survived a crisis in her marriage, she now feels resigned to the humdrum existence of a woman whose partner does not support her career ambitions and has never really confronted her own demons.

Helen is a “good girl,” a thoughtful woman and a devoted mother who has no interest in destroying her family by having an affair. However, she is troubled deeply by the way she feels right now: that Adele can “do no right” and that this is a permanent state for the rest of her marriage. She is surprised by the fact that for 10 years she has endured the crisis caused by Adele’s gambling without its sounding the death knell of their marriage. Yet, out of the blue, she bumps into a former professor who displays interest in her and in her work, and her reaction to this—her interest in him, her irritation that Adele doesn’t do the same thing, and her worry about the aimlessness she is feeling now that her children are older—brings her to a place where she decides to seek help.

R. D. Laing’s Existential Approach to Psychosis

A hallmark of the existential therapies is contesting conventional wisdom, whether it is pointing to the meaninglessness behind life’s apparent purpose or to the inescapable loneliness that persists in spite of our social nature. Similarly, Ronald David (R. D.) Laing, a Scottish psychiatrist whose theoretical association resides in limbo between existential therapy and psychoanalysis, sought to treat severe mental illness, especially schizophrenia, by approaching psychosis as a meaningful reality unto itself as opposed to the more common view of it as a collection of nonsensical symptoms that must be removed.

Trained as a psychoanalyst at the Tavistock Clinic in London from 1956 to 1960, Laing was heavily influenced by object relations theory, especially the work of John Bowlby, D. W. Winnicott, Wilfred Bion, and Charles Rycroft (Laing’s training analyst), but also equally, if not more so, by existential philosophy, including the writings of Martin Heidegger, Jean-Paul Sartre, Martin Buber, and G. W. F. Hegel, among numerous others (M. G. Thompson, 2000; A. Laing, 2007). This blend of existentialism and psychoanalysis is apparent in Laing’s first major work, The Divided Self (1960). Laing contested the conventional wisdom that schizophrenia represented a biological illness, positing instead that it was a complex defense mechanism—an elaborate false-self system—employed to protect the person from overwhelming, painful existential despair, an attempt to ward off severe alienation and invalidation of the authentic self that unwittingly drives the person deeper into a closed loop of interpersonal isolation.

Another major work of Laing’s is The Politics of Experience (1967). Here, Laing committed to a chiefly existential perspective, insisting on the irreducible nature of individual experience and denouncing psychoanalytic theory, the divide between normal and abnormal, and the way society coerces individuals into roles that require them to betray the authenticity of their lived experience. Laing revealed himself to be an ardent humanist and unflinchingly client centered, but he was also a radical without boundaries, his vision implying a kind of experiential anarchy where there was no demarcation between health and dysfunction, no “reality” for the reader to hold on to except the phenomenon of experience itself.

So what would practice in a Laingian vein look like? Cooper (2003) noted that Laing wrote very little about his actual technique but highlights the rapt attention and seriousness Laing gave to his clients’ every experience, reality-based or otherwise, as well as Laing’s arresting presence and uncanny bluntness. For example, Laing was known to sit with catatonic patients for months, imitating their repetitive movements and symptoms, until they finally spoke to him, marking the movement from the cocoon of alienation to being in the world (Cooper, 2003). One of the more detailed accounts of what Laingian technique looked like comes from M. G. Thompson (1997), an existential psychoanalyst who trained under Laing in the days of Kingsley Hall, a group home where clients and therapists, including Laing himself, lived together without hierarchy or professional boundaries. It was common for Kingsley Hall to house all sorts of individuals, from the relatively “sane” to people in the midst of severe mania or psychosis; it embodied the anarchy of experience that Politics theorized.

Thompson (1997) described the primary goal of Laing’s approach as a “fidelity to experience,” meaning that the therapist (or in this case, the treatment community of Kingsley Hall) abided by the clients’ unique experience of suffering entirely as it is for him or her rather than how psychology, society, or anyone else would like to see it. Thompson told the story of Jerome, a young man with features of catatonic schizophrenia and anorexia who moved into Portland Road, another community home overseen by Laing and analogous to Kingsley Hall, where Thompson lived for some time. The treatment account is nothing short of harrowing, with the house members trying unsuccessfully, despite their best attempts at empathy, to get Jerome to connect with others, and even to eat. Jerome slipped deeper into isolation, began defecating in his room, developed awful bedsores, and became dangerously thin. Terrified but exhausted, the house members left Jerome alone, resigning to a complete acceptance of his dangerous behavior. One day, Jerome came down from his room to use the toilet, began talking to the other house members, and eating. Stunned, they asked Jerome what he was up to all this time, and Jerome said that “he had to count to a million, and then back to zero, uninterrupted, in order to experience his freedom,” a task that was impossible with everyone interrupting him for so long (M. G. Thompson, 1997, p. 609). According to Thompson, Jerome never had another psychotic relapse and went on to live a very ordinary life.

As a person, Laing was as radical and contrarian as his theories and approach, becoming something of a celebrity and provocateur. He was ardently against psychiatry and psychology, despised formalized training, and was a major supporter of psychedelic drug use as a road to deeper understanding (M. G. Thompson, 1997; Cooper, 2003; A. Laing, 2007). Laing once told Thompson that he believed one of the prerequisites for psychoanalytic training should be, besides a personal analysis and reading the Standard Edition of Freud, taking LSD (M. G. Thompson, 1997). Laing was also known for using LSD with clients, as well as partying and vacationing with them (M. G. Thompson, 1997; Cooper, 2003). Laing died in 1989 in St. Tropez, France, of a heart attack while playing tennis, his final words when asked if he wanted a doctor, betraying, in vulgar fashion, some of his own philosophy: “Doctor? What fucking doctor?” (A. Laing, 2007). Provided one takes the boundlessness of Laing’s thinking with a grain of salt, many useful perspectives can be gleaned from his work, not the least of which was an unyielding effort to render the inhuman human.

Source: Courtesy of Adam Hinshaw, Ph.D. Used with permission.

Other important existential theorists/therapists are Victor Frankl, who developed his approach, logotherapy, in the 1940s and then wrote the classic Man’s Search for Meaning (1946/1984) after surviving the Auschwitz-Birkenau Nazi concentration camp. You can find more information on Frankl and logotherapy at the Viktor Frankl Institute (https://www.victorfranklinstitute.org/logotherapy.html). In the United States, Irving Yalom is a prominent voice, having written several professional books and novels with existential themes. Organizations of interest include the World Confederation for Existential Therapy (existentialtherapy.net) and the Society for Existential Analysis (www.existential-analysis.org.uk), which was founded by noted ET theorist and practitioner Emmy van Deurzen. Other ET writers of note in the United states are Ruthellen Josselson, Kirk Schneider, and Orah Krug.

As with most major approaches to psychotherapy, ET was developed primarily by White men, many of whom were of the Jewish faith. The approach has a long history, so many of the sources I cite in this chapter may seem dated, but are considered classics. A good example of this would be Yalom’s (1980) book Existential Psychotherapy. Given its origins and history, ET can be criticized as too individualistic, for its emphasis on personal responsibility and contention that we are ultimately alone in the world. I would also note that ET has its origins in existential philosophy, which for the most part I do not reference. More detail about these origins can be found in Cooper et al. (2019).

Basic Philosophy

The basic philosophy of ET theorists is that humans are free, are responsible for their own lives, and have the potential for self-actualization (Craig, 2008). It can sometimes appear to be a rather gloomy approach. Cooper (2003) reported that when asked what ET is, he sometimes resorted to “it’s similar to person centred therapy . . . only more miserable!” (p. 1). Randall (2001) suggested that underlying ET is a philosophy that “the life of each human being is a finite drama enacted in a hostile or indifferent universe; that the purpose of life is not at all given, but must be selected afresh by each individual through conscious acts of willfulness tempered by responsibility, and that no matter how close a person may feel toward another, each ultimately must face life alone” (p. 260). Frankl (1946/1984) added that “to live is to suffer, to survive is to find meaning in the suffering” (p. 11). On the other hand, ET theorists recognize the human capacity for creativity and love. Frankl (1946/1984) wrote that “love is the ultimate and the highest goal to which man can aspire . . . the salvation of man is through love and in love” (p. 57; emphasis in original).

ET theorists have a favorite phrase: “existence comes before essence” (Adams, 2013, p. 11). By this they mean that first we come to be, and then we use our creative powers to develop who we are, our essence. We have no control of the basics (e.g., genetics, gender, race, culture) and are thrust into the world with the fact of our death but no knowledge of when we will die. We have only choice and responsibility and the anxiety that accompanies them because it is hard for us to accept that beyond our initial basics, we are what we choose. As ET theorists put it—we are thrown into life and must make of it what we can (van Deurzen & Adams, 2016).

Lars, Helen’s existential counselor, approaches her with the attitude that she is a free, responsible being who has the potential to grow and flourish. Helen may seem stuck right now, but her distress and sadness are signs of the potential within her to be creative and loving.

Human Motivation

Frankl (1946/1984) contended that the principal motivation of human beings is the search for meaning, and most ET theorists would agree. However, there is some disagreement about the source of this meaning. For Frankl, meaning is inherent in each individual—each individual has an ultimate, true calling—and it is the task of the individual to discover it (Cooper, 2003). For other ET theorists, meaning is created; there is no discovery involved.

Frankl (1946/1984) maintained that we discover life meaning through three routes: “(1) by creating a work or doing a deed; (2) by experiencing something or encountering someone; and (3) by the attitude we take toward unavoidable suffering” (p. 133). Despite statements like this one, some accuse Frankl of implicitly endorsing a religious aspect to meaning (Yalom, 1980).

Proponents of ET generally accept the idea of the unconscious and the dynamic nature of psychological functioning, but the content of the unconscious is not instinctual drives, as Freud proposed (Yalom & Josselson, 2019). Instead, what is relegated to the unconscious is the true nature of our existence: that we are finite beings alone in a meaningless world.

Lars wonders about Helen’s search for meaning. He guesses that in the past she has found meaning through her writing, her marriage, and raising her children. Lars guesses that the vague sense of anxiety that Helen is experiencing stems from her sense of mortality, which is just beneath the surface of awareness right now.

Central Constructs

Modes of Being

ET theory is focused on the being of humans. ET theorists recognize distinct ways of being, although they often use different names for them and the classic terms are in German (van Deurzen, 2010). The first is Umwelt, or being in the physical world. Mitwelt is being in relation to others, the social/interpersonal world, and Eigenwelt refers to the inner psychological world (being in one’s subjective experience). Überwelt is the final dimension, the spiritual world. Truly authentic existence means attending to all realms. However, at a given point in time, we typically have one or two ways of being with which we are most concerned (van Deurzen & Adams, 2016).

Helen appears to be functioning primarily in the Mitwelt—or at least attending to that aspect of her being at the expense of the Umwelt and Eigenwelt. She had spent much time worrying about her family until the recent encounter with her former professor. She is tempted to enter the Eigenwelt, but her early training in her family of origin leads her to be uncomfortable with a self-focused orientation. She learned very early on that women take care of others first.

Anxiety

ET theorists assume that everyone experiences anxiety; indeed, May and Yalom (2005) argued that “anxiety arises from our personal need to survive, to preserve our being, and to assert our being” (p. 271). To experience anxiety is therefore normal and expected, and according to Yalom (1980, 2008), the most powerful anxiety is associated with the awareness of one’s mortality, sometimes called existential anxiety. However, other theorists (e.g., Søren Kierkegaard) associate existential anxiety with the awareness that we are not living up to our potential (Arnold-Baker & van Deurzen, 2008). Anxiety can come in other forms, too, depending on which ET theorist you read, but for these theorists, “anxiety is a teacher, not an obstacle or something to be removed or avoided” (van Deurzen & Adams, 2016, p. 30).

Lars notes Helen’s clear sense of loss of purpose and unrest. Clearly she is becoming aware of her existential anxiety, which he thinks stems from her sense of finiteness and also is related to her feeling that she is not using her talents.

The Ultimate Concerns

Yalom identified four existential themes of human existence: death, freedom, meaning, and isolation (Yalom, 1980; Yalom & Josselson, 2019).

Death

The ultimate concern is death, because “death itches all the time,” according to Yalom (1980, p. 29). We humans have a great propensity to avoid really facing the idea of our own mortality, but when we are able to, we experience the ultimate terror. As a result, much of our psychological life is built around avoiding truly facing our fates: Death and the anxiety that it triggers are the source of most psychological dysfunction. However, the awareness of death leads us to live purposefully and with awareness of our humanity. From this perspective, “death . . . enriches life” (Yalom & Josselson, 2019, p. 275).

Freedom

From an ET perspective, an essential aspect of human existence is freedom—the notion, according to Yalom (1980), that “the individual is entirely responsible for—that is, the author of—his or her own world, life design, choices, and actions” (p. 9). May and Yalom (2005) pointed out the terrifying consequences of accepting one’s freedom: If we are totally free to choose and act, then we must recognize that “there is no ground beneath us: there is only an abyss, a void, nothingness” (p. 280). Ultimately, freedom implies responsibility for ourselves—our actions, but also our failures to act.

Awareness of our freedom implies responsibility to choose. Even if we are not aware of it, we are constantly making choices and our actions reflect these (K. J. Schneider & Krug, 2020). The reality of freedom, choice, and responsibility brings to us the notion of existential guilt: guilt that we experience about possibilities unfulfilled. Existential guilt is unavoidable because every time we make a choice, we are discarding other possibilities (Cooper, 2003).

What if one is trapped in a situation and there is really no way out? Frankl (1946/1984) had the answer; his thoughts were highly influenced by his experience in the Holocaust. He wrote movingly about prisoners in the concentration camps who gave their last food away to others, saying that “they offer sufficient proof that everything can be taken from a man but one thing: the last of the human freedoms—to choose one’s attitude in any given set of circumstances, to choose one’s own way” (p. 86). Frankl describes his experiences in the Nazi concentration camps and how these experiences contributed to his theory of logotherapy; you can read a section of Frankl’s book in Box 6.2.

Box 6.2

An Excerpt from Frankl’s Man’s Search for Meaning

Let us first ask ourselves what should be understood by “a tragic optimism.” In brief it means that one is, and remains, optimistic in spite of the “tragic triad,” as it is called in logotherapy, a triad which consists of those aspects of human existence which may be circumscribed by: (1) pain; (2) guilt; and (3) death. This chapter, in fact, raises the question, How is it possible to say yes to life in spite of all that? How, to pose the question differently, can life retain its potential meaning in spite of its tragic aspects? After all, “saying yes to life in spite of everything,” to use the phrase in which the title of a German book of mine is couched, presupposes that life is potentially meaningful under any conditions, even those which are most miserable. And this in turn presupposes the human capacity to creatively turn life’s negative aspects into something positive or constructive. In other words, what matters is to make the best of any given situation. “The best,” however, is that which in Latin is called optimum—hence the reason I speak of a tragic optimism, that is, an optimism in the face of tragedy and in view of the human potential which at its best always allows for: (1) turning suffering into a human achievement and accomplishment; (2) deriving from guilt the opportunity to change oneself for the better; and (3) deriving from life’s transitoriness an incentive to take responsible action.

It must be kept in mind, however, that optimism is not anything to be commanded or ordered. One cannot even force oneself to be optimistic indiscriminately, against all odds, against all hope. And what is true for hope is also true for the other two components of the triad inasmuch as faith and love cannot be commanded or ordered either.

To the European, it is a characteristic of the American culture that, again and again, one is commanded and ordered to “be happy.” But happiness cannot be pursued; it must ensue. One must have a reason to “be happy.” Once the reason is found, however, one becomes happy automatically. As we see, a human being is not one in pursuit of happiness but rather in search of a reason to become happy, last but not least, through actualizing the potential meaning inherent and dormant in a given situation.

This need for a reason is similar in another specifically human phenomenon—laughter. If you want anyone to laugh you have to provide him with a reason, e.g., you have to tell him a joke. In no way is it possible to evoke real laughter by urging him, or having him urge himself, to laugh. Doing so would be the same as urging people posed in front of a camera to say “cheese,” only to find that in the finished photographs their faces are frozen in artificial smiles.

Source: From Frankl, V. E. (1984). Man’s Search for Meaning (original work published 1946). Reprinted by permission of Beacon Press, Boston.

Meaning

Most ET theorists accept that human existence does not come with built-in meaning (Yalom & Josselson, 2019). Frankl would be the exception to this philosophy, as described earlier (in the “Basic Philosophy” section); however, he believed that each individual’s meaning is unique and is found only as a result of a difficult search and perhaps unavoidable suffering.

Isolation

We are always and ultimately alone, according to ET theorists. We are born and die alone. If we accept our mortality, freedom, and responsibility to create meaning, the realization of our isolation is unavoidable. At the same time, we have a built-in wish for contact or connection with others, so we spend our lives managing the tension between our awareness of our existential isolation and our desire for connection (Yalom & Josselson, 2019).

Helen, Lars thinks, is struggling with all of these concerns simultaneously. She is probably the least aware of her death anxiety, but it is surely the font for her discontent in the other areas of ultimate concern. Helen feels trapped in her current situation and yet guilty for feeling this way. Her sense of meaning has been for a long time invested in raising her children, and although she verbalizes her sense of self-worth tied to this aspect of her existence, now she finds that something is missing. She recalls the sense of meaning and purpose she found in her work as a playwright. Lars thinks that, because of these realizations, Helen probably feels isolated from others and a vague sense of guilt. Lars also wonders if Helen’s experience of isolation is related to being lesbian in a culture that is only beginning to openly accept this identity. Also, there is the notion of Helen’s membership in the White culture, with its norms valuing independence and achievement, accompanied by the restrictions stemming from culturally-based stereotypical roles that dictate that women are to be nurturers and supporters. Although he isn’t sure, Lars also considers the effect of the recent encounter with Helen’s former professor, that the professor is evidently a heterosexual male, and the confusion that this situation may create for her.

Defenses

No matter how hard we try to avoid it, awareness of ultimate concerns is inescapable. When we become aware of one of these issues, we experience anxiety. The result of anxiety is inevitably defense. According to Yalom (1980; Yalom & Josselson, 2019), the most important anxiety is associated with death, and we use two major defenses to ward off the awareness of it: specialness and the notion of the ultimate rescuer. If we are special, death does not apply to us as it does to others. If we have a magical rescuer, they will save us from the possibility of nonexistence.

Lars thinks that Helen’s sense of specialness is not as prominent as her belief in the rescuer. Her disappointment with her wife and her surge of discontent after meeting her former professor would support this hypothesis.

Theory of the Person and Development of the Individual

Existential counselors are not interested in theories of personality because of their orientation toward the essential issues of human existence. They would contend that each individual has the choice, on a moment-to-moment basis, to determine who they are. We are always in the process of becoming, so to imagine a fixed self that can be placed in a diagnostic or personality category is not helpful (K. J. Schneider & Krug, 2020). Theories of personality and development are based on normative patterns and therefore do not capture the unique experience of the individual client. In addition, the existential therapist is more interested in the client’s present experience than their past. However, some ET theorists recognize the developmental sequence from attachment to separation or individuation as inherently tied to the existential dilemma of aloneness (Yaloms, 1980, 1980). Thus, neoanalytic ideas such as those presented in Chapter 3 would fit with the ET perspective.

Lars is more interested in understanding Helen from her perspective than through any scheme describing personality types. He does, however, recognize the influence of Helen’s early environment on the beliefs and ideals she holds as a woman, mother, and spouse.

Health and Dysfunction

A good definition of health from an ET perspective would be authentic (Maddi, 2005). Authenticity involves courage and determination; it involves the willingness to face our own anxiety about not being (Vontress, 2013). Health, in this view, is to be able to deal with the anxiety that is unavoidable as part of being human. Being authentic means to not deceive oneself; such deception is known as acting in bad faith (van Deurzen & Adams, 2016). K. J. Schneider and Krug (2020) write about presence, the capacity to experience the world without distortions, with a fluid and flexible sense of who one is.

In the most general sense, psychological dysfunction in the ET view is the result of living an unexamined life (Arnold-Baker & van Deurzen, 2008). We proceed merrily on our way, going along with the crowd, not thinking about the values and meaning in our lives. If my good friend Laura gets the latest iPhone, then acquiring one becomes a driving force in my life. This kind of existence is inauthentic and ET theorists call it living in bad faith (Vontress, 2013, p. 149). Van Deurzen and Adams (2016) commented that “the path of least resistance leads to a place of least existence” (p. 106), meaning that denying or avoiding the ultimate concerns results in inauthenticity.

For Yalom (1980; Yalom & Josselson, 2019), a major source of psychological dysfunction is conflict, but it is between the individual and the givens of existence, particularly the awareness of death. He proposed that, instead of the psychoanalytic notion that the surfacing of instinctual drives leads to anxiety and then to defense and dysfunction, the correct sequence is the following: The awareness of ultimate concerns (particularly death) raises anxiety, which then triggers the defense mechanisms. More simply put, people “fall into despair as a result of a confrontation with harsh facts of the human condition—the ‘givens’ of experience” (Yalom, 2003, p. xvi). Clients may be troubled by the paralysis of will that comes with human freedom. They may be responding to isolation by frantically fusing with others. Many clients present with feelings of meaninglessness.

However, the most important of the givens is death (Yalom & Josselson, 2019). In dealing with the notion of our own deaths, we rely mostly on two important defense mechanisms, described earlier: feeling special and believing in an ultimate rescuer. Yalom linked the defense of specialness to paranoia and, not surprisingly, narcissism.

The belief in an ultimate rescuer can also lead to dysfunction, and according to Yalom it is a less effective defense than specialness. Investing oneself in the ultimate rescuer can cause the loss of self and a lifestyle that is restricted. This defense is also more likely to break down when one is facing personal illness and sometimes when a special other is threatened.

Another way of looking at psychological dysfunction was presented by Bugental and Bracke (1992). They argued that popular culture has encouraged emptiness and narcissism by focusing on individual achievement without a sense of purpose or meaning. In my opinion, these thoughts still ring true today. We experience emptiness because of this lack of meaning, which stems partially from the loss of connection associated with current lifestyles and norms. We define ourselves through the eyes of others and “are seduced into search for direction, completion, and meaning by seeking more things, desperately fabricating a fashionable appearance, and looking almost exclusively to others . . . to define ourselves” (Bugental & Bracke, 1992, p. 29; emphasis in original). In their version, the healthy person has a “centered awareness of being” (p. 29), which involves searching inwardly for an authentic self.

Frankl (1946/1984) explicitly contrasted “traditional” neuroses and existential neurosis. Traditional or psychogenic neuroses have their origins in the psychological processes identified by other theorists. Frankl was much more interested in what he called noogenic neurosis, difficulties related to existential frustration or the lack of life meaning. Logotherapy, Frankl’s approach, derives its name from the word logos, which means “meaning.”

Lars speculates on Helen’s recounting of her current experience. She clearly presents a sense of aimlessness, a feeling that her existence is “humdrum.” These elements add up to meaninglessness. At present, Helen is not very authentic because she refuses to face up to her existential tasks and have the courage to live without self-deception. However, that she comes to counseling suggests that she is moving in the right direction—with some support, she will likely begin to confront her sense of despair and the reality of her finite existence. Helen does not seem to be very centered right now; she lives more according to the needs of others and neglects her own very difficult feelings. She seems a little vegetative, yet Lars sees movement starting to build.

Nature of Therapy

Assessment

Existential therapists don’t do much formal assessment; most would agree that to assess and diagnose doesn’t capture the essence of individual existence. Furthermore, it creates distance between client and counselor, interfering with the authentic encounter necessary for effective therapy. The existential therapist will look for the client’s assumptions and judgments about themselves and the world and also their interest in undertaking the important task of examining one’s life (Arnold-Baker & van Deurzen, 2008). Assessment is holistic, ongoing, and focused on what is alive for the client in the moment (K. J. Schneider & Krug, 2020).

Lars does his best to get to know Helen, to enter her world, while maintaining his own authenticity. He notes that she is unsettled and questioning the meaning of her life, a good sign for the beginning of therapy.

Overview of the Therapeutic Atmosphere

ET is an experiential approach and is focused intently on the immediate subjective experience of client and therapist (K. J. Schneider & Krug, 2020). Because this approach is very philosophical, you might expect the existential counselor to act like your stereotypic philosopher: thoughtful, passive, turned inward. You would be wrong: Existential therapists are quite active in their relationships with clients (K. J. Schneider & Krug, 2020).

Existential therapy may not be focused solely on the ultimate concerns, but the therapist will not shy away from them (Yalom & Josselson, 2019). Of primary concern to these authors is the immediacy of the therapeutic relationship, the focus on the here and now. Schneider and Krug (2020) discuss this quality as presence, on part of both the therapist and client.

As active as they are, existential therapists do not attempt to give clients solutions to their problems. In fact, they are more likely to challenge clients, encouraging them to have the courage to face the ultimate concerns (Cooper, 2003). As van Deurzen (2006) put it, “An attitude of openness is encouraged and clients are not mollycoddled, though treated with respect, care and understanding” (p. 283).

Generally, ET does not fit in a short-term model. Yalom typically sees clients for several years—and sometimes twice a week. However, he readily acknowledges that many therapists practice in conditions under which longer-term psychotherapy is not possible. Thus, ET theorists acknowledge the possibility of shorter term work (K. J. Schneider & Krug, 2020). In addition, as you will see in the section on research support, short-term versions of ET are being tested in the UK. However, more commonly, ET therapy is longer term, lasting 2–5 years (K. J. Schneider & Krug, 2020).

Lars begins the counseling relationship with Helen with a sure sense of who he is and a ready energy to devote to the process. He is unsure what is to come, but welcomes the challenge and has faith in Helen to be able to handle it.

Roles of Client and Counselor

The therapist in the ET tradition has been described as a consultant who has a very real, deep caring for the client (Bugental & Kleiner, 1993). The therapist also attempts to demystify the counseling process and relate authentically to the client. As part of relating authentically, the counselor must have attended to their own existential issues, for as van Deurzen (2010) pointed out, the counselor should not be “existentially lazy” (p. 256). The therapist who has accomplished this existential scrutiny will not hide behind authority or therapeutic neutrality and will treat the client as an equal, or as Yalom and Josselson (2019, p. 275) wrote, as a “fellow traveler.” In this role, the therapist is to be as authentic and genuine as possible. To accomplish this therapeutic stance, it is necessary for the existential therapist to have their own therapist (van Deurzen & Adams, 2016).

Spinelli (1997, 2007) saw therapy as a challenge for both therapist and client. He maintained that the therapist must be an active participant, not an observer of the process, and thereby risks having their values and beliefs shaken by experiences with clients. Further, the therapist stands beside the client, maintaining an attitude of respectful curiosity, even if the client’s way of being is alien or uncomfortable for the therapist (Spinelli, 2019).

The client must also be an active participant in the counseling process, struggling with choices and recognizing their freedom (Schulenberg et al., 2008). Ideally, clients must summon the courage to be wholly present in the moment and to tolerate the anxiety that goes along with the ambiguity of life and our responsibility, freedom, aloneness, and finite being.

As Lars engages in the relationship with Helen, he relies on an attitude of respect and curiosity, with the awareness that what he brings to the relationship will be evident only if he is as authentic as he can possibly be. He is prepared to care deeply about Helen and to feel challenged by the paths of exploration she chooses and the likely sense of suffering and pain that will emerge.

Goals

Perhaps the simplest statement of the goal of ET came from Norcross (1987), who opined that “the purpose of psychotherapy is to set people free: free of symptoms and free to be aware and to experience one’s possibilities” (p. 48). A more detailed description from Cooper et al. (2019) is this:

Existential therapies explore our lives, as an engagement with existence and the world: they explore what it means to exist, to stand out in the world. They investigate what it means to be here, right now, as a living being. Faced with choices, dilemmas and limitations existential therapies ask what it means to be human and how to best tackle our challenges, obstacles, and problems. They explore—with courage, openness, and humility, the very grounds of human being (p. 1).

K. J. Schneider and Krug (2017) identified several aims of ET counseling, including helping clients to be authentic (“present to themselves and others” p. 22) and to explore ways they avoid this, to help clients take responsibility for the construction of their being, and to choose ways of being based on the awareness of existential concerns (e.g., limitations, freedom, finiteness).

Ultimately, the client, who is typically feeling bored and apathetic or unhappy with life, needs to “come face to face with herself, in the ruthless honesty of inner silence” (van Deurzen, 2012, p. 204). Then they can decide what they really value—gives meaning to life—and go for it.

Lars hopes that Helen, ultimately, can find her way out of her current “stuckness” into authentic experiencing. She must accept her own sense of freedom and the responsibility that is hers alone for what she does with this freedom. Lars believes that Helen will acknowledge her limited existence and the aloneness that will first catapult her into existential terror. However, Lars is certain that Helen will eventually find her way out of the abyss by examining her current existence and moving forward to develop new meaning in her life.

Process of Therapy

A clear contract should be established as ET begins, including length of therapy, location, and fees (van Deurzen & Adams, 2016). As with any approach to helping, the early sessions should be focused on building a strong, trusting, therapeutic relationship. The actual working phase of therapy follows, in which, according to van Deurzen and Adams (2016), the existential counselor assesses the client’s material in terms of the four ways of being: Umwelt, Mitwelt, Eigenwelt, and Überwelt. With this knowledge (e.g., with which way of being the client is most comfortable), the counselor can then help the client examine their strengths and weaknesses and their beliefs and values and can gently point out where they are self-deceiving (Arnold-Baker & van Deurzen, 2008).

K. J. Schneider and Krug (2020) discuss the process of ET as prioritizing cultivating presence in both the therapist and client, which allows the client to struggle with their deepest conflicts. Ultimately, resistance or self-protection will emerge, and this stance on the part of the client is to be respected—but the therapist’s job is to allow the client to struggle. If clients are able to overcome their understandable fear and pain, meaning will emerge and they become more alive. If all goes well, a sense of awe is born, “which is the humility and wonder, thrill and anxiety, of simply life itself. It is the capacity to experience the adventure of life” (K. J. Schneider & Krug, p. 279; emphasis in the original).

Although existential therapists always keep their versions of the ultimate concerns in mind, Yalom reminded us that these concerns are not in the forefront for all clients or for a particular client at all times. He warned us that “therapy should not be theory-driven but relationship-driven” (2003, p. xviii). However, M. Frank (2011) argued that the most important process in ET is for the client to become aware of her existential issues.

Some proponents of ET take an interpersonal approach, seeing the client’s pattern of interpersonal relationships as reflective of their stance toward self, others, and the world—in other words, their way of being in the world (K. J. Schneider & Krug, 2020; Spinelli, 2007; Yalom & Josselson, 2019). This orientation would translate to a focus on the therapeutic relationship, or the encounter, as an indicator of the client’s selfhood. Focusing on the relationship is also another intensification of presence, according to K. J. Schneider and Krug (2020). The relationship between therapist and client often becomes the center of therapy. As Schneider and Krug put it: “there is something profoundly naked about the turn to an immediate interaction. It takes the parties out of their inward routine . . . and focuses the spotlight on a new and utterly alternative reality—themselves” (p. 272).

When the client is struggling to confront the ultimate concerns, existential therapists call this reluctance or protection (K. J. Schneider & Krug, 2020; van Deurzen & Adams, 2017). This reaction can be seen as stemming from the client not accepting the therapist’s agenda or from an understandable desire to stay with the safe and familiar. van Deurzen and Adams (2017) reserve the term resistance for situations when clients are not aware that they are avoiding facing the ultimate concerns; they will dismiss the possibility that they are evading. However, they caution that therapists need to be aware that they can be wrong, so when a client appears to disagree with the direction of therapy, it is unwise to automatically label them as resisting.

Schneider and Krug (2017) discussed transference in ET work, noting that clients bring into therapy protective patterns of interacting that are enacted with the therapist but are reactivations of previous experience. These patterns are seen as expressing the client’s sense of themselves, which is usually negative, and also often cast the therapist in some negative light. As with resistance, however, it is important that the therapist working with these interactions to avoid assuming that they are correct in their assumptions about the source of the transference—a cautious approach is best, assessing to see if these are truly old patterns, disagreements about the course of counseling, or misunderstandings based on differences between client and counselor (e.g., cultural backgrounds, gender, gender identity, sexual orientation, ableness, etc.). Also, ET theorists also acknowledge the possibility of the therapist’s values or experiences seeping into the therapy, or countertransference. The potential for countertransference, then, is another reason that the ET therapist should have their own therapist or consultant.

Lars and Helen begin by negotiating a therapy contract. As their relationship begins, he attempts to enter her world as best he can, staying present in the moment and true to himself. Lars anticipates that his encounter with Helen will change both of them. Lars observes that Helen seems to be most comfortable in the Mitwelt, although she is beginning to consider the Eigenwelt. As he listens carefully to Helen, Lars anticipates that there are times that he will get off track, will be distracted, or will experience emotions that are connected with their encounter. When this happens, Lars will try to be authentic in dealing with these experiences.

Therapeutic Techniques

Existential counselors are not big on techniques. In fact, Cooper (2008) commented that they “are often much better at saying what they don’t do than what they do do” (p. 237; emphasis in original). For some, techniques are seen as potential barriers to an authentic relationship; they can get in the way of the counselor’s understanding of the client on a meaningful level (Vontress, 2013). Other ET writers have accepted that, although for the most part existential counselors do not advocate any specific techniques, they do tend to draw from a wide array of interventions found in existing counseling approaches (K. J. Schneider & Krug, 2020); for instance, most existential counselors would agree that self-exploration, insight, and challenge are important elements of therapy. The therapist meets the client where they are and tries to determine what is most important for them in that moment. I will present below a few techniques mentioned most often by ET advocates, with emphasis on how they might be used to address ET goals.

Relationship and Presence

ET therapists are very invested in the therapeutic relationships, as authentic fellow travelers (L. Hoffman, 2019). Both the therapist and the client must have presence, which is more than just being present in the moment. It has both interpersonal and intrapsychic elements. Schneider and Krug (2017) wrote that “presence involves aspects of awareness, acceptance, availability, and expressiveness in both the therapist and the client. Presence implies that the encounter is real” (p. 21).

Lars begins with Helen, committing himself fully to the relationship, yet with a humble appreciation for the power of the encounter. He hopes that Helen will be able to have the courage to engage authentically and to experience the encounter, the presence, of the therapeutic process.

Questioning

Existential counselors engage their clients in self-examination, holding the belief that the client will find meaningful answers only through exploring their own experience and values (van Deurzen & Adams, 2016). The therapist participates in ‘questioning-with’ rather than an interrogative ‘questioning of’” (p. 48), creating a Socratic dialog with the client to explore their being and existence. In this dialogue, the therapist must be very careful not to offer solutions or advice, because to do so would be to assume an “expert” stance inconsistent with the practice of ET. In reality, ET therapists sometimes offer information or advice, but must be very mindful of their motivations in doing so.

Lars and Helen discuss what is important in her life. Lars asks a bunch of questions of Helen, such as “What makes you happiest these days?” “Tell me about what seems most important to you of late.” “Are these priorities the same as you have always held, or have things shifted for you?” In this discussion, Helen struggles with a feeling of emptiness, not really being able to identify what is important to her; she feels a deadness inside. Lars asks her to describe that deadness.

Bracketing

The existential counselor must learn to suspend their own beliefs and biases in favor of fully understanding the client’s world (Cooper, 2008). This process is called bracketing and allows the therapist to adopt the attitude of “un-knowing” recommended by Spinelli (1997). However, modern ET advocates acknowledge that complete objectivity on the part of the counselor is impossible; the best we can do is to be aware of our assumptions so that they do not impede the client’s exploration of their world (van Deurzen & Adams, 2016).

Lars works hard to clear his mind of his own beliefs and values when he encounters Helen. However, he is aware that this is not entirely possible, so he brackets his material, but remains aware that it is there without focusing on it.

Attention to Nonverbal Behavior

Because the emphasis in ET is on awareness of one’s being, existential counselors are very interested in observing the client’s nonverbal expression (Cooper, 2003; K. J. Schneider & Krug, 2020). In some instances, the therapist may simply use the observation to more fully understand the client’s way of being. In other instances, the therapist might call the client’s attention to the nonverbal behavior as a way of enhancing experiencing, or presence in the moment. Schneider and Krug describe a technique they called embodied meditation, in which the therapist helps the client locate tension in their body and then explore associations with it (e.g., thoughts, feelings, images).

Lars observes Helen for nonverbal signs of her current state. He notes that she clasps her hands across her body and asks her to notice this and try to describe what she is experiencing. Helen responds that she is feeling isolated and alone and the clasp of her hands is a way of soothing herself.

Self-Disclosure

It is quite common for ET practitioners to share their personal reactions with their clients; the therapist must be capable of being known to the client (Yalom & Josselson, 2019). Stemming from the ET value that the counselor must be authentic and present, self-disclosure is seen as deepening the therapeutic encounter. The counselor can disclose in one of two ways: about the process of therapy (i.e., the client–counselor relationship) or about the therapist’s own existential struggles (Colledge, 2002). Yalom and Josselson (2019) thought that disclosure should be most often about the therapeutic relationship in the moment, commenting that “it is the examined therapeutic relationship that heals” (p. 295, emphasis in original). Therapist self-disclosure can also help in clarifying and challenging the client’s worldview (Spinelli, 2007). Great care must be taken when using these disclosures because they might overwhelm or confuse the client or turn the focus away from the client’s process of exploration.

Lars is willing to open himself to Helen, should the moment arise. For instance, he might respond to the feeling that he is distant from Helen and express his real wish to more fully encounter her. Lars might also reveal some aspect of his own search for life meaning.

Paradoxical Intention

One of the best-known ET techniques, paradoxical intention, originated with Frankl (1946/1984). Used mainly for what Frankl termed neurotic fear (as compared to the realistic fear of unbeing), it involves encouraging the client to “go with” a troublesome symptom or problem and experience it deliberately, while adding humor to the experience (Schulenberg et al., 2008). Facing and experiencing whatever it is we greatly fear allows us to engage the unique human capacity to laugh at ourselves and thereby gain distance from our symptoms. In addition, experiencing our difficulty deliberately brings us to the awareness that we can exist despite it, or better, with it (Längle & Klaassen, 2019). An interesting tidbit is that currently, paradoxical intention is considered an evidenced-based treatment for insomnia—basically the client is asked to try to stay awake as long as possible (Jansson-Fröjmark, 2022). However, the underlying theoretical rationale for this intervention is not rooted in ET.

Because Helen does not report a specific, traditional symptom, paradoxical intention may not be a good choice, thinks Lars. However, he does consider asking Helen to deliberately experience “humdrum” to more fully explore this sense of stuckness. She should take the time to be as absolutely humdrum as possible. No one can be more humdrum than she!

Dereflection

Another strategy offered by Frankl, dereflection, consists of directing the client to turn their attention out to the world. It is meant to combat the tendency that Frankl saw in some distressed individuals to focus too intently on internal processes (Schulenberg et al., 2008). It was often used to combat impotence and other sexual dysfunction—Frankl (1975) described a number of case studies in which dereflection involved prohibiting sexual activity, resulting in good outcomes.

Lars observes that Helen does not seem excessively self-focused at this time. Rather, she seems more intent on meeting the needs of others, and this is a long-time pattern for her. Lars concludes that using dereflection is not advisable, but he is always open to the possibility that it might be useful later on in therapy.

Dream Analysis

Yalom (1980; Yalom & Josselson, 2019) is a big fan of dream analysis. Rather than looking for unconscious conflicts between psychic entities as a psychoanalytic therapist would, however, the existential therapist is looking for manifestations of the client’s issues around the four ultimate concerns. According to Yalom and Josselson, dreams can reveal metaphors about the deepest parts of the client, or they can be comments on the therapeutic relationship. Another perspective on dream analysis comes from van Deurzen and Adams (2016), who advocated for an exploration of a dream for meanings at the four levels of existence—physical, social, personal, and spiritual. Determining the meanings in the dream is totally up to the client, even if the therapist suspects something other or more than the client finds. “There are always multiple ways to understand a given dream, but the ‘true’ meaning of the dream is whatever resonates with the client” (van Deurzen & Adams, 2016). According to van Deurzen (2012), it is always better for the client to discover such meanings when they are closer to being ready to act on them.

Helen relates a dream to Lars about being swept away by a river. Her family watches from the banks, passively. The college professor is also on the banks, but seems to be upset and follows her progress closely. Together, Lars and Helen explore the meaning of this dream, finding that it symbolizes her feelings of powerlessness, the state of her relationships with her family, and her ultimate aloneness. The professor is the only hope, the dream seems to say. He may be the ultimate rescuer; however, it is likely that on a deeper level the professor-figure is a reflection of a part of Helen that wants to take action to find new sources of meaning in her life. Lars notes that the dream is very physical yet involves many social elements, too. Also of interest is that Helen doesn’t seem, in the dream, to be terrified, but more intently observing what is happening. Lars thinks this is a good sign for therapy.

Guided Fantasy

Yalom (1980) described using imagery to increase death awareness (p. 175). The client is asked to meditate on their death in some way: for example, picture their funeral, write their obituary, or speculate on where, how, or when it will happen. This kind of imagery can also boost the client’s awareness of what is meaningful and important, prompting the client to assume greater responsibility for their life.

Lars considers having Helen contemplate her death. She is at first very afraid of this exercise, but goes on to paint a vivid picture. She cries as she connects with the feelings of aloneness.

Evaluation of the Theory

ET is criticized on a number of counts. First, it is not really a cohesive theory of psychotherapy—it seems more a collection of components of existential philosophy on which to base a technically eclectic practice. The very diversity of viewpoints makes it difficult to form a coherent sense of ET. It also makes it difficult to empirically test the ET model, because there isn’t one universally accepted theoretical structure. A second criticism is that writers in this area are often difficult to read. They tend to use abstract terms and sometimes convoluted language and rationales. For English-speaking readers, the borrowing of terms from German is often difficult. The philosophical nature of the approach and the emphasis on introspection have led to observations that the approach is most appropriate for highly educated clients (Vontress, 2013).

Qualities of the Theory

Precision and Testability

You have probably divined by now that the ET approach is not very testable because of its philosophical nature and the variations in theoretical structures across theorists within this camp. However, one line of research in social psychology explores terror management theory, or the ways in which humans avoid evidence of their mortality. In Box 6.3, I provide a brief summary of this theory and research. Also, logotherapy has provided some testable constructs (e.g., meaning in life, paradoxical intention); research in this area is summarized under “Theory-Testing Research” and is supportive.

Box 6.3

Terror Management Theory: Existential Theory in an Experimental Paradigm

Despite claims by many that existential theory could not be studied in traditional scientific paradigms, in the early 1980s three graduate students decided to try. Sheldon Solomon, Jeff Greenberg, and Tom Pyszczynski, reviewing the current state of social psychology, concluded that it was quite elegant in describing how we function but lacking in explanation about why. Solomon et al. (2004) identified two critical questions that were neglected by mainstream psychology:

Why are people so intensely concerned with their self-esteem?

Why do people cling so tenaciously to their own cultural beliefs and have such a difficult time coexisting with others different from themselves? (p. 14)

They set out to study these issues, developing what they later named terror management theory (TMT). Their early research efforts got a less-than-warm reception from their social psychology colleagues, but they were not dissuaded. Based partially in evolutionary theory, Solomon et al. (2004) postulated that, because humans are self-aware, we are also aware of our own mortality. To compensate for the resulting terror, we developed culture. Culture gives us a sense of self-worth (we are valuable members of a meaningful venture), safety and security, symbolic immortality through preserving cultural artifacts and traditions (e.g., art and science), and protection for our children. Sometimes culture implies religion, which assures us of the “real” immortality of an afterlife.

The need for self-esteem, in this view, is universal (Solomon et al., 2004, p. 17). Self-esteem is connected to culture, for it is derived through membership in the meaningful culture and adherence to cultural rules. However, the existence of other cultural groups who have different values is inherently threatening: To acknowledge the validity of beliefs at odds with our own is to perceive that ours is not the true, protective cloak that shields us from mortality. A third important buffer is close interpersonal relationships (Pyszczynski et al., 2021). Thus, three essential processes protect us from the terror of death: (a) belief in our cultural worldviews, which leads to (b) self-esteem attained through meeting our culture’s standards, and (c) important relationships, which provide further support for one’s views and self-esteem.

Solomon et al. (2004) set out to test their theory, and a particularly interesting aspect of this research is that involving the mortality salience (MS) hypothesis: “If cultural worldviews and self-esteem provide beliefs about the nature of reality that function to assuage anxiety associated with the awareness of death, then asking people to ponder their own mortality should increase the need for the protection provided by such beliefs” (p. 20). MS interventions, for example, should produce positive affect for those similar to us (who hold the same beliefs) and denigration of those who are different. Typical MS interventions ask participants to write down feelings invoked by thoughts of their own deaths.

Terror management hypotheses have since been confirmed in hundreds of studies Schimel et al., 2019). In one early example, J. Greenberg et al. (1990) asked participants who were Christian to evaluate target individuals who were either Christian or Jewish after receiving or not receiving an MS intervention. They found that these Christian participants reported more positive reactions to the Christian target and more negative reactions to the Jewish target when they had received the MS intervention (they called these effects “worldview defenses”). No such differences were found in the control (no MS intervention) condition. Subsequent studies confirmed these attitudinal effects and found behavioral differences, too. Other research has demonstrated that MS interventions create activity directed at bolstering self-esteem and that relatively high self-esteem appears to reduce the need to enact worldview defenses. In addition, MS can also promote socially constructive behaviors when prosocial attitudes are salient (Schimel et al., 2019).

Subsequent research examining the mechanisms underlying terror management processes has supported the theory (J. Hayes et al., 2010; Schimel et al., 2019). Further investigations have examined other variables related to terror management. For example, Yaakobi (2015) found that the desire to work serves as a buffer from death anxiety induced by MS intervention, even when comparing cultures that differed in the extent to which they valued work. Reasoning that humor was also a way to deal with existential anxiety, Long and Greenwood (2013) found that participants primed with MS intervention composed funnier cartoon captions when compared to those written by individuals primed with thoughts about physical pain. A more recent study of internet memes during COVID-19 related lockdown in Israel found that the humor in them functioned in three ways to buffer death anxiety raised by the pandemic crisis, all consistent with TMT (Mahat-Shamir & Kagan, 2022). First, humor was used to connect to one’s cultural worldviews. It also emphasized one’s membership in a chosen group, and finally, it allowed one to increase one’s sense of control in a threatening situation. For example, Israeli cultural values that promote wanting to have and raise children gave rise to the meme “Carona death rate: 2.4% of patients, quarantine with children death rate: 100% of parents” (p. 5). An example of group membership: “your ancestors fought the Nazis and the Arab armies, paved roads, dried up swamps. You are only asked to wash your hands, put your ass on the couch and watch Netflix. Can you please not screw it up?” (p. 5). Humor was a way of gaining control through the release of tension: “Wait, when they said on the news, they are closing schools and kindergartens they meant with the kids inside? Right?” (p. 7).

So terror management is alive and well—if you believe the research (but you would have to be of a culture that values such scientific activity, according to the theory). You might want to give these ideas some thought the next time you are facing a client of a different worldview.

Empirical Support

ET folks are not too enthusiastic about traditional empirical research. Vontress (2013) opined that “existential therapy is essentially a philosophy for living. As such, it seems illegitimate to compare its outcome with those of psychologically based therapeutic models” (p. 155). Some opine that qualitative approaches to the study of ET make sense (e.g., Finlay, 2012), but these investigations seem few and far between. Further, the general lack of structure and clarity of ET as a theoretical orientation contributes to the difficulty. However, some outcome research has recently emerged, and a significant amount of research has accumulated around several ET constructs, as you will see when you read the theory-testing section below.

Research Support

Outcome Research

In earlier editions, I started this section with the statement “formal outcome research on ET is rare.” However, in the previous 10 years or so, several systematic quantitative studies of existentially-based therapy have appeared. Rayner and Vitali (2016) studied existential experimentation (EE), a short-term approach based in ET. Not surprisingly these days, the study was performed in the United Kingdom National Health Service (NHS) primary care system, because services are free and a number of systemized psychological treatments are made available in an attempt to make psychological services more accessible. In this study, clients experiencing depression or anxiety were “arbitrarily” (p. 363) assigned to EE or another recognized treatment, and received six sessions of EE on a weekly basis. A total of 41 clients completed EE treatment but not all participants completed all of the outcome measures. Of those who did (a little more than half of the group), strong pre- to post-therapy change was observed on all measures. This is a modest study given the problems with response rates for the measures and questions about the nature of assignment to treatments, but can be taken as some evidence that a variant of ET was successful with this small group of clients. If arbitrary assignment is synonymous with random assignment (to treatment), then this study has the strength of a true experimental design.

Stephenson and Hale (2020) studied existential-phenomenological therapy (EPT), also in the NHS environment. They compared EPT outcomes with those of clients who completed cognitive behavior therapy (CBT) on a standardized measure that taps both well-being and symptom reduction. This study used a naturalistic method (i.e., no random assignment to treatments) to follow 43 clients in EPT and 109 clients in CBT. Pre- and post-therapy measures showed that the EPT clients’ improvements were comparable to those of the clients in CBT. Both groups showed statistically significant reductions in distress. However, some features of this study would lead us to be careful in our level of confidence in these results, for example, the small number of clients in EPT and the lack of random assignment to treatment. However, some would argue that the naturalistic setting of this research was a strength—they studied EPT and CBT in real-world conditions.

Logotherapy, administered in various formats, has also received some empirical support. Observing that patients diagnosed with prostate cancer often experience depression, anxiety, and fatigue, Arefpour and Mahdavi (2022) randomly assigned 15 Iranian patients to an online group intervention based in logotherapy, comparing post-treatment scores (after adjusting for pretest scores) for this group to those of 15 participants in a control group. After eight sessions of treatment, group participants showed significant improvement on all measures compared to the control participants, reporting lower levels of depression, anxiety, and cancer fatigue, and higher levels of psychological capital. This study, of course, is limited by the small sample size and we should note that an online group intervention is likely to be fairly different than traditional in-person individual therapy. Also, very little information was provided regarding the nature of the control group, although we can probably assume that they simply completed the measurements on the same schedule as the treatment group. A similar design was used by Soetrisno et al. (2017) in a study of logotherapy with Indonesian Muslim women undergoing medical treatment for cervical cancer. The women who received therapy, compared to a group that did not (15 participants in each group), reported lower levels of pain and depression, and had lower levels of cortisol, a stress-related hormone. Interestingly, Soetrisno et al. attributed the success of the logotherapy intervention to its consistency with Javanese cultural beliefs and the Muslim religion. Other studies have shown logotherapy to be effective for decreasing social isolation among older adults in Egypt (Elsherbiny & Maamari, 2018) and in building a healthy sense of identity among adolescents in Turkey (Şanli & Ersanli, 2021). Taghlidabad and Mashhadi (2020) reported on a study in which group logotherapy for individuals suffering from irritable bowel syndrome resulted in better quality of life and decreased severity of symptoms. So, it seems that there is some evidence for the efficacy of logotherapy with a range of client presentations and also a geographic range of clients. However, I would note that most of these studies did not include information about the full range of participant demographics; often very little information was provided about participant diversity.

Julom and de Guzmán (2013) reported on a study of logotherapy with Filipino/a clients who were para- or quadriplegic as a result of spinal injury. Using measures of purpose of life, they identified 32 individuals who displayed high levels of meaninglessness and randomly assigned 16 of these clients to a logotherapy intervention and the rest to a control condition. Analyses indicated that both groups found increased meaning in life over time, but the logotherapy groups’ increases were larger than the control groups’. However, very little information was provided regarding the intervention in this research, and it also seems likely that the control group was receiving services as well (possibly accounting for the observed improvement).

Theory-Testing Research

ET theorists generally advocate case study or qualitative approaches to research, although Yalom (1980) reviewed research from general psychology that he asserted supported J. K. Schneider & Krug (2020) also noted that support for ET can be found in common factors research that looks at the therapeutic alliance, empathy, and genuineness.

Still, some direct tests of ET theory can be found. In fact, there has been significant interest in the construct of authenticity in recent years. Sutton (2020) described a meta-analysis of the relationships between authenticity, well-being, and engagement with work. As you might expect, authenticity is associated with a wide array of positive outcomes (e.g., relationship functioning, self-esteem, social support). Sutton’s analysis of 51 studies found positive relationships between authenticity, well-being, and engagement. The relationships were even stronger in samples from cultures considered to be more individualistic, raising the question of whether being authentic might conflict with norms regarding self in relationship to family or the larger group in collectivistic cultures.

As you saw in Box 6.3, TMT explores some hypotheses developed from existential theory. J. Hayes et al. (2010) provided a review of TMT research, finding hundreds of studies over the last 20 years, and concluded that TMT is well supported. A more recent review came to the same conclusion (Schimel et al., 2019). As you will find if you read the box, TMT is largely concerned with our awareness of the most important ultimate concern, our finiteness.

Another construct relevant in ET theory that has received research attention is meaning in life (MIL). MIL has been linked to a number of psychological outcomes, including depression, anxiety, stress, negative emotions, life satisfaction, and physical health and our perceptions of it (Czekierda et al., 2017; S. Huang et al., 2020, Lin, 2021). A recent search revealed many studies investigating aspects of MIL and interesting life outcomes. In the following sections, I will review a select few and leave further review for the interested reader. One interesting feature of the MIL research is that it does seem to be multinational in scope, with some potential cultural differences, as you will see in the following review.

Some conceptualizations of meaning in life identify two possible aspects of it: the presence of meaning (POM), and the search for meaning (SFM; J.-B. Li et al., 2021). Li et al.’s recent meta-analysis suggested that POM was moderately related to subjective well-being (measured in various ways across the 147 studies considered), and had the strongest relationship with life satisfaction. However, the relationship between SFM and well-being was small and SFM and POM were only weakly related. These results would seem consistent with some interpretations of ET theory in that those who had found a level of life meaning would be better off than those still searching. However, a more complex theory, called the dialectical model of MIL, predicts that cultural individualism-collectivism will influence the relationships among MIL, SFM, and POM, with SFM more important to well-being in collectivistic cultures and POM more important in individualistic cultures (Steger et al., 2008). Li et al.’s results confirmed this hypothesis, suggesting that in individualistic cultures, the possession of meaning is important, whereas in collectivistic cultures, the search for meaning is more critical, because it may represent a perceived route to self-improvement.

P. K. Lutz et al. (2022) were interested in three empirically identified elements of authenticity, authentic living, self-alienation, and accepting external influence, and how they might relate to meaning in life and life satisfaction. The participants in this study were 203 Canadian undergraduates (59.6 White, ages 17–35; no other demographics provided), who completed measures of these variables daily for 2 weeks. As you might expect, authentic living was positively correlated with MIL and positive emotion, whereas self-alienation and accepting external influence were negatively related to the well-being measures (MIL and satisfaction with life) and positively to negative affect. Some evidence emerged that supported the prediction, consistent with ET theory, that authenticity leads to well-being, rather than the other way around.

Conner et al. (2022) examined MIL among 126 adolescents (70% female; 80% White; no other demographics provided) who were hospitalized in an inpatient psychiatric facility. They focused on variables that might predict non-suicidal self-injury (NSSI). The adolescents were those who had been admitted under crisis conditions; the outcome of interest was the number of NSSI incidents in the previous 12 months. Results showed that MIL, and particularly presence of MIL was a strong predictor of incidents of NSSI, even beyond variables such as risk seeking, experience seeking, and emotional dysregulation.

Reasoning that the COVID-19 lockdowns would affect MIL, Baños et al. (2022) surveyed Spanish adults during periods of strict and relaxed lockdown. The respondents were about 83% women and 63.2% had a partner. A longitudinal analysis showed that presence of meaning in life (PML) and search for meaning in life (SML) both decreased during the strict lockdown but stayed stable when lockdown was relaxed. That MIL did not increase in the relaxed period could be because the threat of COVID was still present, and the two periods of restrictions were close in time, so meaning making had not yet recovered. Baños et al. see their results as consistent with terror management theory (see Box 6.3)—participants were experiencing an encounter with death.

Finally, an interesting study looked at the relationship between negative affect, MIL, and life satisfaction among Israeli natives and immigrants. Russo-Netzer et al. (2021) reasoned that for most people, meaning in life can buffer the effects of negative life experiences. However, for immigrants, who are experiencing acculturative stress, which may result in a loss of meaning, this buffering effect would not be possible. They studied 179 native Israelis and 86 immigrants, who had emigrated from the former Soviet Union. About 60% were female and 75% were in a relationship. Results confirmed the prediction that MIL was a resource that protected life satisfaction in the face of negative feelings, but only for native Israelis. The authors speculated that the inbetweenness (my term) of the immigrant experience may cause immigrants to struggle with a sense of identity; indeed they likely struggle, to some extent, to make sense of the new culture. Both of these dynamics would intuitively point to a search for meaning rather than a stable sense of MIL. Unfortunately, the measure of MIL used did not allow for the distinction between presence and search. Also, Russo-Netzer et al. did not report on how long the immigrants had been in Israel, which in my opinion, would have a significant effect of the acculturation status of the individual immigrant.

J. M. Adler et al. (2013) demonstrated that the quality of clients’ meaning narratives was associated with sudden gains in psychotherapy. Narratives that indicated that the client was actively seeking coherent meaning were associated with sudden gains in well-being. Looking from a bird’s-eye view, Oishi and Diener (2014) used data from the Gallup World Poll to demonstrate that suicide rates were lower in countries having higher reported meaning in life. Wealthier countries also had lower meaning in life than poorer countries, but this effect was explained by religiosity—poorer countries were found to be more religious than wealthier countries. Oishi and Diener also tested other variables that might account for the relation between wealth and meaning, such as educational level and individualistic attitudes, finding that they were indeed related to wealth and meaning in expected ways (e.g., wealthier nations were more individualistic, and individualistic societies reported less meaning), but religiosity was still a strong predictor of meaning in life after accounting for these variables. These results would seem to contradict Frankl’s assertion that meaning does not have to involve religion.

Fabry (2010) reviewed the literature on paradoxical intention (PI), finding 19 studies of the effects of this intervention. In some cases these studies were not specifically theoretically grounded in logotherapy theory (e.g., Broomfield & Espie, 2003). All 19 studies produced data in support of the effectiveness of paradoxical intention, but when compared with other bona fide therapeutic interventions, paradoxical intention was not found to be more effective. Obviously, this review is quite out of date, but I was unable to find any more recent summary reviews in this area. However, as I noted earlier, paradoxical intention is a noted technique for addressing insomnia. Jansson-Fröjmark et al. (2022) meta-analyzed data from 10 trials of PI, finding that in comparison to wait list or no treatment, PI had statistically large effects. When compared to active interventions (e.g., attention-control placebo, desensitization, imagery, progressive relaxation) the effects of PI were smaller, but still considered moderate.

Issues of Diversity

ET is seen as very useful with a wide range of clients, although there is little empirical evidence to this effect. An exception to this statement might be the studies of logotherapy that I reviewed earlier, but in actuality, ET proponents have not until recently attended to underserved and traditionally marginalized groups. L. Hoffman (2019), a prominent ET writer, admits that although in the past, attention to diversity was less than optimal among ET theorists and practitioners, the current state of affairs is improving. ET proponents argue that its emphasis on the universal concerns of human existence transcends culture (Vontress, 2013; Yalom & Josselson, 2019). Vontress (2013) pointed out that a number of existential ideas are compatible with values of non-Western cultures, such as the philosophy associated with Umwelt that humans are inseparable from our physical environment and the notion that we are all connected (Mitwelt). Advocates of ET see diverse identities as essential elements of the client’s being, to be investigated in the therapy process for their meaning to the client (Yalom & Josselson, 2019). Fans of ET would point to The Wiley World Handbook of Existential Therapy (van Deurzen et al., 2019), which contains chapters on the implementation of ET in a wide range of countries, including Eastern Europe, Russia, and Latin American countries, as evidence that ET is international in scope. Other sources address ET intervention with individuals in Africa, China, and many other countries (L. Hoffman, 2019).

However, the emphasis on individual choice and responsibility in ET theory can be problematic in considering people from cultures other than the White, Western European variety. A particular problem might arise where the client is from one of the groups that have historically experienced oppression (e.g.,

LGBTQ

+

,

Black, Native American)—they might find the emphasis on free will and choice to be counter to their experiences of the world. Also, freedom is often contrasted with conformity, implying that alignment with cultural and family norms is undesirable (L. Hoffman et al., 2019). Such a stance potentially denies the client’s sense of being, and ignores the protective factors inherent in cultural grounding and belonging. In addition, L. Hoffman et al. (2019) pointed to the historic bias toward the individual identity established in relation to others, overlooking the formulations of identity or self in collectivistic cultures in which the family and culture is embedded in the self and inseparable from these.

Kass (2014) wrote an interesting analysis of the history of women writers/theorists in ET, pointing out that there were many more than most people realized. She noted that aspects of ET, such as attention to the therapeutic relationship/presence, authenticity, explorations of freedom, choice, and responsibility may align more with stereotypically feminine qualities than with masculine ones. She did not, however, speculate on whether ET had strengths or drawbacks in working with clients identifying as cisgender women. K. J. Schneider (2008) suggested that themes relevant in feminist therapy, such as power, gender, and sexuality, are consistent with ET’s emphasis on courage, freedom, and responsibility and also with the exploration of limitations and constrictions that is an important part of ET. The implication would be that if ET’s emphasis is comparable to feminist theory, a good match for clients who identify as women, ET may be a good fit for these clients. At this point, it might be good to note that most of these discussions treat sexual identity as binary, neglecting other, more fluid, senses of identity.

Some ET theorists argue that labels such as homo- and heterosexual are the result of the operations of historical social power dynamics (you can refer to the discussion of Foucault’s ideas in Chapter 15 to get a sense of this) and that their socially constructed nature implies an element of choice (see Crabtree, 2009, for a discussion). Although this conceptualization depathologizes what was historically considered “perverse” sexuality, this stance would clash with the ideas of many lesbian, gay, bisexual, and transgender (

LGBTQ

+

) individuals who see sexual orientation as biologically determined (Medina, 2008). Crabtree (2009) suggested that writing sexuality off to social forces can lead to ignoring the prejudice and discrimination experienced by individuals who identify as

LGBTQ

+

.

Medina (2008) encouraged counselors to transcend the causal debate and instead concentrate on the client’s construction of sexuality/sexual orientation and the meaning that they give to it. Similar arguments could probably be advanced in viewing gender identity from an ET perspective.

Du Plock (2014) offered an ET critique of gay-affirming therapy (or any affirmative therapy), warning that overt advocacy in the interests of overcoming clients’ negative experience with authority figures in the past, risks the therapist assuming an expert stance that is contrary to the ET position. Instead, it is probably better to help the client explore their experiences of self and the role of self and cultural perceptions in constructing their sense of being. Similarly, other elements of affirmative approaches, such as advice giving (e.g., read this book, join this group), in Du Plock’s view, take the dialogue away from the client’s experience, which is the central interest in ET. Ultimately, Du Plock opines that it is not that the ET therapist should never affirm or advise, but should closely examine one’s motives in doing so, writing that

The client’s worldview is not the result of chance or accident. It has been constructed over time and is intended (or was intended in the past) to function as a defence against existential anxiety. Any attempt to demolish this would be anti-therapeutic and deeply disrespectful. At the same time, we owe our clients an opportunity to see their lives from a new perspective, and colluding with their identity as victim (or anything else) may foreclose this. It may be that a gay-affirmative therapist is less likely, in their wish to introduce their own view of the ‘‘healthy homosexual”, to attend fully to the individual client than a sensitive therapist from another orientation (p. 152).

Pointing out that most discussions of sexuality, sexual identity, and sexual orientation tend to focus on one-to-one, or monogamous, relationships, Berry and Barker (2014) argued for an existential sex therapy for those in open nonmonogamous relationships. They characterize ET sex therapy as non-pathologizing and rejecting a binary view of health and dysfunction, thereby making it ideal for working with clients engaging in nonmonogamous relationships. However, Berry and Barker do point to the necessity of the therapist engage in bracketing, no matter what their personal sexual practices are, and to, as in all good ET therapy, contextualize clients’ choices in the whole of the client’s being.

The Case Study

The case of Helen was relatively easily conceptualized from an ET perspective. She is at a stage in her life in which she is reevaluating meaning, which fits perfectly with ET assumptions. Because she appears to from a social situation where she has the means and support to engage in such reflection, the application of ET theory was fairly straightforward. However, identity as a lesbian woman in a same-sex marriage has likely opened her to some oppression from the dominant culture, which from an ET perspective, would be grist for the mill—how to make meaning of the discrimination and oppression would be part of her ET journey. Her identity as a White cisgender woman would also be a consideration in understanding Helen’s experiences—she holds the privilege of Whiteness but is also subject to the stereotypic views of women’s roles still immersed in mainstream U.S. culture.

Summary

ET theory is grounded in philosophy more than perhaps any other theory of counseling. Its advocates unite in the contention that humans are motivated to seek meaning in life. Yalom (1980) presented the four ultimate concerns of life: death, freedom, isolation, and meaning. Psychological health is seen in authentic living and in awareness and acceptance of our plight as human beings.

ET is seen as an encounter between two beings focused on the present. The relationship between therapist and client is central and is often the vehicle for interventions, such as when the therapist self-discloses to the client. Very few specific techniques are identified in this approach.

ET theory is criticized for being difficult to read and understand, and its diverse nature makes it difficult to test directly under traditional scientific paradigms. However, research is emerging that bears upon ET theory and ET outcomes, and is supportive. Advocates also draw supportive information from the more general studies of psychotherapy or psychological functioning. ET is a flexible approach, so it is often characterized as helpful to a wide range of clients. However, its emphasis on freedom and individual responsibility may not fit with the worldview of clients who are members of groups that have been oppressed.

Box 7.1

Excerpt from Gestalt Therapy Verbatim

So we come to our basic conflict and the basic conflict is this: Every individual, every plant, every animal has only one inborn goal—to actualize itself as it is. A rose is a rose is a rose. A rose is not intent to actualize itself as a kangaroo. An elephant is not intent to actualize itself as a bird. In nature—except for the human being—constitution, and healthiness, potential, growth, is all one unified something.

The same applies to the multi-organism, or society, which consists of many people. A state, a society, consists of many thousands of cells which have to be organized either by external control or inner control, and each society tends to actualize itself as this or that specific society. The Russian society actualizes itself as what it is, the American society, the German society, the Congo tribes—they all actualize themselves, they change. And there is always a law in history: Any society that has outstretched itself and has lost its ability to survive, disappears. Cultures come—and go. And when society is in clash with the universe, once a society transgresses the laws of nature, it loses its survival value, too. So, as soon as we leave the basis of nature—the universe and its laws—and become artifacts either as individuals or as society, then we lose our raison d’etre. We lose the possibility of existence.

So where do we find ourselves? We find ourselves on the one hand as individuals who want to actualize themselves; we find ourselves also embedded in a society, in our case the progressive American society, and this society might make demands different from the individual demands. So there is the basic clash. Now this individual society is represented in our development by our parents, nurses, teachers, and so forth. Rather than to facilitate the development of authentic growth, they often intrude into the natural development.

They work with two tools to falsify our existence. One tool is the stick, which is then encountered again in therapy as the catastrophic expectation. The catastrophic expectation sounds like this: “If I take the risk, I will not be loved any more. I will be lonely. I’ll die.” That’s the stick. And then there is the hypnosis. Right now, I am hypnotizing you. I am hypnotizing you into believing what I say. I don’t give you the chance to digest, to assimilate, to taste what I say. You hear from my voice that I try to cast a spell on you, to slip my “wisdom” into your guts until you either assimilate it or puke, or feed it into your computer and say: “That’s an interesting concept.” Normally, as you know if you are students, you are only allowed to puke on the examination paper. You swallow all the information and you puke it up and you are free again and you have got a degree. Sometimes, though, I must say, in the process you might have learned something, either discovered something of value, or some experience about your teachers, or about your friends, but the basic dead information is not easy to assimilate.

Source: From Perls, F. S. (1969). Gestalt therapy verbatim. Real People Press.

Second- and third-generation students of GT, such as Jon Frew, Lynne Jacobs, Erving Polster, and Gary Yontef, continue to practice and promote the approach. These later theorists have promoted a more moderate form of GT than the confrontive, stagey “Perlism” (Parlett & Hemming, 1996a, p. 95; J. C. Watson et al., 2011). There still seems to be significant activity around this theoretical orientation, particularly in Europe. Yontef et al., (2019) reported that there is a GT institute in every major U.S. city and in many other countries around the world. In the United States and Canada, emotion-focused therapy (see Box 7.2 for a description), which combines elements of Gestalt and person-centered theories, is considered a respected theoretical development. Enough supportive research on this approach has accumulated for it to be referred to as evidence-based experiential psychotherapy (L. S. Greenberg, 2017).

Box 7.2

Jessica is a 30-year-old Black woman who is a police officer. She is physically fit and verbal and appears open to counseling. Jessica has a 5-year-old son, Dale, from a previous marriage. Jessica and Dale have had no contact with Dale’s father for several years.

Jessica seeks counseling because she is troubled in her current relationship with Ramone, with whom she has been living for 2 years. Recently, the couple had a serious fight involving physical contact. Jessica had been trimming Ramone’s hair, and she moved his head too abruptly. Ramone became angry and Jessica apologized. Ramone remained agitated and got up, threatening to leave their apartment. Jessica, who feared that Ramone would not return, took Ramone’s car keys. Ramone reacted by locking the door, closing the blinds, grabbing Jessica by the neck, and shoving her against a wall. Ramone then retreated to the bedroom. The couple did not speak about the incident afterward, and they have not discussed it since then. This altercation was the fourth episode of violence in Jessica’s relationship with Ramone.

Jessica is the oldest in a family of four children. Her parents divorced when Jessica was 12, and her mother remarried shortly afterward. She has two step-siblings as a result of this marriage, but she is not close to them. Jessica reports a “normal” childhood and some emotional turmoil as a teenager (in reaction to the divorce), but overall says the household in which she lived was relatively calm. Jessica characterizes her mother as distant and businesslike and reports that she has difficulty relating to her.

Jessica had a positive relationship with her biological father, who has not remarried, up until she decided to become a police officer. Her biological father reacted very negatively when Jessica told him, saying, “Cops are pigs. If you become a cop, I never want to see you again.” Jessica pursued her wishes despite this reaction and has spoken with her father only three times in the last 8 years.

Jessica admits that she is afraid of Ramone when he gets angry, but says that otherwise they have a good relationship. Jessica seems to take responsibility for anything that goes wrong in her relationship. Ramone sees no real problem with the violent incidents in the past and does not want to come to counseling. According to Jessica, he is very much in charge of their relationship—specifying how and when things get done around their apartment. Jessica’s son, Dale, and Ramone generally get along but are not close.

Jessica wants to learn how to create a better relationship with Ramone so that they do not get into as many fights. She sees herself as responsible for many of the problems in the relationship. Jessica thinks that if she tries harder to meet Ramone’s expectations things will get better.

Gestalt Plus Person Centered Equals Emotion-Focused Therapy

Emotion-focused therapy (EFT) combines elements of the person-centered (PC), Gestalt (GT), and systemic approaches. Based on a humanistic, non-pathologizing philosophy, EFT specifies that emotions signify what we should pay attention to and at the same time prepare us to react. Emotions must be processed adaptively, and thus dysfunction results when individuals fail to process emotions (either because they avoid attending to them or transform an unwanted emotion into another more acceptable one), are unable to regulate emotions, or have difficulty creating meaning from them (Goldman & Greenberg, 2022). The goal of EFT is to promote creative adjustment to situations, so that clients experience more freely and behave more adaptively, particularly when faced with novel experiences (Goldman & Greenberg, 2022). The EFT counselor first creates a warm, accepting therapeutic relationship and then uses active, directive techniques to help the client experience and transform maladaptive emotion. EFT theorists are clear that the therapeutic alliance is the same as that created in PC therapy; the therapist must be congruent, empathic, and sensitively present (L. S. Greenberg, 2017).

Techniques used in EFT are those seen in PC counseling, such as focusing on specific experiences, particularly emotions, and chair dialogues similar to those used in GT (which will be discussed later in this chapter) are used to further deepen experiencing (two chair and empty chair). The PC-style interventions promote emotional exploration, and that leads to the transformation of the feelings so that clients can gain new meanings from them and behave more adaptively. Two-chair dialogue is intended to help clients more fully experience aspects of themselves that are in conflict or inhibiting experiencing.

There are many sources of current information on GT, including a number of organizations, websites, and journals, such as The Gestalt Therapy Page (http://gestalt.org). The International Association for the Advancement of Gestalt Therapy (www.iaagt.org) has biannual conferences and supports research in GT. A very visible journal is Gestalt Review, sponsored by the Gestalt International Study Center. Much of the activity in GT seems international in nature, although there are GT institutes in the United States, in New York, Philadelphia, and Cleveland, and other cities.

Basic Philosophy

GT theorists begin with the notion that humans are growth oriented. A very basic value is holism (Haley et al., 2022): Humans can’t be separated from their environmental, social, and historical contexts, nor can they be divided into parts (such as body and mind). Physical and psychological functioning are inherently related; thoughts, feelings, and physical sensations are all a part of a unified being. GT theorists often use the term organism to convey the inseparable psychological and physical aspects of human nature; the process of being in touch with one’s experience (defined in the broadest sense) is known as organismic self-regulation (Yontef et al., 2019).

GT is a humanistic/existential approach, and as such it emphasizes individual choice and responsibility (Haley et al., 2022). In fact, GT theorists sometimes used the term response-ability to reinforce this perspective (F. Perls, 1970a). Another important quality of GT is its phenomenological orientation—an emphasis on awareness as an end state rather than a means to some end, as in other approaches (Mann, 2021).

One can see the GT view of humans as neutral. Fritz Perls seemed to see humans as simply another form of biological life, yet the emphasis in the theory on growth and actualization would seem to support a positive view of human nature. According to GT theory, all organisms have an innate tendency to grow toward fulfillment and actualization (Haley et al., 2022). In GT, the focus is on growth and excitement, not dysfunction (Sheldon, 2013, p. viii).

An important aspect of the GT mentality is an emphasis on being creative, spontaneous, and taking risks (Wheeler & Axelsson, 2015). It is expected that healthy behavior will sometimes be in conflict with societal norms. Perls (1970a) wrote, “Society has undergone a process that has moved it so far from healthy functioning, natural functioning, that our needs and the needs of society and the needs of nature do not fit together any more. Again and again we come into such conflict until it becomes doubtful whether a healthy and fully sane and honest person can exist in our insane society” (p. 16).

Paralleling developments in many approaches (e.g., person-centered therapy, psychoanalysis), GT theorists of late have placed great emphasis on the inherent relatedness of the human condition, identifying a relational approach to GT (Hosemans, 2021; Jacobs, 2019; Wheeler & Axelsson, 2015). These contemporary GT theorists focus more on the role of interdependence in human life; as Jacobs (2019) put it “We have no experience that is prior to relatedness” (p. 205). You will see this relational spirit in current writers’ re-emphasis on field theory. Kurt Lewin (1951) originated field theory, which was a foundational concept in early GT theory, emphasizing our embeddedness in our environment (Francesetti & Roubal, 2020). Although the concept of field is difficult to define precisely, it translates into the recognition of the mutuality of person and environment, and that the therapist (and everyone else we contact) is a part of the environment, so that that client and therapist are co-creators of the therapeutic field (Mann, 2021; Skottun & Krüger, 2022). It may help you to know that some GT theorists prefer the term situation to field, because the former is more pragmatic and understandable.

Enrico is Jessica’s Gestalt therapist. He begins his work with her from the premise that she is a growing organism living an existence embedded in the environment and tries to understand how she perceives her reality and how it is organized. Jessica has the potential to grow in creative ways, actualizing herself in relationship to the world around her. She has the capacity to accept responsibility for herself and make choices that are true to her actualization. Enrico, who is of Peruvian ancestry and identifies as a heterosexual man, is very aware that who he is will become part of the field in his work with Jessica—they will co-create the therapeutic reality together.

Human Motivation

Human behavior is motivated by the drive to satisfy needs. Both biological and psychological needs are important. Although GT theory does not present a specific list of needs, biological needs are clearly important, and further reading of GT literature suggests that one very important need is connection to other human beings. The existential philosophical basis of GT adds the desire to create meaning to what motivates humans (Haley et al., 2022).

Another way to look at motivation from a GT perspective is to see humans as striving to regulate the organism so that it can grow. The goal of the process of self-regulation is harmony with the environment, maturity, or actualization. Self-regulation involves the process of determining what is good and bad for the organism, which should lead toward acceptance of the good and rejection of the bad. The tendency to self-regulate is innate, and humans adapt easily to the changing environment (Skottun & Krüger, 2022).

Enrico sees Jessica as striving to meet her needs so that she can grow and mature. She gravitates toward experiences that maximize her growth, including wanting contact with other people. Jessica strives to adapt to her environment in a harmonious way.

Central Constructs

Contact

Contact is the central feature of life, according to GT. It is defined as meeting the environment, which can be either external to the person or aspects of the self. Seeing, hearing, touching, moving, talking, smelling, and tasting are all ways of contacting the environment. Healthy contact results in assimilation of novel elements (i.e., things not already a part of the organism) and hence growth (F. Perls et al., 1951). Following contact, the organism withdraws for a period of rest to “digest” the results of the contact (Mann, 2021). Assimilation involves aggression and destruction, which are natural processes essential to making new experiences part of the organism, thereby creating growth (F. Perls et al., 1951). As a result, Gestalt therapists see aggression as a natural and healthy part of life rather than as an antisocial behavior.

Effective contact is essential to life because it is necessary for the satisfaction of needs. Probably the most important form of contact is that with other people. Yontef et al., (2019) asserted that there is no self without the other, emphasizing the importance of our relational existence. Contact can occur in a fully aware state, such as when we deliberately touch someone else, or in the sort of automatic mode that we use in most of our daily living. An example of the latter kind of contact is breathing, during which we make contact with the physical environment.

The individual makes contact with the environment at the contact boundary (Mann, 2021). An important aspect of the contact boundary is the differentiation between self and other. There is much more to say about contact and boundaries in the sections to come.

Jessica is able to make basic contact with her environment. She is healthy, indicating that she obtains the basic substances she needs. Enrico observes that she has a number of relationships, indicating that she is able to establish some kind of contact with other human beings. Jessica appears to have a sense of self; Enrico has a hunch that this sense varies from relationship to relationship.

Needs

Life is a process of need satisfaction (J. C. Watson et al., 2011). GT theorists use the notion of Gestalt, a German word roughly meaning “whole” or “shape” (Mann, 2021) to describe this process. A Gestalt has a figure, or feature that stands out, and a ground, which is the rest of experience (i.e., the background). In perceptual terms, the figure is clear and compelling to our attention, and everything else becomes ground. Look at the picture shown in Figure 7.1. What you make of this picture depends on what features become figural to you. If you are able to shift your attention, you will see that two different perceptions of this drawing are possible (a young woman and an old woman). Figure 7.2 illustrates another basic aspect of the GT theory of perception—the fact that we strive to integrate pieces into a complete Gestalt. (Do you see the horse and rider?)

Figure 7.1. A Figure–Ground Exercise.

Figure 7.1. Full Alternative Text

Figure 7.2. A Perceptual Integration Task.

In GT theory, a need is an incomplete Gestalt that emerges into the organism’s awareness; it becomes figure, and the rest of experience becomes ground. Think about how difficult it would be to concentrate on this paragraph if you were very hungry. Your mind would probably keep drifting to images of pizza! Once a need has become figural, the person initiates behavior aimed at meeting the need. When the organism is successful at satisfying the need, the Gestalt is completed and it is said to be destroyed (Frew, 2013)—the need disappears, perceptually. At this point, the organism is in a state called the “fertile void” (Mann, 2021, p. 49), a state of pure awareness. Another way to describe this part of the cycle is to say that the individual has reached closure (Frew, 2013). However, soon another incomplete Gestalt emerges. At any given time, there are many possibilities for the individual’s focus; Mann (2021) warns us that life is not a structured progression from one need, desire, or experience, to the to the other. Whatever need is most urgent to the organism at a given time becomes figure. It is important to note that awareness (of the need) is critical to this cycle. I will pause here to note that the term need should be construed broadly: what is meant here is that something in the environment becomes most important to us in the moment, be it physical need (e.g., hunger, thirst), or psychological process (e.g., loss of an important other). Also, you must keep in mind that even though I just did it, physical and psychological functioning are not separable, according to GT theory.

The continual process of need emergence, satisfaction, and Gestalt destruction is the essence of life. Healthy growth requires this natural rhythm of figure–ground cycles. In fact, GT theorists like to draw pictures of the cycle of experience or awareness, and Clarkson (2014) acknowledged that everybody seems to have their own version of the cycle and name for it. It is in this spirit that I have created Figure 7.3.

Figure 7.3. The Cycle of Awareness.

Figure 7.3. Full Alternative Text

Enrico makes some very basic observations in his early interactions with Jessica. He sees that Jessica is aware of the environment around her; he assumes that the degree to which she is aware varies from situation to situation. She appears to be meeting physiological needs adequately. Enrico tries to deduce current needs from Jessica’s presentation and wonders if one thing that is figure for her is a need to be loved. Her work and relationships with intimates other than Ramone seem to be ground at present.

Polarities

GT emphasizes the holistic nature of human functioning, and this allows the recognition of the power of polarities. If something exists, the opposite must as well; for instance, light implies dark, and right creates left (F. Perls, 1969a). Other relevant polarities are life and death, good cop and bad cop, passive and aggressive, and masculine and feminine (Levitsky & Perls, 1970). Perls maintained that Freud partly described one of the most important polarities when he acknowledged the superego. However, Freud did not label the other end of the dimension, which Perls (1969a) called the infraego. More commonly, Perls called this polarity top dog and underdog. Contemporary GT theorists would add connection/separation to the list of important polarities (Yontef et al., 2019).

Polarities are a natural part of life, and we have within our psyche both ends of the polarities. However, sometimes we don’t want to accept one end of the polarity, so we rigidify them into dichotomies and reject one end of the continuum (Yontef et al., 2019).

Enrico suspects that Jessica can recognize a number of polarities operating in her experience. Some particularly critical polarities seem to be bad–good and strong–weak. Enrico wonders how her occupation as a police officer is complicated by the polarities about police in current society, and particularly in the Black community. However, Jessica has not mentioned this issue as figural, so Enrico follows her lead. In her relationship with Ramone, she seems to reject the strong part of the strong–weak polarity.

Contact Disturbance

When the cycle of awareness is disrupted, problems are seen at the contact boundary. Perls et al., (1951) identified some basic ways that contact is interrupted; these processes, in traditional GT, are called contact disturbances or boundary problems. They are also sometimes called resistances (to awareness). Traditional GT practitioners deem these ways of operating dysfunctional if used chronically and inappropriately (F. Perls et al., 1951). For example, in discussing introjection, or the swallowing whole of experience, Perls et al., (1951) declared, “On this point we differ with Freud. He held that some introjections are healthy . . . but in this he was obviously failing to make the distinction between introjection and assimilation” (p. 190). Most current GT theorists maintain that these processes should be seen as modifications of contact—simply the ways the individual meets the environment—and are not inherently good or bad (Frew, 2016). Frew (2016) pointed out that the original identification of these contact modifications as problematic was culture bound, and contemporary GT therapists would not consider them as interruptions or avoidances unless this quality emerged from dialogue with the client.

For Perls, though, the most primitive contact disturbance was introjection, or the taking in of experience or food without digesting it. Infants survive by introjection of food, and the introjection of the attitudes and values of parents is to some extent an unavoidable feature of early childhood (Frew, 2016). For the infant, the only alternative to introjection is vomiting or spitting out, by which the infant deprives itself of nourishment. Once the child develops teeth and can bite and chew, they are able to digest and assimilate both physically and psychologically (Clarkson, 2014). For example, we often operate, or believe we should operate, on the basis of rules that are dictated by society—a sure sign of introjection (Mann, 2021). You should be nice, be quiet, and obey the rules! The problem, according to GT theory, is that we have not really considered whether these are our own values, or in the typical GT way of saying it, we have not chewed them up, digested them, and assimilated them. They are foreign, alien things that sit in our stomachs.

The counterpart to introjection is projection, in which an unwanted part of the self is expelled into the environment. According to Perls and colleagues, we are aware of the impulse but can’t cope with it, so we conclude that it has to come from outside of us. A good example of projection is seen when we avoid the experience of our own hate for someone by believing that they hate us. A less dysfunctional view of projection is that it is essential to empathy. Empathy involves identifying with another’s experience, and one way to do that is to use one’s own experience as a guide (Parlett & Hemming, 1996b).

Confluence is similar to introjection, except that it refers to a complete loss of self in which the individual cannot separate themself from the environment—most importantly, from other people (Mann, 2021). Yontef et al., (2019) pointed out that confluence occurs when the individual is unable to withdraw when it is appropriate to do so. An individual in confluence with another person has trouble expressing their own beliefs and values. A good example of confluence might be a kid who becomes a gang member and adopts the identity (self) of the gang. As with all of the boundary disturbances, confluence can be healthy, particularly in intimate relationships. The experience of falling in love or singing with a large crowd are examples of healthy confluence (Mann, 2021).

In retroflection, the unacceptable impulse is turned toward the self, such as when John tenses his muscles to resist slapping someone (Mann, 2021). For this reason, Gestalt counselors are often interested in the physical expressions of their clients as clues to where awareness has been interrupted. Retroflection can be healthy because it is sometimes dangerous to express our impulses (such as by hitting someone); the extent to which the retroflection is adaptive depends on whether the individual has a rational reason for restraining the impulse (F. Perls et al., 1951). Awareness is the key to understanding healthy retroflection. Unaware, chronic retroflection is, according to Perls et al., (1951), equivalent to repression and is therefore neurotic.

Various writers have identified several other defenses or contact disruptions. An individual can isolate themself, losing contact with both the environment and the self. Although withdrawal can be healthy at times (e.g., to avoid bad things), persistent isolation is dysfunctional (Yontef et al., 2019). In deflection, we turn away from contact (Mann, 2021). Essentially, we direct our attention away from something, often seen when we ignore other people’s words or actions (Skottun & Krüger, 2022).

Jessica seems to be demonstrating several modifications to contact. Enrico thinks that she has introjected cultural values that mandate that women can’t be assertive and angry, and particularly, negative stereotypes about Black women and anger. She also appears to be very critical of herself, suggesting retroflected feelings that might have originally been directed at Ramone. Allowing Ramone to control the household may be evidence that she is in confluence with him. Because Jessica is Black, Enrico considers how much of these modifications are culturally based—Black culture tends to be more collectivistic and less individualistic than White culture, leading to what might look like confluence but is, in reality, a culturally supported relational view of self. Also, Enrico considers the influence of sex role norms and stereotypes—women are supposed to let men call the shots. If Enrico unthinkingly sees some of these modifications as problematic, problems could arise. At the same time, Jessica is seeking help so there is something in her field that is keeping her stuck.

Theory of the Person and Development of the Individual

Originally, Perls revised the developmental theory of psychoanalysis, shifting the focus from the sexual instincts to the hunger instinct (Clarkson, 2014). Infants progress from sucking to biting; development culminates with the ability to chew food thoroughly so that it can be digested and assimilated. Perls and his followers later de-emphasized this model, although elements of it can be seen in the descriptions of the process of need satisfaction as destructive and in the use of eating-related metaphors (e.g., introjection as swallowing whole).

Historically, GT had relatively little developmental or personality theory. M. V. Miller (1989) maintained that the anti-intellectual bias of GT (largely a product of the 1960s influences) was responsible for this indifference to the “why” of behavior. Perls (1969a) even said, “Why and because are dirty words in Gestalt therapy” (p. 44; emphasis in original).

Current formulations of personality and development in GT theory emphasize the relational nature of humans—there is no understanding of a person apart from the environment in which they are situated (Yontef et al., 2019). The environment, or field, is composed of the physical world, one’s biological being, and most importantly, other people. The organism is always in the process of creative adjustment through the cycle of awareness (Skottun & Krüger, 2022). Needs appear, contact is made, and if the need is satisfied, the figure recedes and the organism rests. The creative adjustments made in this process are the best we can do in a given situation. However, adjustments made in our past (the best we could do at the time) may not serve us well at other times (Skottun & Krüger, 2022). To take a simple example, behavior that may have gotten us attention as children is not effective in the adult world, generally speaking.

Even though they lack an elaborate theory, GT theorists acknowledge the importance of childhood events. According to Perls (1970a), “Maturation is the development from environmental support to self-support” (p. 17). To grow healthfully, children need support from the environment as well as love and respect (Yontef, 1995). Events in childhood that are related to the frustration of need satisfaction can live on in adulthood and create trouble for the individual (see the later discussion on unfinished business). Perls noted that children need to learn to deal with frustration and overcome it, thereby increasing their independence. He said, “In the process of growing up, there are two choices. The child either grows up and learns to overcome frustration, or it is spoiled” (1969a, p. 32).

The self is simply the organism at the contact boundary, created when we interact. It is not something we are all the time—it is something we act or express in the moment (Skottun & Krüger, 2022).

Jessica has developed from needing complete environmental support to a level of self-support that allows her to function adequately as an adult in her community. However, Enrico suspects that some early childhood experiences of need frustration are still plaguing her.

Health and Dysfunction

Healthy people are those who live in harmony with the environment, according to GT theory. The process of self-regulation guides the individual to be aware of shifting needs of the organism, which then organize behavior (Yontef et al., 2019). The organism simply follows its natural tendencies to self-regulate, taking in what is good for it, digesting it, and assimilating it (Clarkson, 2014).

The healthy individual recognizes their interconnection with the environment, so although they are self-supporting they strike a balance between taking care of one’s self and attending to the needs of other people and their community. Creative adjustment is a term used by GT counselors to describe this balance between changing the environment to meet the needs of the organism and changing the organism to fit the environment (Yontef et al., 2019).

Healthy contact with the environment results in a “clear bright figure freely energized from an empty background” (F. Perls et al., 1951, p. 255). It is clear which need is most important, the person can attend to it, and the bright shiny need is satisfied. Once the need is satisfied, the Gestalt is closed and something else important emerges.

Health can also be described as living an authentic existence (Mann, 2021). The healthy individual is spontaneous, emotionally responsive, and expressive and can make direct interpersonal contact with others and relate authentically. They take responsibility for the choices they make in life and can “love, work and play” (Wheeler & Axelsson, 2019, p. 43).

Dysfunction in GT counseling is called dis-ease to emphasize the view that the person is not in harmony with the environment (Clarkson, 2014, p. 52). Neurosis is seen as a “growth disorder” that results from the interruption of the cycle of awareness (F. Perls, 1969a). When the continuous process of Gestalt formation and destruction has failed in some way, the result is unfinished business, because the need that is not met hangs around to bother the person (Mann, 2021). Significant unmet needs drain the person’s energy and psychological resources, interfering with the healthy processes of awareness and contact. The person does not clearly perceive their current needs and may appear confused or uncertain about what they want. They may also display stereotypic or rigid behavior, signaling that their behavior is governed not by the organismic search for homeostasis but by the unfulfilled need (Clarkson, 2014). In practice, the unfinished business is often emotion that the individual blocks from experience and therefore doesn’t acknowledge, such as hurt, anger, or grief (Skottun & Krüger, 2022).

Gestalt counselors recognize that dysfunctional behavior is a creative adjustment made in an earlier difficult situation (usually childhood) that is no longer functional in the present (Yontef et al., 2019). Probably, these behaviors protected the organism from injury or pain or somehow allowed a limited form of need satisfaction in what was then an emergency. Unfortunately, the use of this neurotic self-regulation in the present prevents the person from responding spontaneously and creatively to the environment as it now is. Healthy organismic self-regulation is replaced by the will to control experience instead of accepting it.

Perls (1969a) contended that modern society (defined as the kind existing in the United States and in Western European countries) contributed a great deal to the development of unhealthy functioning. Western culture encourages people to artificially separate mind and body. Social norms often punish aggressive behavior, which according to GT theorists is a normal and helpful kind of human behavior. Other “shoulds” are introjected at early life stages, and these are not necessarily in alignment with healthy organismic self-regulation.

If we focus on our experience long enough, we will eventually come across something uncomfortable or unpleasant. We inherently want to avoid such experience, so we interrupt our awareness of the now (F. Perls, 1970a). Many times what we don’t want to experience is our own cruelty or aggression, and we disown the experience rather than tolerating it in our awareness. Society doesn’t help when it encourages us to reject these experiences. By interrupting our experience, according to Perls, we reveal ourselves as frightened children who, instead of assuming adult responsibilities, retreat into phony social roles: “These phony roles are meant to mobilize the environment for support instead of mobilizing one’s own potential. We manipulate the environment by being helpless, by playing stupid, asking questions, wheedling, flattering” (F. Perls, 1970a, p. 18).

If the client can get past the phony roles, they might be able to observe the impasse, the point where they are stuck. They no longer have support from the environment, but do not have sufficient self-support to function adequately (F. Perls, 1969a). Mackewn (1997) characterized the impasse as the point where growth and resistance to growth are in a deadlock. Yontef et al., (2019) described the experience of impasse as one of terror. If the client can stay in the impasse long enough, they will eventually start to experience authentically and will eventually attain self-support and improved awareness.

GT theorists don’t spend much energy discussing what might be called traditional forms of dysfunction, such as depression, anxiety, and so forth. They recognize emotions as signals to the self about unmet needs or danger (Cole, 1998). An exception to this position is that anxiety is seen as resulting from two possible processes. The first process is cognitive. Anxiety is “futurizing—failing to remain centered in the present” (Yontef et al., 2019, p. 323). Perls (1969a), in his characteristically flamboyant way, called anxiety “stage fright.” Anxiety can also be created through faulty breathing. When an individual becomes aroused, deep breathing is required. If the individual breathes shallowly and quickly, they are likely to experience symptoms that feel like an anxiety attack (e.g., hyperventilation; Yontef et al., 2019).

Jessica is not optimizing her integration with her environment. She has interrupted contact and appears to be carrying around some unfinished business, with associated behavior patterns. Enrico guesses that her early experiences with her withholding mother may have created an unfulfilled need for love for Jessica. She responded, he thinks, by burying her need because allowing it into awareness was painful. Jessica learned to deny her needs and feelings in intimate relationships through this early solution. Her experience with her father about becoming a police officer is another piece of unfinished business. Jessica felt close to her father, yet she has almost completely isolated herself from this relationship in recent years.

Jessica’s relationship with Ramone is problematic because she is denying aspects of her experience in it by using old patterns of defense. She is not experiencing some very vivid feelings that she has about how she and Ramone relate, probably because she has introjected the societal rule that girls and women should be “nice” and stereotypic negative views of Black women’s anger situated in U.S. culture. Further, her experiences with her mother and father—that uncompleted need for love and acceptance—are likely active in her relationship with Ramone. Instead of experiencing and expressing her feelings and needs, she retroflects her dissatisfaction to herself, becoming critical of her own behavior in the relationship. She also shows confluence with Ramone in her failure to assert her own needs and wants.

Nature of Therapy

Assessment

No formal assessment is used in GT, although Yontef (1995) noted that nothing in the theory absolutely forbids it. Generally, the Gestalt counselor is the assessment tool, using their powers of observation to assess how the client functions in their life. The therapist observes how the client makes contact with them in the here and now but is also interested in history, as a way of assessing where unfinished business resides. Also, the GT therapist must be very aware that they are now part of the equation—nothing is totally “inside” the client (Mann, 2021). Enright (1970) put it more colorfully: the Gestalt therapist tells the client to “sit down and start living, then note[s] where and how he fails” (p. 113).

Traditional diagnosis is also viewed with suspicion by hard-line GT advocates based on the humanistic idea that labeling people is dehumanizing (Clarkson, 2014). Further, traditional diagnosis breaks individuals into pieces, a philosophy that is counter to GT’s holistic perspective (Haley et al., 2022). Traditional diagnoses locate the problem inside the person rather than in the field. Other GT practitioners take the position that diagnostic terminology helps in communication with other professionals and can facilitate therapy (Joyce & Sills, 2010).

Enrico greets Jessica and simply asks why she came in. He listens and observes closely as she relates her story about the fight with Ramone. As she talks, he notes her tone of voice and physical reactions. Jessica pauses in her narrative, and Enrico inquires, “What are you experiencing right now?” Jessica stiffens and looks surprised. She then tentatively begins to describe her feelings of anxiety about being in therapy, her fear of Ramone, and a feeling of being alone.

Overview of the Therapeutic Atmosphere

The essence of Gestalt counseling is observed in the therapist’s emphasis on the immediate experience of the client. A famous GT slogan is “I and Thou, Here and Now,” which Perls borrowed from the philosopher Buber (Yontef & Jacobs, 2000). Yontef et al., (2019) modified the phrase to “what and how, here and now” to emphasize the present-centered, experientially focused nature of GT (p. 327).

The dictate to remain in the present does not mean that the past or the future is never the subject of therapy; it means that these are examined as they are experienced in the present through remembering and planning (Clarkson, 2014). Laura Perls (1992), reacting to the misperception that GT does not deal with the past or future, wrote “The past is ever present in our total life experience, our memories, nostalgia, or resentment, and particularly in our habits and hang-ups, in all the unfinished business, the fixed gestalten. The future is present in our preparations and beginnings, in expectation and hope, or dread and despair” (p. 52).

Traditional Gestalt therapists are very suspicious of intellectual activities because they tend to lead to talking about rather than experiencing and acting. Another famous Perlism is “Lose your mind and come to your senses” (F. Perls, 1970a, p. 38). Seeking intellectual understanding (asking the why question) is avoiding life. Gestalt counselors tend to believe that “in modern life we suffer from too many explanations…. Perls’s Gestalt therapy gave up on explanations; it became impatient for something to happen. Happening, after all, is the best explanation” (M. V. Miller, 1989, p. 12). The traditional emphasis on action, rather than talking, usually leads to the construction of experiments in awareness, in which the counselor asks the client to actively experience some disowned aspect of their life in the session (Wheeler & Axelsson, 2015). However, current GT therapists, although not totally eschewing experimentation, also acknowledge dialogue and relationship (with the therapist) as an important process in therapy (Haley et al., 2022).

Because experiencing the unfinished situation in the therapy session arouses anxiety, Perls characterized therapy as a “safe emergency” (F. Perls et al., 1951, p. 286). The re-experiencing of the rejected experience in the safe environment of counseling allows the completion of the Gestalt and thus the assimilation of the experience. An important consideration is the balance between support from the counselor (safety) and the therapeutic emergency (risk). The client is not allowed to stay in “safe but infertile territory,” but neither are they exposed to experiences too threatening (M. Polster & Polster, 1990, p. 104).

The current approach to Gestalt counseling is more moderate than what Perls presented. Support of the client is considered very important, and Gestalt counselors tend to emphasize the building and exploration of the here-and-now relationship between therapist and client more than Perls did and are less rejecting of the intellectual elements of counseling (J. C. Watson et al., 2011). The Gestalt therapist strives to create an authentic relationship with the client, which is referred to as the therapist’s presence (Mann, 2021). Contemporary GT advocates still write about the importance of experimentation, warning against an unhealthy split between dialogue and experimenting (Mann, 2021). Yontef et al., (2019) added that good therapy involves a fluid back-and-forth shifting on the therapist’s part from attending to the client’s process to focusing on the relationship between therapist and client.

Gestalt counseling can be either short or long term (Yontef et al., 2019). Although Perls maintained that group psychotherapy using the “hot seat” method (in which one client becomes the object of the therapist’s attention while everyone else watches) is superior to all other forms of counseling, contemporary Gestalt therapists disagree, practicing individual, couples, family, group, and organizational GT (Yontef et al.).

Enrico endeavors to help Jessica stay in the here and now without sacrificing his support of her. He makes observations about how he feels in relation to her in an honest, open way. He asks many how and what questions and no why questions. Enrico encourages Jessica to reveal her present experience as she talks about her relationship with Ramone. If she brings up her father, mother, or family, Enrico will encourage Jessica to explore her feelings about them as they are present in the here and now.

Roles of Client and Counselor

As is the case with Albert Ellis and rational emotive behavior therapy (see Chapter 9), the role of the counselor in GT often gets confused with the person of Fritz Perls. In Perls’s (1970a) version of GT, the role of the counselor is to frustrate the client’s avoidance of self-support. The client is often confronted with their attempts to get the counselor to take care of them and their reluctance to be authentic. One of Perls’s favorite labels was “phony” (Nelson-Jones, 2000). Clearly, confrontation was the hallmark of Perls’s approach to GT (Yontef et al., 2019). N. Friedman (2003) commented that the therapist in this version is something of a stage director or coach and related that Laura Perls maintained that in interacting with clients in this way, Fritz Perls “turned away from the patient” (p. 63). Although this extreme approach is not used by many (if any) Gestalt counselors currently, the extent to which confrontation is used probably varies greatly among GT practitioners.

In more recent versions of GT, the abrasive style of Perls is softened. Gestalt counselors are expected to be authentic, present, and transparent in their relationships with their clients. This authenticity promotes a nonhierarchical alliance between counselor and client (Frew, 2016). In this dialogic or relational GT (Jacobs & Hycner, 2009), acknowledgment is made of the dependence, or really interdependence, of the client and counselor, and “support, healthy confluence, compassion, kindness, accepting the validity of the patient’s wishes, are all part of a good therapeutic attitude” (Yontef, 2009, p. 44). The GT therapist must give themselves to the relationship, be willing to be changed by it and to acknowledge mistakes (Yontef et al., 2019).

Dialogic, or relational views of GT lead to a focus on the between, or the co-created reality that emerges when counselor and client make authentic contact. The relational elements of GT lead the counselor to keep in mind that the way the client interacts in the therapy situation is similar to the way that they do outside of it. The client plays an important role in the relationship—they must agree to be present and self-responsible, just as the therapist does (Haley et al., 2022). Mann (2021) describes the terror inherent in opening oneself to this type of contact that arises from not knowing if one will be met, likening it to the terror of the impasse (discussed earlier in the section on health and dysfunction). The terror of contact is present for both client and counselor. Mann wrote that the therapist must resist the temptation to retreat into technique or questioning to avoid the scary risk of contact, and the client might be tempted to retreat in their own way. It might take a process, but ultimately, if the contact is successful, therapy can proceed.

Despite the claims for nonhierarchical relationship in GT counseling, the job of the counselor is to support the client, providing a safe place where the client can increase awareness of experience they have been avoiding (Yontef et al., 2019). The GT counselor does this by close observation of the between, and observing how the client manages awareness, and most importantly, how the client interrupts awareness of the present. Often, signs of interruption are found in nonverbal behavior, such as muscle tension and breathing patterns. So, although the therapist is authentic and present in the relationship, they are still a guide, a curious supporter that helps the client toward deeper levels of awareness.

To maintain this level of awareness, a Gestalt therapist must have a significant emotional commitment, according to Clarkson (2014). Candidates should undergo personal psychotherapy, similar to the training analyses of psychoanalysts, only from a Gestalt counselor, of course. Parlett and Hemming (1996b) warned us that “Gestalt therapy is not an approach which can be applied by people who are themselves largely unaware of their own contact style or bodily experience” (p. 207). It is also considered important for the GT counselor to be in good physical health and practice growthful habits, such as getting the type and amount of rest, recreation, and diet that they know is personally helpful (Clarkson, 2014).

The client in Gestalt counseling is expected to engage actively in the process of self-discovery—they must be willing to risk authentic contact with the therapist and the exploration of the difficult parts of experience that have been avoided. They must own their experience, rather than just knowing about it (Yontef et al., 2019). As Haley et al., (2022) put it, “Gestalt counseling is the client’s responsibility—with the support of the counselor—to explore their experiences as both a physical and emotional being in relationship to others and the larger world” (p. 176).

Enrico ‘s first goal is to connect with Jessica in an authentic relationship. Enrico observes Jessica as she talks about her experience and also pays attention to his responses to her (e.g., he has an image of her in her police uniform that quickly alternates with an image of a small child). Enrico also notices that his muscles are tensing and that he has impulses to rescue Jessica.

Jessica, eager for the therapist’s help, openly discloses about her situation. She is willing to engage with Enrico. Jessica has a little difficulty expressing her own wants and preferences in counseling, but Enrico helps her stay with it until she is able to fully experience in the session, identifying and expressing her needs.

Goals

The one big goal in GT is awareness. Perls (1969a) said, “Awareness per se—by and of itself—can be curative” (p. 16; emphasis in original). Gestalt therapists are not really interested in behavioral or cognitive change, increasing life satisfaction, getting rid of symptoms, or increasing the client’s sense of well-being, although these things may happen as a result of GT counseling (Crocker, 2019). There are two kinds of awareness: awareness of a moment, process, or aspect of content, and awareness of one’s own awareness (Mann, 2021). The point is that, although the Gestalt therapist wants the client to be aware of a current situation in therapy, they are also interested in the client understanding the process of awareness so that they can apply it to other situations. An added benefit of this kind of awareness is that it promotes taking responsibility for behaviors enacted (Yontef, 1995). Parlett and Hemming (1996b) described the goal of GT a little differently, saying that the process should “promote self-support sufficient for the person to live a life of freedom and choice (thus increasing his or her ‘response-ability’)” (p. 205; quotes in original).

Awareness also involves modification of the contact style if it is dysfunctional (Frew, 2013). Such modification will ultimately result in the growth of the individual, for increased awareness will result in better harmony with the environment and enhancement of the organism through assimilation of needed things. Thus, a goal of GT could be said to be growth. In fact, many Gestalt therapists maintain that people come to counseling not for remediation, but for the facilitative aspects of GT. M. Polster and Polster (1973) emphasized the growth orientation of Gestalt counseling when they wrote “therapy is too good to be limited to the sick” (p. 7).

Enrico hopes to help Jessica become aware of the unfinished business she is carrying around. Clearly there is some with both her mother and father. He’d like to help her recognize the ways she avoids contact with the environment and aspects of herself. Enrico has no predetermined ideas about what she should do about her situation or relationships; he’d like her to become aware so that she can decide for herself. Ideally, Jessica will come to value awareness and responsibility in her life, taking these tools out of therapy to use in future life experiences.

Process of Therapy

Gestalt counseling has three central elements: relationship, awareness, and experiment (Clarkson, 2014). The first step is for the Gestalt counselor and client to establish an authentic relationship. This relationship is often the medium through which awareness is explored. For example, the client’s desire to be dependent on the therapist can be brought up explicitly, with the client living and describing this experience in the session. Awareness, of course, is critical, because interruptions in the awareness process are what bring the client to counseling. Experiments are therapeutic activities created to further awareness; they are central in GT and discussed later under a separate heading.

Levitsky and Perls (1970, pp. 140–144) described the rules of GT; the most critical of these are (a) staying in the now; (b) maintaining I and thou, or the emphasis on aware and authentic communication; (c) using “I,” not “it,” language, or taking responsibility for all statements; and (d) asking no questions—because they are seen as asking something of the counselor and therefore as aspects of the client’s passivity or laziness. The client is urged to turn questions into statements. Clients in therapy groups are expected to follow the “no gossip” rule: One must speak directly to any individuals present, not about them. O’Leary (2013) includes using I language under what she labels “language techniques,” which also include things like changing can’t into won’t, eliminating qualifiers (e.g., maybe, sort of, possibly), and making demands (instead of being ambiguous or passive). As you will see in the section on diversity, the early emphasis on direct communication can be problematic from a multicultural standpoint. Contemporary GT therapists would be less likely to impose such rules, even in group therapy.

An aspect of GT that sets it apart from many other approaches is its emphasis on physical or body sensation and functioning as a critical aspect of human existence. Unfinished business is often seen in the body of the client. Thus, Parlett and Hemming (1996b) suggested that in Gestalt counseling “the body is regarded as a source of wisdom, a provider of organismic truth” (p. 200).

Gestalt therapists refer to the paradoxical theory of change (Mann, 2021; Yontef et al., 2019). By this term, they mean that the more you try to change, the more you stay the same. Change is, instead, accomplished by becoming aware of and accepting who you are. The Gestalt therapist needs to be aware of this dictate so that they will not align with aspects of the client that pressure the client for change. Perls et al., (1951) recommended that the Gestalt counselor adopt a stance of creative indifference toward their work. This somewhat confusing term does not mean that the counselor is truly indifferent to the client, only that they are not intensely invested in some particular outcome or process in therapy (Mann, 2021). Essentially, the therapist (and the client) are surrendering to the fertile void and waiting to see what emerges.

Field theory brings the idea that the person should always be viewed in context, and that includes the therapist and the therapy situation, too. The therapist is an integral part of the therapy, not a detached observer. Further, according to Parlett (2005), the field has inherent structure, which should be examined in therapy. These ideas connect to the relational emphasis in current GT theory—the therapist and client both have input into the here-and-now situation, and to this they must attend (Jacobs & Hycner, 2009). Another important implication of the field perspective is that, similar to family systems therapists (see Chapter 13), Gestalt therapists are aware that any change in the field will affect the rest of it (Yontef, 2005).

Client resistance is not to be fought, eliminated, or overcome in Gestalt counseling. In fact, Frew (2013) declared that “there is no concept of resistance in Gestalt therapy” (p. 240). Instead, resistances are identified as the energy of the organism placed in service of opposing experience that might be harmful (Yontef et al., 2019). The resistance might involve a need that, if it emerged, might be dangerous, or something coming from the therapist (i.e., the therapist’s agenda). Some of these behaviors (i.e., the neurotic adaptations or contact modifications) stem from adaptive responses to past experience, as described earlier. Instead of wanting the client to overcome the resistance, the GT counselor wants the client to experience it, encourage it, and bring it to the center of awareness. In this way, resistances, which are ways of avoiding meaningful contact, can be used to resolve unfinished business (Joyce & Sills, 2010). Mann (2021) noted that it is not healthy to continually be in full contact with our environment, so in this view, resistance can be seen as positive. In fact, some clients need to construct resistance—they are too open to the environment.

In the GT view, transference is not seen as purely the client’s distorted way of perceiving the world, although it is seen as a possible clue to how the client habitually structures experience. In fact, Mann (2021) argued that the term transference should be replaced with enduring relational themes. These are brought into therapy by both the counselor and client, and then influence the reality that is co-created in the therapeutic field. Gestalt therapists acknowledge that we do bring the past into current situations, particularly when we carry around unfinished business. If the counselor notices what may be an enduring relational theme brought by the client, this observation should be held lightly and considered in context (Mann, 2021).

It seems that contemporary GT therapists don’t spend a lot of time discussing countertransference. In general, countertransference would be seen as a failure of bracketing, or a contact disturbance on the part of the therapist—the therapist’s enduring relational pattern entering the room. However, some time ago, Clarkson (2014) identified three kinds of countertransference that are worth reviewing. The first occurs when the counselor’s unfinished business is activated while in a relationship with the client. The Gestalt counselor must be alert to this event and be able to set these responses aside (termed bracketing) to be dealt with in supervision or personal therapy (Mackewn, 1997, p. 95). However, the counselor’s reactions can also be those experienced by others in the client’s life or past, perhaps reactions to the client’s transference behaviors. Third, Clarkson discussed a confluence-based response in which the counselor experiences the client’s experience—the feelings, thoughts, or response tendencies that the client has or even the ones they may be avoiding (p. 128). It is most important that the counselor, in continuing recognition of the dialogic nature of GT work, be able to acknowledge their own input in the relationship and be able to distinguish between the types of countertransference.

Enrico focuses on the three elements of Gestalt counseling with Jessica. It is relatively easy to establish a relationship with her, but Enrico is sensitive, at first, to the relatively superficial level of their contact. As time goes on, the relationship becomes more authentic.

Awareness is always central for Enrico. He endeavors to be aware of his own experience in relation to Jessica, and everything he does in counseling is directed toward helping Jessica become aware of her experience. For example, when she is talking about her mother, Enrico notices that she assumes a rather flat tone of voice. Enrico asks Jessica if she is aware of how her voice has changed.

Enrico sees Jessica struggle with contact around her feelings for her mother and father. When he asks questions, attempting to get Jessica to experience these in the session, he notes that she becomes more closed physically and less responsive verbally. Attempting to explore the resistance, Enrico asks Jessica to become aware of how she is feeling, physically and emotionally. If she still shows a need to protect herself, Enrico accepts this as a sign of Jessica’s strength and helps her verbalize this to him. He is not adamant about reciting the rules of therapy with Jessica, although he does encourage her to use “I” language.

Enrico notes no countertransference, although he is aware that this could happen. He has recently returned to therapy to explore some of his own interruptions and typical relational patterns. He will be vigilant in looking for signs that his own issues are intruding on his interactions with Jessica. Noting that he experiences Jessica as wanting him to direct and support her, Enrico decides that this is his response to her typical way of operating based on her unfinished business. He finds ways to share his reactions with Jessica and they explore their experiences.

Therapeutic Techniques

GT has often been perceived as synonymous with its techniques, particularly dialogue techniques and the “empty chair” (discussed later). Current Gestalt theorists and therapists reject this perspective, saying, “Most modern Gestaltists would adopt a therapeutic relationship characterized more by dialogue and an appreciation and exploration of the subtle exchanges, some explicit, others implicit, that arise between counsellor and client, rather than techniques involving invasion or deprivation” (Clarkson, 2014, p. 27). At the same time, when other writers approach GT technique, the first word that typically comes up is experiment. So, it seems there may be two camps of GT counselors—those who emphasize a more unstructured exploration of the client’s awareness, and those who are more apt to suggest experiments in awareness. Ultimately, it would appear that Gestalt counselors are technically eclectic; any technique that fosters awareness is considered acceptable (Yontef et al., 2019).

In the following, I describe some of the techniques used in traditional Gestalt counseling; you should keep in mind that many contemporary GT practitioners would likely be less structured in their approaches.

Experiments

Experiments are activities that help the client increase awareness. The idea is to create a new experience for the client within the therapy room, or what GT theorists sometimes call safe emergencies (Mann, 2021). Although the experiment is most often suggested by the therapist, the relationship should be such that the client will feel they can decline (Joyce & Sills, 2010). The spontaneity of the experiment is important—the “creative adventure” arises from the moment-to-moment experience of client and therapist (Roubal, 2009, p. 272). Although experiments are often described as one-of-a-kind experiences tailored for the specific client, many of the techniques described in this section are considered experiments in awareness; dialogues are probably the most notorious example.

Enrico expects that he and Jessica will devise experiments in awareness spontaneously as they work together. In his close attention to Jessica he notices that when she talks about her fight with Ramone, she seems to shrink into her chair and crosses her arms across her chest. He asks her if she is aware of these sensations. Would she like to try an experiment? When Jessica agrees, he asks her if she can focus on these sensations in her body and describe them.

Therapist Self-Disclosure

Often, the Gestalt therapist, attending closely to their experience, will disclose their awareness to the client (Wheeler & Axelsson, 2015). “Sometimes the therapist is bored, confused, amused, angered, amazed, sexually aroused, frightened, cornered, interrupted, overwhelmed and on and on. All of these reactions say something about both the patient and the therapist and they comprise much of the vital data of the therapy experience” (E. Polster & Polster, 1973, p. 18). The Gestalt counselor authentically discloses an experience, and then the client and counselor discuss it in the immediacy of the relationship. However, Mann (2021) discussed self-disclosure as part of presence, cautioning that “any disclosure needs to be in the service of the dialog” (p. 231; italics in original)—the therapist needs to assess whether disclosure (a form of presence) is appropriate to the state of the relationship at that time. Disclosing prematurely or too intensely can overwhelm a client, but not disclosing may make the client feel unheard or that the therapist is not very interested.

Enrico decides to disclose his alternating images of Jessica as a child and police officer to her. She bursts into tears, saying that she feels like the child in the moment. Enrico replies that he feels like taking care of her.

Dialogues

In the interest of increasing awareness and addressing unfinished business, Gestalt counselors often ask the client to create a conversation, or dialogue, in the counseling session. Dialogues often involve an empty chair, in which the client places a person or an aspect of the self. In other approaches, two chairs are used, and the client switches back and forth, playing the entities in the chairs, as in the top dog and underdog dialogue, described next. So, often you will hear these the dialogue techniques referred to as two chair or empty chair. These dialogues can be among parts of the self, to complete unfinished business, or to bring awareness about relationships, often by putting some important individual in the client’s life, past or present, in the empty chair (Hycner, 1987). Dialogues are also created between the “splits” or polarities in the client’s personality (Mann, 2021).

Historically, one very well-known dialogue is top dog and underdog (Levitsky & Perls, 1970). In this experiment, the client plays two parts of themself: the critical, demanding top dog and the whiny, excuse-using underdog. These are the end points of a critical polarity inherent to humans and, according to Perls (1969a), we use the conflict between the top dog and underdog as a way of torturing ourselves. In top dog–underdog dialogue, the client alternates between playing the two poles. They boss like the top dog and whine like the underdog. The goal of the dialogue is to have these two aspects of the self listen to each other. Ultimately, full expression of these aspects of the self will result in their integration (M. V. Miller, 1989). That is, the two aspects will no longer be “split off” from each other, but integrated as parts of the personality. Many modern Gestalt therapists would likely reject this version of dialogue as outdated, although some sources still acknowledge it (Mann, 2021).

A contemporary perspective on dialogue is found in emotion-focused therapy (EFT; see Box 7.2 for a brief description; Goldman & Greenberg, 2022; L. S. Greenberg, 2017). EFT theorists recognize different purposes for two-chair and empty-chair dialogues. Two-chair dialogues are aimed at healing split aspects of the self, whereas empty-chair dialogues are interventions for unfinished business. Anything or anyone can be put in the empty chair, and the client talks to the entity. Often, the client is asked to play the part of the person or projection in the chair and switches seats as they do this enactment. Sometimes the Gestalt counselor plays the entity in the empty chair. This approach has many uses from the GT perspective, including creating a situation in which unfinished business can be completed with significant others, helping the client resolve internal conflicts, and allowing the client to experiment with behavior that is threatening and scary.

Enrico asks Jessica if she’d like to talk to her mother, guessing that Jessica has unfinished business with Mom about love and belonging. Hesitant at first, Jessica agrees to try the experiment.

Enrico: Tell your mom what you’re experiencing right now.

Jessica: I wish I could get close to you.

E: What are your feelings?

J: I am sad. I’m angry. I want to hurt you.

E: Say that again.

J: I’m ANGRY!!

Playing the Projection

To increase the experience of disowned parts of the self, the Gestalt counselor might ask the client to play the role of the projection (Haley et al., 2022). For instance, if our client Jan’l sees someone as angry and hateful toward them, the therapist might ask Jan’l to act out an angry and hateful person. The therapist could then ask Jan’l if they could find these qualities in themself.

Because Jessica does not seem to be projecting, Enrico decides that playing the projection is not a technique he will use.

Exaggeration

If the client appears to be unaware of some aspect of their experience, the Gestalt counselor guides them through the process of exaggerating the identified element (Levitsky & Perls, 1970). The target of exaggeration can be a nonverbal (a movement or a posture) or something verbal (tone of voice or a specific statement) (Haley et al., 2022). Often, the original expression of the client is incomplete or stunted; the therapist helps the client make the movement more authentic. The client might be wiggling their leg. The astute Gestalt counselor asks them to exaggerate the wiggle, attempting to get the client to increase awareness of this expression and the beliefs, feelings, or history associated with it (Wheeler & Axelsson, 2015). Exaggeration can also be used when the counselor hears the client glossing over something they say and asks them to repeat it, perhaps more forcefully.

When Jessica talks about her mother, Enrico notices that she hunches up her shoulders. He asks Jessica if she notices this. Jessica says, “Not really,” so Enrico asks her to exaggerate the tension and describe what it is like. Jessica reports that she is protecting herself from psychological blows from her mother.

Reversals

Recognizing that observable behaviors are sometimes the opposite of underlying impulses (i.e., at the opposite end of a polarity), the Gestalt counselor directs the client to act the reverse (Haley et al., 2022; Levitsky & Perls, 1970). For instance, a shy client could be asked to play the extrovert. Therapist and client then explore what it was like for the client to experience this avoided part of the self.

Enrico has observed (from watching her dialogue with him in the empty chair) that Jessica is passive in her relationship with Ramone, always trying to please him. He asks Jessica to put Ramone back in the chair and play the bossy, bitchy, overbearing woman, the opposite end of the polarity they have discovered. Jessica is hesitant at first but eventually comes around to taking on the role.

Dream Work

Perls (1970b) called the dream the “royal road to integration” (p. 204), seeing dreams as the most spontaneous form of human expression. Despite the allusion to Freud’s position on dreams (“the royal road to the unconscious”), the way dreams are handled in GT is very different from the way they are addressed in traditional psychoanalysis.

In Perls’s approach to GT dream work, the client takes on the role of the parts of the dream, giving each its own speech and experiences. Perls (1970b) insisted that the client “play” all of the objects and people in the dream, giving them voice and action, because this represents experiencing aspects of the self symbolized in the dream elements. Most likely, these aspects are ones that the client has disowned or that represent important people in the client’s life (Staemmler, 2004). The therapist does not interpret the dream other than in the general sense of regarding it as meaningful to the client—the client does the interpreting, if any occurs (Mann, 2021).

Joyce and Sills (2010) described a much broader approach to dream work. Although including the traditional play-the-part method, they also suggested that clients can benefit from interventions such as (a) telling the dream in present tense, (b) creating different endings for their dreams, (c) nonverbally telling the story of the dream, and (d) devising dialogues between dream elements, among others.

Jessica dreams that she is a gardener. She has her hoe and her spade and her gardening gloves. She gleefully plants flowers and vegetables and watches them grow.

Enrico asks Jessica to play the parts in the dream. First, she is the hoe, turning up the soil. Then she is the spade, moving things around, carrying soil to where it belongs. The gloves protect. Flowers and plants struggle against soil and emerge into sunlight. Moving around Enrico’s office, she gains physical awareness of all of these elements of the dream—and of herself. What parts of Jessica are here, wonders Enrico?

Awareness Training or Bodywork

In one sense, all Gestalt counseling is awareness training. In a more specific sense, Gestalt counselors work with their clients to become more aware of their physical sensations because these are often clues to aspects of experiences blocked out of awareness (Mann, 2021; Wheeler & Axelsson, 2015). The client might be asked to attend closely to any body sensation that the counselor thinks is important—breathing, tone of voice, physical gesture, and so on. Often this request occurs in one of the GT experiments or chair dialogues.

Enrico notices that Jessica clenches her fist when she talks about Ramone. He asks that she attend to this motion and experience what the tensing is like. He might even ask her to “play” her fist.

Evaluation of the Theory

Historically, responses to GT were numerous and rarely moderate! Crocker (1999) commented that GT had a reputation as “an intrinsically rude and confrontational method, lacking in both gentleness and a respect for clients, and practiced by people with questionable moral standards” (p. 7). GT has also been characterized as “wild, uncontrolled, undisciplined—in a word, dangerous” (E. W. L. Smith, 1991, p. 62). These criticisms seem to stem from two sources. First, the approach was highly identified with Perls and his confrontive, abrasive approach. GT in the classic form overemphasized the individualistic. Moreover, Perls acted unethically and was sometimes abusive (Clarkson & Mackewn, 1993). Captivated by Perls’s charismatic style, many insufficiently trained people put on their Gestalt therapist hats and created havoc (Parlett & Hemming, 1996a). A second reason that GT is thought to be wild and dangerous seems to be connected to its adoption of the rebellious, antiauthoritarian stance of the mid- to late 1960s. This reaction also seems to be the result of GT’s emphasis on raw experiencing and lack of structure.

Contemporary approaches to GT would seem less susceptible to these critiques. Modern Gestalt therapists are careful to explain that “the experiment is not simply a facile technique to be applied indiscriminately” and to caution counselors to provide support in conjunction with challenge (M. Polster & Polster, 1990, p. 104). Relational GT therapists may eschew such experimentation altogether.

The lack of supporting theory is also seen as a failing of GT; the approach was historically seen as little more than a collection of gimmicky techniques, the most notorious of which is the empty- or two-chair dialogue (M. V. Miller, 1989; Wagner-Moore, 2004). Miriam Polster (cited in Hycner, 1987) argued that the excessive reliance on technique is seen only among inexperienced or narrow-minded Gestalt counselors. Haley et al., (2022) echoed the concern that inexperienced counselors might jump on the technique bandwagon with injurious results to clients. Indeed, if you read contemporary GT sources (e.g., Jacobs, 2019; Wheeler & Axelsson, 2015), relational GT folks will discuss few structured techniques and will have a pronounced focus on the phenomenological exploration of the client’s experience. Other current GT therapists review the use of classic techniques such as chair dialogues or write more generally about experiments, but the approach is much more tentative, with lots of caveats about maintain boundaries and monitoring the client’s experience (Haley et al., 2022; Mann, 2021; Skottun & Krüger, 2022).

Qualities of the Theory

Precision and Testability

Gestalt theory (the perception theory) was based on well-constructed laboratory research. The constructs of GT theory diverge from classic Gestalt theory, and some are very difficult to operationalize. They are difficult to define (e.g., contact) and observe, partly because they are so broad (e.g., awareness). At the same time, L. S. Greenberg (2017) and associates (see Elliot et al., 2004 and Brownell, 2016 for a summary of early research), proponents of emotion-focused therapy (EFT) have achieved some success in operationalizing particular GT techniques and processes, such as attempts to capture client levels of experiencing and investigations of the effects of chair dialogues (see Box 7.2 and the discussion of research in the following sections).

Empirical Support

Traditionally, Gestalt advocates have been rather reluctant about traditional methods of research—questioning whether they can capture the unique and individualized nature of GT (Yontef et al., 2019). At the same time, the current practice environment in many countries emphasizes evidence-based intervention; hence, there have been numerous calls for research on GT (Roubal, 2016). GT is considered one of the humanistic-existential psychotherapies, and meta-analytic evidence shows good support for these as a general class; this research will be summarized in the sections following (Elliot et al., 2021). Less support exists for the theoretical structure on which Gestalt counseling rests, possibly because it is so difficult to operationalize. Again, the exception to this generalization is the research of L. S. Greenberg and associates on EFT.

Research Support

Outcome Research

Elliot et al., (2013) reported on a meta-analysis of studies of humanistic–experiential psychotherapies (HEP), finding large effect sizes when pre- to post-therapy comparisons were made. The set of studies included investigations of person-centered, experiential, focusing, gestalt, motivational interviewing, or studies in which the treatment included empathy and client experiencing as central elements. In studies that compared treatment to untreated control groups, the effect sizes were large in favor of treated clients (0.96 versus 0.19). No differences in effectiveness were found when studies comparing HETs to other approaches were analyzed. However, it should be noted that there were very few studies of GT in this analysis. Elliot et al., (2021) followed up on the 2013 meta-analysis, analyzing 91 studies of HEP published between 2009 and 2018. Notably, Elliot et al. indicated that in this new set of studies, the diversity of clients and cultures represented was much broader than in the earlier meta-analyses. Their results were similar to the 2013 analyses, with HEP being associated with significant change among clients. Also, Elliot et al., (2021) were able to test the effect size for 17 tests of what they classified as Gestalt/psychodrama treatment and found significant levels of change over time. When studies comparing HEP to other treatment approaches were the subject of analyses, HEP were found to be equivalent. Specific comparisons of HEP to cognitive behavioral approaches (CBT) produced showing some evidence that CBT had stronger effects, but these differences disappeared for randomized controlled trials when researcher allegiance effects were accounted for (i.e., the tendency for results to fall in the direction of the researcher’s preferred approach). However, there were not enough studies of GT to do separate comparisons with other approaches. In the end, Elliot et al., (2021) concluded that there was sufficient support for HEP as evidence-based interventions.

It seems that there are few, if any randomly controlled trials of GT (RCTs). Therefore, studies of GT have been mostly effectiveness studies, without random assignment, treatment manuals, or control groups. Attempting to address the lack of standardization of GT intervention, Fogarty et al., (2020) described the construction of a measure to facilitate GT research, the Gestalt Therapy Fidelity Scale. Fidelity scales are used to determine whether therapists are actually delivering a specified therapeutic approach, and therefore, can help determine the efficacy of an approach as well as in investigating the relative effectiveness of therapeutic approaches. Fogarty et al. completed three studies to create their scale. In the first study, GT experts examined items measuring eight foundational concepts in GT: developing awareness, dialogic relating, working in the here and now, phenomenological practice, working with embodied awareness, field sensitive practice, working with contacting processes, and experimental attitude. The results of three studies showed that items developed to represent these constructs (in terms of whether a stimulus therapist demonstrated them) were good measures of the constructs and showed good psychometric properties. Further, participants’ (mostly GT therapists) ratings using the scale distinguished between therapists practicing GT and those practicing CBT. Perhaps most importantly, the participants across studies could agree on the core concepts of GT, suggesting that there is a recognizable core of GT theory. Despite this development, however, I have not found any further research using this instrument, perhaps because it is relatively new.

Stevens and Wakelin (2016) reported on an effort within the UK Gestalt community to tackle the issue of GT therapy outcomes using a naturalistic (effectiveness; see Chapter 1) method. Using a measure that is the most commonly used outcome measure in the UK health system (the National Health Services; NHS), the researchers collected data from 249 clients of GT therapists across a range of practice settings (both public and private practice). A total of 135 complete data sets resulted (some clients dropped out early or were not finished with therapy at the time data were analyzed in 2010). Stevens and Wakelin reported that clients in the GT sample showed improvement roughly comparable to several other samples with much larger datasets. Two of the benchmark datasets compared CBT, person-centered, and psychodynamic therapies’ outcomes in NHS settings, finding no differences in client outcomes among the approaches, and one collected outcome data for benchmarking across a wide array of therapy types. Approximately 74% of the clients in the study’s sample showed recovery or significant improvement. Although a little dated, this study does provide some support for the effectiveness of GT, but you must keep in mind that this was not a randomly controlled trial, so it’s possible that many kinds of bias crept in to influence the results.

Several other studies are worth reviewing, although they have weaknesses as well. In a small group of 30 participants, the effectiveness of hypnosis therapy and Gestalt hypnosis therapy combined with CBT were compared to a control (passive listening) for depression in Mexican participants (Gonzáles-Ramírez et al., 2017). Clients were assigned to treatments “alternately” so it is not clear that random assignment was used. Outcome was assessed via a well-known measure of depression. Both treatment groups showed significant decreases in depression from pre- to posttest whereas the control group appeared not to change. Because the treatments in this study were not described in detail, however, it is not clear how relevant this study is to the efficacy of GT.

Djoric et al., (2016) studied responses to GT group therapy among offenders in prisons in Italy and Serbia. Very little information was given about the GT group treatment, although standardized outcome measures were used. They failed to find decreases in symptoms and improvements in well-being among the participants, but argued that this result was due to the very low pretest scores of participants, pointing out that participants did not have psychiatric diagnoses, or that they might have been motivated to appear well, given the prison environment. Again, there were no comparison groups (and no random assignment to treatment), so although providing some weak evidence supporting GT, strong conclusions about the effectiveness based on Djoric et al., (2016) and Stevens and Wakelin (2016) are not wise.

Elliot and colleagues (2004; L. S. Greenberg, 2017) have established a respected research program that investigates emotion-focused therapy. Although not directly intended to test GT outcomes and theory, these investigations are still relevant to our understanding of GT because EFT is a hybrid of Gestalt and person-centered therapies. Previous research summaries produced strong support for individual EFT; however, recent research seems to focus more on EFT for couples (Spengler et al., 2022). One recent study in the in the Irish national health service compared EFT and CBT for generalized anxiety disorder in a well-designed RCT (Timulak et al., 2022). In the study 29 clients in each treatment completed 16–20 sessions of treatment, with both approaches producing significant and large pre- to post-therapy change and similar outcomes across other measures. These changes were maintained at 6 months after treatment ended. Interestingly, therapist fidelity was assessed in this study and all therapist showed moderate levels of fidelity.

In earlier work, L. S. Greenberg (2017) summarized the EFT program of research, which looked at both process and outcomes in EFT. EFT is manualized, and a number of earlier RCTs produced positive results (e.g., Ellison et al., 2009; L. S. Greenberg et al., 2001; L. S. Greenberg & Watson, 1998). However, to their credit, Elliot et al., (2004) did point out that this research is conducted almost entirely by advocates of EFT, warning that allegiance effects could play a part in the process (see Chapter 1).

In summary, the research investigating the outcomes of GT is sparse and with a few exceptions, generally doesn’t meet the gold standard of randomly controlled trials. Effectiveness studies (mostly pre- post-therapy studies of clients nonrandomly assigned to GT) seem to produce positive results, but the methodology leaves us with questions about the quality of the evidence.

Theory-Testing Research

Process research relevant to GT has focused mainly on chair dialogue, and much of it has been performed by EFT advocates. L. S. Greenberg and his colleagues conducted quite a bit of research on chair dialogue, but much of it is dated. For example, L. S. Greenberg and Malcolm (2002) analyzed the process and outcomes of ECD in resolving unfinished business. They found that clients who displayed indications of having resolved the unfinished business had better therapy outcomes than those who did not. In a study of clients who had experienced child abuse, clients were assigned to either empty chair work or empathic exploration (the clients talked to the therapist about their abusers rather than to them, as in empty chair). Those using chair work had stronger positive effects. However, the dropout rate was higher among participants who enacted the empty-chair dialogue compared to those that did not use chair dialogue (Paivio et al., 2010).

A more recent exploration of chair dialogue was conducted by Łysiak (2020), who tested the effects of an expanded form of chair dialogue called dialogical temporal chair technique (DTCT). In DTCT, clients/participants are asked to construct a dialogue among past, present, and future selves. Participants in this research were students recruited through advertisements at universities and by school counsellors. They completed measures of meaning of life and four emotional states (anxiety, anger, depression, and curiosity) prior to and after performing the dialogues. Participants did show increases in meaning of life and also curiosity after the dialogues. However, no differences were found for the other measures.

Although not specifically grounded in GT theory, some research interest has centered on unfinished business (UB). Holland et al., (2020a) developed the Unfinished Business in Bereavement Scale, finding that the scale was composed of two factors: unfulfilled wishes and unresolved conflict. The scale showed good psychometric properties, suggesting that the construct of unfinished business can be reliably measured. Not surprisingly, they reported that overall UB was strongly related to prolonged grief, although unresolved conflict seemed to be the more detrimental of the two dimensions. Research has also established that UB in the form of unresolved conflict with at deceased one could be distinguished from bereavement-related regrets, and they also verified that unresolved conflict was more strongly related with complicated grief syndrome (Holland et al., 2020b). Masterson et al., (2018) studied unfinished business among advanced cancer patients—in their study 72% of patients reported recognizing UB in their lives. The UB was related to higher levels of anxiety and hopelessness, and lower levels of personal meaning, compared to patients that did not report UB. Studying something in the forefront for all of us of late, S. S. M. Lee et al., (2022) investigated individuals’ reactions to losing loved ones to COVID-19. Participants reported experiencing at least one of the following: types of self-blame (guilt, shame, regret) or UB. Again, unresolved conflict was a strong predictor of problematic grief, which in turn was not related to time since the loss. In summary, it appears that we can be fairly certain that UB is distressing and related to poor outcomes among those who are terminally ill or grieving. Whether this research is strong support for GT theory, however, is questionable, although in general, the proposition that UB is problematic is certainly in line with GT theory.

Issues of Diversity

Many critics have pointed a number of biases in GT. Starting historically, Saner (1989) opined that “most American Gestalt Therapy theorists and practitioners are unaware of being influenced by culture values or fixed gestalten best described as individualism or individualistic neurosis. My claim is that the contemporary form of Gestalt Therapy made-in-U.S.A. is not universally valid and needs theoretical and methodological revisions in order to be truly cross-culturally valid and meaningful” (p. 59). Similarly, Priester (2014) noted the very American and individualistic emphasis on self-disclosure, catharsis, personal responsibility, and present-time orientation. Mann (2021) pointed to the pathologizing of confluence and introjection as a further example of bias in GT theory. Clarkson (2014) wrote that “currently, there is increasing recognition . . . that responsibility for the self inevitably includes responsibility for the others who share our world” (p. 32). Frew (2016) noted that current writers are likely to address issues of diversity, citing numerous examples in an article addressing “creatively adjusting in an increasingly diverse world” (p. 106).

The emphasis in GT on verbal, emotional, and behavioral expressiveness is counter to the values of many cultural groups (Sue et al., 2022). Latinx and Asian individuals may see the control of emotions and behavior as signs of wisdom. Also, GT’s emphasis on self-disclosure may be in opposition to these groups’ values. At the same time, GT’s disavowal of insight may be consistent for individuals who want action, such as individuals of lower socioeconomic status. The relative lack of focus on content and the ambiguous structure of GT, on the other hand, may be disconcerting to clients of diverse cultural backgrounds, such as Asian or Latinx clients (Sue et al., 2022).

Fernbacher (2005) argued that the emphasis on awareness in GT is facilitative in working with clients from diverse backgrounds, provided that the therapist is aware of their own process. She also pointed to the field theory construct of GT as a positive, promoting the understanding of the client and counselor as indivisible from their contexts (e.g., culture, society, political systems). However, Fernbacher also cautioned that the heavy reliance on nonverbal observation and intervention in GT calls for attention to differences across individuals to understand the meaning and impact of these expressions.

Frew (2016) provided a thoughtful analysis of present and past GT thought and practice with regard to diversity issues, focusing primarily on cultural diversity (as compared to sexual orientation, identity, ableness, and so forth), based in E. T. Hall’s (1976) intercultural communication theory (ICT). I will provide a brief summary here, but would encourage budding GT therapists to pursue this article. ICT distinguishes cultures on a number of dimensions: high vs. low context, direct vs. direct communication, individualism vs. collectivism, emotional expression vs. emotional restraint, small vs. large power distance. You are probably familiar with these terms except for high vs. low context—the extent to which meaning is expressed through verbal messages. High context cultures value explicit verbal communication, whereas low context is conveyed through nonverbal means and reference to context. Small vs. large power distance refers to cultural values of equality vs. hierarchical structure. Frew maintained that modern GT is high context, sensitive to indirect communication, aware of collectivism, emotionally restrained, and large power distance than in past versions. I am not certain I buy all of these contentions (e.g., I have a hard time seeing GT therapists as routinely setting up large power differentials), but the point really is to understand these dimensions and to see that in GT, modifications can be made to address differences among them. Frew conceded that point, in fact. Another compelling message in this model is the value of curiosity in working with clients, and what Frew called the platinum rule: Do unto others as they want to be done; that is, treat others as they wish to be treated (p. 121).

Several writers have pointed to the identities of the creators of GT and its situation in the rebellious 1960s as evidence for its attention to issues of social justice. The roots of GT have been characterized as liberationist (Lazarin, 2019). Yontef et al., (2019) wrote

The founders of Gestalt therapy were all cultural and political outsiders. Some were Jews, and some of them were immigrants—including Fritz and Laura Perls—who had fled persecution in Europe. Some were gay. All were interested in developing a process-oriented theory that could provide support and encouragement for people to explore their own life paths, even if those life paths did not fit neatly within extant cultural values. Thus, instead of establishing content goals for successful therapy (e.g., achievement of genital sexuality), they established a process goal: awareness (p. 342).

At the same time, the very origins in the individualistic 1960s brought that bias, and also a bias toward White as the normative group/identity (Mann, 2021), and I would venture heterosexual and cisgender as well. Plummer (2019), based on a presentation at the Association for Advancement of Gestalt therapy, discussed radical respect. Although not specifically addressed to the therapeutic moment, she did point to the multiple identities that we all carry, and indicated that reacting to someone as a function of only one of those identities was disrespectful. I think you can see the implications here for working with your clients.

Based on a survey of recent issues of Gestalt Review and the other recent sources I consulted for this chapter, it was a little surprising that I didn’t see discussions in the current GT literature about working with clients who represent diversity in terms of gender identity, sexual identity, ableness, religion, and other important dimensions of diversity. In the past, these issues have been addressed, so I will briefly review those comments.

Attention to the issues of gay, lesbian, and bisexual individuals can be seen in chapters written by F. Curtis (1994) and Singer (1994) on GT with gay and lesbian couples. Singer provided a good description of issues specific to gay couples, while also acknowledging that GT counseling with a gay couple is not that different from GT counseling with a heterosexual couple. Curtis discussed critical issues for lesbians, such as the strong heterosexist bias in most cultures, and applied GT constructs to issues likely to emerge with lesbian clients in counseling, such as shame.

Enns (1987) described a feminist perspective on GT and, in my view, many of her observations are still relevant today. She maintained that GT is in many ways consistent with a feminist orientation because it emphasizes awareness and personal power. In this system, women can be encouraged to become aware of parts of themselves that are culturally discouraged (e.g., intense feelings of anger). GT can also support women as they go against existing norms in defining themselves separately from others. At the same time, the emphasis on responsibility and individuality found in GT can be problematic. Enns (1987) also highlighted GT’s neglect of the fundamental interrelatedness of humans. Women traditionally equate their self-worth with gaining and maintaining the love and approval of others. GT’s support for growth and personal responsibility may help clients who identify as women find their worth in themselves rather than in others’ perceptions of them. Again, the more recent relational approaches to GT likely address some of these criticisms.

The Case Study

Jessica presents with troubled feelings about her relationship, for which she blames herself. This internalization fits well with a GT approach because it suggests that she is denying her personal dissatisfaction with the relationship. She has lost contact with her aggression and anger as well as her need for love. Jessica’s history, especially her unfulfilling relationships with her parents, also seems to be amenable to a GT viewpoint. She seems to have lots of avoidance of contact as well as unfinished business.

Potential problems with a GT approach for Jessica would potentially involve her feelings of responsibility for the relationship with Ramone. Women are taught by Western culture to take care of relationships, so insisting that she violate these cultural rules could create difficulty for her. That Jessica is Black could also be a factor in employing a GT framework because the emphasis on individualism may be counter to the more collectivistic approach of Black culture. There may also be issues with encouraging Jessica to get in touch with her anger and express it, given the societal tropes about angry black women.

Summary

Gestalt counseling is an existential–humanistic approach to human functioning. Individuals are seen as functioning holistically and striving to meet needs, such as physical and emotional support. Needs are met through contact with the environment in an unending cycle of need emergence, activity by the individual aimed at satisfying the need, need satisfaction, and disappearance of the need. Contact with the environment is sometimes scary or painful, so we sometimes avoid contact by introjecting, projecting, deflecting, retroflecting, or moving into confluence. When we avoid contact and needs go unmet, we create unfinished business, holes in the personality, and psychic splits. Our awareness of the environment (which includes the self) is disrupted and contributes to further dysfunction.

Gestalt therapy is conceptualized as an encounter between two individuals. No formal assessment or diagnosis is used. The counselor is to be authentic in the relationship and will self-disclose if it seems helpful. The goal of GT is to support the client so that they can freely experience themself and their environment. Numerous techniques can be employed, and most Gestalt counseling involves some form of experiment in awareness.

GT has been faulted for its extreme emphasis on individual responsibility. This orientation may lead to problems in using this approach with individuals who are from cultures that are more relationship or group oriented. Some, but sparse, outcome research supports GT as a viable approach to psychotherapy, and some research supports the use of chair dialogue, and the power of unfinished business.

Box 8.1

John B. Watson on Behavior and the Concept of Mental Disease

For some years I have been attempting to understand the physician’s concept of mental disease. Not long ago I had the pleasure of attending a medical meeting and of listening to a physician who has been very successful in his treatment of neurasthenia. Several cases of neurasthenia were described. Since none of the patients showed general organic disturbances of a serious kind and since all of the neurological tests showed normal functioning of the reflexes of the central nervous system, the physician concluded that the disease was “purely mental.” He then began to describe the condition of such a patient’s ego—the general content of consciousness, the inward reference of attention, and the peculiarities of the field of attention. At the end of his discourse two or three eminent physicians stated their satisfaction that the speaker had been willing to come out clearly and say that the disease was “mental.” In other words, they expressed their approval of the fact that the speaker did not, in functional nervous cases, deem it necessary to find lesions in the central nervous system or even a toxic condition of the nervous system before admitting that the patient had a disease.

Being the only psychologist present, I did not like to admit that I did not understand the physician’s use of the term “mental.” (I do not wish by this assertion to stir up strife or bitter argument, but rather to confess ignorance on my own part and to seek for some common ground of discussion.) As a sequel to this meeting I began to attempt to formulate my own ideas as to the terminology I should use in describing a mental disease. I think that at the outset I should admit that I know a good deal more about terminology than I know about diseases of any kind. I am strengthened in this attempt to give my concept of mental diseases by the difficulty I have had in understanding the terminology (involving throughout and often transcending the current concept of consciousness) of the psychoanalytic movement.

I have been for some years an earnest student of Freud (and other psychoanalysts), but the further I go into their terminology [p. 590] the more sure I am that there is a simpler and a more common-sense way (and at the same time a more scientific way) of describing the essential factors in their theory. I am convinced of the truth of Freud’s work, but as I teach the Freudian movement to my classes I drop out the crude vitalistic and psychological terminology, and stick to what I believe to be the biological factors involved in his theories (Freud himself admits the possibility of this). The central truth that I think Freud has given us is that youthful, outgrown, and partially discarded habit and instinctive systems of reaction can and possibly always do influence the functioning of our adult systems of reactions, and influence to a certain extent even the possibility of our forming the new habit systems which we must reasonably be expected to form.

… I think the chief difficulty in completing the description in terms of the every-day language of habit formation lies in our failure to look upon language (the patient’s here) as being only a system of motor habits. As a short cut—a system of economy—the human animal has formed a system of language habits (spoken words, inner speech, etc.). These language habits are built up from and always correspond more or less closely to the general system of bodily habits (I contrast here for convenience of expression language habits and bodily habits) such as the eye-hand, ear-hand, etc., systems of coordination and their complex integrations. This general correspondence between language and bodily habits is shown clearly in the football field, where we see the player making a complex series of movements and later hear him stating in words what systems of plays he employed; and in the case where we hear a man tell us what acts he is going to perform on a horizontal bar and later see him executing these acts. Words have grown up around motor acts and have no functional significance apart from their connection with motor acts. I have come recently to the view that speech should be looked upon as a vast system of conditioned reflexes … Words as words are learned largely by imitation, but words receive their standing as functional units in integrated habit systems by virtue of the fact that they become substitutable for the stimulus which originally initiated an act. A simple illustration will possibly serve to make clear my point. The cold air from an open window leads a child who has gone to bed to draw up the covers. The words of the nurse “cover up, dear” will lead to the same act. Of course in habit systems as complex as those in speech, words get further and further divorced from the original stimuli for which they were substituted (i.e., from the original integrations in which they first played a part). The final test of all words, however, is the question whether they can stand adequately (be substituted) for acts. We often see an instructor despair of telling a student in words how to conduct an experiment. He then resorts to acts and goes through the experiment for the student. Our words thus stand as a kind of shorthand sketch of our repertoire of acts and motor attitudes.

Source: Watson, J. B. (1916). Behavior and the concept of mental disease. Journal of Philosophy, Psychology, and Scientific Methods, 13, 589–597.

Watson and his graduate student (and later, second wife) Rosalie Rayner applied Pavlov’s ideas about conditioning to create conditioned fear in their famous report about Little Albert (see Box 8.2; J. B. Watson & Rayner, 1920/2000). Later, Watson’s student Mary Cover Jones (1924/1960a) used these ideas to eliminate fear in a 3-year-old boy, Peter (see Box 8.5). It is also interesting that Jones (1924/1960b) acknowledged the usefulness of observational learning (see the brief description in the following paragraphs) in her discussion of eliminating children’s fears.

Box 8.2

Shirley is a 79-year-old single White female. She has been married twice; both husbands are deceased. Shirley has no children and no surviving relatives. She does not work; she lives on Social Security and income from pensions.

Shirley was ordered to come to counseling by the municipal court because she has been caught shoplifting on multiple occasions. Mandated counseling was assigned as an alternative to traditional sentencing after she was recently arrested. Based on her description of the incident that brought her to counseling, it appears that Shirley was an ineffective thief. She did not check to see if she was watched; instead, she just grabbed some items and headed out the door of a department store.

Shirley was a last-born child, raised in Chicago. She describes a very unhappy relationship with her mother, whom she characterizes as unloving, harsh, and domineering. She describes a good relationship with her father, although she resented that he never stepped in to protect her from her mother. Shirley graduated from college with a degree in finance and was one of the few women working in business in the 1940s. She describes herself as very successful at her job managing investments, despite being in a male-dominated career. Her first husband was a military officer. After they married, Shirley left her job and moved with her husband through a number of assignments across the United States and Southeast Asia. Shirley’s second husband owned an auto parts store. During this marriage, Shirley focused on her role as a homemaker and was involved in volunteer work in her community. Shirley portrays both of her marriages as very happy and rewarding.

Currently, Shirley reports being involved in community service with older adults, helping out at a senior citizens’ center about once a week. She no longer drives a car, instead relying on the bus for transportation. Shirley lives alone in an apartment and reports that she has few social contacts outside of her volunteer work.

As she reluctantly discusses her shoplifting, Shirley says that she has recurrent obsessive thoughts about stealing when she is in a store. She describes a feeling of anxiety that does not subside until she has stolen something and left the store. Shirley immediately feels guilty about her actions. She says that she never steals anything particular; it does not matter what she takes. Shirley reports that she first began to steal things when she was in her 40s, after the death of her mother. Her first husband knew about the shoplifting, but she was better able to control it back then. Her second husband apparently never knew about it. Shirley has not experienced legal difficulties as a result of her stealing until recently.

Shirley is unhappy about being referred to counseling. She believes that she is the only one who can prevent her “compulsive stealing” as she terms it, and that therapy can do little to help her. Shirley is extremely embarrassed to see a counselor and expresses a good deal of shame about her behavior.

The Story of Little Albert

John B. Watson was a famous behaviorist. In 1920, he and his graduate student Rosalie Rayner decided to see if they could create human fear through conditioning principles that Watson had outlined in an earlier article (J. B. Watson & Morgan, 1917). They chose as their subject of study Little Albert, an 11-month-old infant whom they described as “stolid and unemotional” (J. B. Watson & Rayner, 1920/2000, p. 313).

Watson and Rayner presented a white rat to Albert. When Albert touched the rat, a loud noise was made by banging a steel bar with a hammer. Albert immediately showed signs of distress and on the second pairing began to cry. Seven subsequent pairings were conducted, and it was clear that the presentation of the rat produced a strong reaction because on the last trial Albert “raised himself on all fours and began to crawl away so rapidly that he was caught with difficulty before reaching the edge of the table” (J. B. Watson & Rayner, 1920/2000, p. 314; emphasis in original).

Watson and Rayner also tested whether the conditioned emotional response would transfer to other stimuli. They presented Albert with a rabbit, dog, sealskin coat, cotton wool, and Santa Claus mask. All of these presentations evoked responses from Albert, as did Watson’s hair. Albert’s reactions were similar 5 days later. Finally, the researchers looked at the effect of time on the conditioning, finding that 31 days later the fear reactions still persisted, without any further pairing of the noise and stimuli.

Unfortunately for Albert, he was mysteriously removed from the hospital a day after the tests of persistence were made. Watson and Rayner never had the chance to decondition him, although they speculated that either pairing feared objects with food or sexual stimulation or simply repeatedly presenting the feared stimuli until habituation occurred would cause the “fatigue” of the reflex.

True to his behaviorist ideology, Watson (and Rayner) took on the Freudian perspective in the report’s discussion. “The Freudians twenty years from now, unless their hypotheses change, when they come to analyze Albert’s fear of a sealskin coat—assuming that he comes to analysis at that age—will probably tease from him the recital of a dream which upon their analysis will show that Albert at three years of age attempted to play with the pubic hair of the mother and was scolded violently for it” (J. B. Watson & Rayner, 1920/2000, p. 317).

The second model of learning, the operant model, originated with the work of E. L. Thorndike, who studied the behavior of cats. He would put cats in a puzzle box and entice them to figure out how to get out of the box by placing food outside. Thorndike noticed that in repeated trials the cats became faster and faster at getting out of the box. From his observations, he formulated the law of effect, which proposed that behavior is learned through its consequences.

B. F. Skinner is probably the most famous name associated with the operant approach, which is sometimes called radical behaviorism. The focus of this approach is on the consequences of behavior. Skinner, who performed most of his research with laboratory animals (rats and pigeons), was aware of the potential applications of his science of behavior to developing intervention techniques for people, but he did not pursue this (Spiegler, 2016). In fact, Skinner and his colleagues were credited with the first use of the term behavior therapy in a report on using conditioning principles with hospitalized schizophrenics (Fishman et al., 2011). However, Skinner was more interested in broad applications of his work, such as in his novel Walden Two (1976), in which he describes a community based on behavioral principles. Others went on to apply the principles outlined by Skinner to working with psychological dysfunction, as was the case with Ayllon and Azrin, who developed the notion of token economies (Glass & Arnkoff, 1992). Token economies are systems of behavior change based on the awarding of a token, such as a coin, for performing desired behavior. Tokens can then be exchanged for other things desired by the participant, such as coveted food, toys, or recreational time.

A third force in BT came from the work of Albert Bandura, who recognized the power of observation in learning (Spiegler, 2016). Bandura (1969, 1974) developed social learning theory, which emphasizes the role of social events such as the observation of others in learning. The individual who demonstrates a behavior is called the model, and hence this approach is sometimes referred to as modeling theory.

Recognizing the power of observation was a revolution because it turned our attention to cognitive processes in learning. Bandura discovered that his participants could learn a behavior through observation and then, placed in the same situation, refuse to perform it. This finding led to the assumption that the learning is stored cognitively in some way (Kazdin, 2012). In current applications, modeling is typically combined with other behavioral techniques, such as when a counselor models a desired social skill as a prelude to teaching it to the client (Antony et al., 2020). The label social-cognitive theory is often used to describe the current version of social learning theory (Antony, 2019).

It is difficult to discuss the history of BT without pointing to the influence of Hans Eysenck and his controversial study of psychotherapy, which I reviewed in Chapter 1. Psychotherapy was the term that Eysenck, a classical conditioning behaviorist, used to refer to approaches other than behavioral, and he expended a great deal of energy attempting to discredit the former and promote the latter. A particularly rabble-rousing quote from Eysenck (1960) is the following: “Learning theory does not postulate any such causes, but regards neurotic symptoms as simple learned habits; there is no neurosis underlying the symptom, but merely the symptom itself. Get rid of the symptom and you have eliminated the neurosis” (p. 9; emphasis in original).

BT is currently a vital approach, and the prominent professional association of these counselors is the Association for Behavioral and Cognitive Therapies (ABCT; www.abct.org). It was formed in 1966, and until 2005 was known as the Association for Advancement of Behavioral Therapies (the name change should tell you something). The Behavior Therapist is the official journal of the ABCT.

A subcategory of BT is applied behavior analysis, or ABA. ABA is the term generally used for an approach to working with individuals diagnosed with autism that is grounded in the principles of operant learning (although to be fair, its proponents argue that ABA is useful in many more contexts than just with those who have autism). You might often hear this approach called the Lovaas method, named for the psychologist who published groundbreaking research on intensive behavioral therapy with kids. Lovaas (1987) claimed that half of the children in his study achieved average intelligence assessments after the very intensive treatment (40 hours per week for over 2 years). Although there are criticisms of this method, it is still widely used and is considered very effective (Sadavoy & Zube, 2022). An organization for the applied behavior analysts is the Association for Behavior Analysis International (www.abainternational.org).

The first journal exclusively devoted to BT was Behavior Research and Therapy, originated by Eysenck and Rachman, and the first to promote operant principles was the Journal of Applied Behavior Analysis, which debuted in 1968 (Fishman et al., 2011). There are many journals devoted to BT, including Behavior Research and Therapy and Behavior Modification. Division 25 of the American Psychological Association is the Division of Behavior Analysis (www.apadivisions.org/division-25). In testimony to its historical roots, Division 25 sponsors a B. F. Skinner award for innovative research on a yearly basis.

S. C. Hayes et al., (2006) identified a third wave of BT approaches that are cognitively oriented, but focus more on the context and function of thought than the specific content of it (as does, for example, classic cognitive therapy; see Chapter 10). That is, these approaches, particularly acceptance and commitment therapy (ACT), look at the situation in which thoughts occur and the effects of the thoughts in terms of behavior and beyond to life satisfaction. Chapter 16, “Mindfulness Approaches,” reviews two of these: ACT and dialectical behavior therapy.

Historically, BT theorists engaged in very little discussion of diversity, broadly defined. However, one technique that is seldom used today, aversive conditioning, was at the center of a controversy regarding sexual orientation. One “problem” to which this type of technique was applied was homosexuality. In the 1960s, there was a flurry of interest in changing sexual orientation, and many times this was approached by showing clients same-sex erotic stimuli (e.g., photographs) while administering shock. The shock was terminated when heterosexual erotic materials were presented (Haldeman, 1994). Of course, the ethics of such treatment were eventually questioned, even when used with men who voluntarily sought such treatment. The ethical issues, arguments about whether these techniques really produced aversion, and lack of support for their effectiveness resulted in their abandonment in the 1970s (Haldeman, 1994; LoPiccolo, 1990).

Contemporary BT advocates are vocal about their attention to diversity. Antony et al., (2020) commented on cultural sensitivity in BT, describing ways in which it can be adapted for individuals of diverse backgrounds. As you will see in the sections on diversity and research, there currently is much interest in adapting behavioral techniques (mainly referenced as CBT) for a wide range of client presentations and identities.

Basic Philosophy

Because contemporary BT is more of a general orientation than a specific theoretical approach, the assumptions behind the orientation are helpful in understanding how it is currently practiced. Martell (2007) outlined eight basic principles of BT; these are listed in Box 8.3. I will present here a general overview of the philosophy of the approach, which will touch on these principles.

Box 8.3

The Principles of Behavioral Therapy

Behavior, whether public or private, is strengthened or weakened by its consequences.

Behaviors that are rewarded are increased; those that are punished will decrease.

The approach is functional rather than structural.

Neutral stimuli, paired with positive or negative environmental stimuli, can take on the properties of the environment in which they are presented and be conditioned to be positive or negative.

Behaviorism is antimentalist.

Behavior therapy is data driven and empirically based.

Changes clients make in therapy must generalize to their day-to-day lives.

Insight alone is not beneficial to a client.

Source: From Martell, C. R. (2007). Behavioral Therapy. In Rochlen, A. (Ed.), Applying Counseling Theories: An Online, Case-Based Approach, pp. 143–156. Prentice Hall. Used with permission.

Behaviorists tend to take a neutral view of human nature. Although they recognize genetic influences, ultimately they believe behavior is determined by the environment, so to rate humans as inherently “good” or “bad” is useless (B. F. Skinner, 1971).

Behavior therapists tend to emphasize, as you might expect, behavioral descriptions of people rather than trait descriptions (Spiegler, 2016). They are more likely to describe how someone talks (e.g., they speak very quickly) than to characterize someone using trait descriptions (they are snotty). At the extremes, behavioral therapists would rather discuss behavior disorders or problems in living than traditional diagnostic categories because the latter are imprecise and involve trait language. However, a review of BT resources will demonstrate that traditional diagnostic categories are often used for organizational purposes.

Early resources, such as Ullmann and Krasner’s (1965) classic Case Studies in Behavior Modification, pointed out that traditional approaches to behavior change were based on what they called the “medical model” (p. 2). In this approach, also called the disease model, a person experiencing psychological difficulties is viewed as sick or diseased, and the sickness results from some underlying causal factor or mechanism inside the individual (such as repressed conflicts). What needs to be changed, then, is the underlying cause, not the symptom. If you don’t treat the cause, you get more symptoms—perhaps different ones, but symptoms just the same; this process is called symptom substitution. Taking a medical approach to psychological dysfunction leads to a “doctor knows best” attitude because the real causes of behavior can’t be seen. Diagnosis becomes central in the medical model, which should then guide treatment.

In stark contrast to the medical model, BT adopts the psychological or learning model of dysfunctional behavior, which focuses on overt behavior—and in the case of CBT, cognition, too. In this model, the symptom is the focus of attention rather than the assumed underlying causal factor(s). Behavior is seen as simply behavior, which gets defined as pathological because it deviates from social norms (Bandura, 1969). BT counselors see themselves as scientists who rely on the results of experimental studies of learning to help their clients. They do not search for deep, hidden causes of behavior; it is not necessary to know the origins of a problem to solve it (Spiegler, 2016).

Historically, a controversy within the ranks of behavior therapists has centered on the roles of cognition and emotion in human behavior. These arguments allow the identification of several varieties of BT, ranging from radical behaviorism to cognitive-behavior modification. Radical behaviorism, rooted in the ideas of Watson and Skinner, would totally exclude cognitive or otherwise inferred processes from causal explanations of behavior (Goldfried & Davison, 1994). That is, although these theorists recognize that thoughts and feelings exist, they can be controlled or modified using the same manipulation of antecedents and consequences as any other behavior (Rummel et al., 2012). A more moderate position is the one that was presented by Martell (2007): “behaviorists do not accept that there is a mind apart from the body” (p. 147). At the extreme, these theorists adhere to an “outer model of psychopathology” and accused cognitively oriented behavior therapists of adopting the medical model because they pay attention to events inside people that cannot be observed directly (Reitman, 1997, p. 342).

At the other end of the spectrum fall the cognitive-behavior therapists and social learning theorists, who allow for the influence of internal events such as cognition and imagery in understanding and changing behavior. Most behavior therapists today probably fall into the cognitive-behavioral camp; in fact, as early as 1982 a study of the members of ABCT showed that a majority of them used cognitive techniques (Gochman et al., 1982), and Craighead (1990) reported that 69% of respondents to an ABCT membership survey characterized themselves as cognitive-behavioral in orientation. To clearly describe behavioral principles, my presentation of BT will rely mostly on classic discussions of the theory; readers should keep in mind that current practices are pragmatic and integrative (Antony et al., 2020). Cognitive techniques will be covered more extensively in Chapters 9, 10, and 17.

JaNelle is the behavior therapist who accepts Shirley as her client. She is a moderate behavior therapist who, at times, attends to cognitive processes. Approaching Shirley with a neutral attitude, JaNelle assumes that Shirley’s behavior is mostly environmentally determined. She is aware that some therapists (and indeed some behavior therapists) would associate Shirley’s behavior with a Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2022a; Fifth Edition-TR; DSM-5) diagnosis of obsessive-compulsive disorder. JaNelle prefers to simply describe the behavior and look for the elements that support it. JaNelle is also interested in the cognitions that Shirley has at the times when the problem behavior occurs.

Human Motivation

Behaviorists see humans as motivated to adapt to the environment. Adaptation in this view means survival; thus, our behavior serves to obtain things that help us survive—things that then become valuable to us, or reinforcing—and to move us away from behaviors or experiences that don’t promote survival—experiences that then become aversive. According to Skinner (1971), “The process of operant conditioning presumably evolved when those organisms which were more sensitively affected by the consequences of their behavior were better able to adjust to the environment and survive” (p. 114). On a more general level, Wolpe (1990) defined adaptive behavior as that which “actually results in satisfying the individual’s needs, brings them relief from pain, discomfort, or danger, or avoids undue expenditure of energy” (p. 8).

JaNelle sees Shirley’s behavior simply as the most recent way she has adapted to the environment. Shirley seeks positive stimulation and avoids aversive situations. In this way, Shirley is seeking the resources she needs to survive and moving away from experiences that might be harmful. Unfortunately, Shirley’s behavior has become maladaptive for her because it places her in opposition to society. Getting resources (i.e., items from the store) is adaptive in some ways, but social rules have determined that Shirley’s behavior is dysfunctional.

Central Constructs

To understand contemporary BT, it is helpful to know the three major models of learning: classical, or Pavlovian; operant, or Skinnerian; and observational, or modeling. The first two approaches generate a distinct set of techniques, whereas the theory of observational learning is generally applied as a way to enhance operant and classical interventions through adding attention to cognitive and social influences on behavior (Bandura, 1969). Although the distinctions among the models can be fuzzy, and the connections between the models and techniques are not as simple as one would like, I present the models because a basic understanding of learning principles is useful in many situations.

Classical Conditioning

Classical conditioning is thought to be an involuntary, reflexive process (Ullmann & Krasner, 1965). In this model, a relation between a stimulus and response that is presumably “wired in” for evolutionary reasons gets associated with a new stimulus, which can then elicit the response. For Pavlov, this sequence had to do with a bell, food, and dog saliva. We could diagram this relation in humans as follows:

8.4-1 Full Alternative Text

This classical conditioning model is the basis of Wolpe’s approach to changing dysfunctional behavior, which he called reciprocal inhibition (Wolpe, 1960, 1990). Wolpe reasoned that anxiety is a dysfunctional behavior when it occurs in circumstances in which there is no objective threat to the person (Wolpe, 1960). The idea is that anxiety (the unconditioned stimulus, or UCS) gets conditioned to some stimulus that is normally not anxiety provoking (the conditioned stimulus, or CS). In other instances, anxiety is a natural and adaptive response, or the “autonomic response pattern or patterns that are characteristically part of the given organism’s response to noxious stimulation” (Wolpe, 1960, p. 88).

A little green garden snake, for example, is not really an occasion for a major anxiety attack because it is not harmful to me (provided that I have correctly identified it). So why do I jump and scream when I see one of these little critters? Using a classical conditioning model, we would see the snake as a CS, having been paired with some other natural event that was indeed threatening or noxious, the UCS. That other event (and we often don’t know what it is) is what originally evoked the anxiety. The snake now evokes anxiety because of its earlier association with the UCS.

The association between a conditioned stimulus and a conditioned response can be weakened or eliminated by repeated presentation of the CS in the absence of the UCS, a process called extinction (Wolpe, 1990). For example, Pavlov could repeatedly ring his bell and never present food to the dog. Eventually, the dog will stop responding with salivation when the bell rings because it hasn’t gotten any food in a long time—the salivation response is extinguished. Some BT techniques are based on the principle of extinction, such as when an individual (maybe your author?) is made to sit in a room with a garden snake until their anxiety goes away, a procedure called exposure therapy. You will learn more about exposure interventions later in the chapter.

Because Shirley’s problem behavior involves anxiety, JaNelle considers the possibility that classical conditioning is involved. Somehow, anxiety has been associated with being in a store for Shirley, and it disappears when she steals something and leaves the store. JaNelle wonders if Shirley has somehow associated being in a store with a truly threatening situation that would logically lead to anxiety. Perhaps she experienced a life-threatening event in a store in the distant past. In terms of intervention, it does not matter how or when the original conditioning occurred, except that JaNelle needs to be sure that the anxiety is conditioned to the store, not something else. For example, the problem could be more general. Shirley might experience anxiety every time she leaves her home. JaNelle knows that she needs to explore this issue with Shirley as well as the abrupt cessation of the anxiety that she experiences upon leaving the store.

Operant Conditioning

Developed most elegantly by B. F. Skinner, the operant learning model starts with the idea that behavior is maintained by its consequences. The term operant is used because it emphasizes that behavior operates on the environment to produce consequences that, ideally, contribute to the person’s adaptation (Nye, 2000; Skinner, 1953); it contrasts with respondent (classically conditioned) learning, in which the behavior considered is seen as sort of automatic.

In the operant model, behavior is said to be contingent upon its consequences (Skinner, 1971). Reinforcement is the formal term for consequences that maintain a given behavior. That is, reinforcers are consequences that increase the probability that a behavior will occur. Whether a particular event is reinforcing is a function of an “individual’s biological endowment, learning history, and current situation” (Milan, 1990, p. 71). To take a simple example, some people like salty foods, and others like sweet foods. The reinforcement value of potato chips is higher for me compared to that of chocolate.

Two kinds of reinforcers can be distinguished—positive and negative (Skinner, 1953). Positive reinforcers increase the likelihood of a behavior occurring because something good is presented following the appearance of the desired behavior. Negative reinforcers increase the probability of behavior through the removal of aversive stimuli. Keep in mind here that the terms positive and negative are not used in the ways we typically use them. In BT language, positive refers to the addition of something that causes behavior to increase, whereas negative refers to the removal of something, resulting in an increase in behavior (Nye, 2000). In other words, do not confuse negative reinforcement with punishment. When Mom pats little Johnny on the head after he does a cartwheel, she has employed positive reinforcement; you are likely to observe more cartwheels. When Dad gives Laura a cookie to stop her tantrum, Dad’s cookie-giving behavior is negatively reinforced; it terminated an aversive stimulus (the tantrum). You will likely see Dad give cookies when future tantrums appear. Note that Laura’s tantrum behavior is positively reinforced, assuming that she likes cookies and has not just eaten a truckload of them. Box 8.4 gives another example of positive and negative reinforcement.

Box 8.4

Behavior Modification in Humans and Felines

I have a cat. His name is Skat, but he is also known as the Cat from Hell. Skat the Cat is, like most cats, used to going where he wants to when he wants to. Skat is equally comfortable roaming the neighborhood or sleeping on my feet.

Sometimes Skat the Cat wants inside when he is, in fact, outside. He is not very patient, and one way of demonstrating this is through screen-scratching behavior. Clearly, someone at some point must have let him in the house following screen-scratching behavior, thereby positively reinforcing his screen-scratching behavior (it was not me, of course). As a good student of behavior modification, I would never positively reinforce screen-scratching behavior, yet because some visitor(s) have, this behavior is on an intermittent schedule of reinforcement with a very long interval. The intermittent schedule thus accounts for Skat’s persistence in the behavior—he has been known to keep it up for hours … despite it being 3 a.m.

What is my response to Skat’s behavior? I consider screen-scratching behavior an aversive stimulus, so my first impulse is to yell at him. This behavior on my part, as you might guess, is extinguished very quickly because it produces no change in the noxious stimulus. I could opt for an extinction approach (i.e., never opening the door), but because he is apparently on a long-interval intermittent schedule, it would take a very long time and many screen replacements to extinguish his behavior. Chasing him away is even more aversive to me because I must get out of bed in the middle of the night to do so. Also, Skat might just find my chasing him a positive reinforcer! “Hey look! I got Mom out of bed and all upset! This is fun! Maybe I can get her to do it again!”

One night I had a glass of water at hand and, perhaps vaguely remembering some observed relationship between Skat’s behavior and the experience of getting wet, decided to throw the water thorough the screen. Bingo! Skat was gone … and my water-throwing behavior was negatively reinforced. The noxious stimulus of screen scratching was terminated as a result of my water-throwing behavior. The next time he appeared at the screen, guess what I did? (I threw the water, of course.)

But what of Skat’s behavior? Because screen scratching was immediately followed by a consequence that decreased the probability of that behavior, we conclude that he experienced punishment. Now we know that punishment merely suppresses behavior and could have some other problematic consequences, such as avoidance, but Skat likes inside and food too much to avoid me altogether. Instead, he substituted another behavior for screen scratching, a very loud meow. Choosing the lesser of two evils, I now immediately let him inside when he yowls (thus positively reinforcing the yowling behavior). Every now and then he delicately puts a few claws on the screen to show me that he has not forgotten his power and then yowls. Mostly, though, we are satisfied with the contingencies we have established.

Reinforcers come in all shapes and forms. The most basic reinforcers are food and sex because they relate to the evolutionary goals of survival and reproduction (Nye, 2000). Skinner (1953) called these primary reinforcers. Many things are reinforcers because they have been historically linked with survival. Skinner (1971) gave the example of a person moving out of the hot sun into the shade. The behavior of moving is reinforced by the reduction in temperature that follows, which is presumably good for the organism’s survival.

Unfortunately for neophyte behavior modifiers, though, what is reinforcing to one person may not be to another. The power of a given reinforcer can also vary across time. Many things affect whether a given consequence is reinforcing; for example, food is not reinforcing just after a big gourmet meal. Too much of a good thing is called satiation; the power of a reinforcer is decreased in these circumstances (Skinner, 1953).

Many things become positively reinforcing because they are associated with gaining desired outcomes; they are not the desired consequence itself. These conditioned reinforcers become reinforcing because they tend to occur at about the same time that reinforcement occurs (almost in a classical conditioning sense; Skinner, 1953). Some stimuli occur in the presence of many kinds of reinforcers, and these stimuli become generalized reinforcers. Money is a good example of a generalized conditioned reinforcer. The paper or metal substance is not in itself positively reinforcing, but it becomes so because it is associated with getting reinforcing things (food, clothes, or other things that support survival). Attention from others is a conditioned reinforcement, presumably because babies have to get someone’s attention to get things that meet survival needs, such as food or clothing (Ullmann & Krasner, 1965). Manipulating the environment is a generalized reinforcement because many kinds of reinforcers occur only following such behavior (Skinner, 1953).

Sometimes a stimulus in the environment signals that a given contingency is operative. This is called a discriminative stimulus, and you can think of it as a traffic light of sorts. When the light is green, a behavior such as walking across the street will result in reinforcement (getting to where one wants to go, a conditioned reinforcer). When the light is red, it is a signal that behavior will not be reinforced (i.e., you could get hit by a car and smushed, which would be considered punishment, I think). As we all know, however, a traffic light is not truly a discriminative stimulus because, if you are careful, you can still walk across the street on a red light and receive the reinforcer of getting to the other side. Perhaps a better example would be a light on a drawbridge. If you go against the red light, you will not be reinforced; instead, you will probably be punished unless you are a very good swimmer!

When behavior becomes controlled by discriminative stimuli, it is said to be under stimulus control. Discriminative stimuli can become conditioned reinforcers, as in the case of money. The acquisition of money becomes reinforcing because it signals that the behavior of giving money to others gets us desired things (food, swimming pools, shoes; Ullmann & Krasner, 1965).

Once a discriminative stimulus is established, generalization can occur, and the reinforced behavior will appear in situations in which a stimulus similar to the discriminative stimulus is present. For example, if Laura receives cookies from Dad when she throws a temper tantrum, Dad becomes a discriminative stimulus for tantrum behavior. Generalization is seen when Laura also shows tantrum behavior in the presence of other male adults or in the presence of adults in general.

Extinction is said to occur when the reinforcement maintaining behavior is removed and a response becomes less frequent and finally disappears (Skinner, 1953). The behavior is extinguished because the contingencies supporting it are no longer in effect. An important thing to know about extinction, however, is that early in the process “emotional behaviors,” such as anger or frustration, may occur (Skinner, 1953, p. 69). Also, the target behavior may intensify (i.e., increase in frequency or strength) under extinction conditions (Spiegler, 2016). For example, Sam exhibits loving behavior toward Sally, calling her daily on the phone and visiting her in the evenings. She reinforces him by cooking his dinner and allowing sexual contact. However, Sally suddenly decides that she no longer desires relationship behaviors with Sam and discontinues reinforcing his loving behaviors. At first, his phone-calling behavior intensifies; he calls her hourly and drives by her house every night. He probably displays some emotional behavior, such as anger or sadness. If Sally continues to ignore Sam, his behaviors of calling and driving by will eventually decrease and then disappear.

Reinforcements can be given after every response (called continuous reinforcement) or after some responses and not others (intermittent reinforcement). Resistance of the target behavior to extinction varies depending on the schedule of reinforcement (Skinner, 1953). Behavior reinforced intermittently is extremely resistant to extinction, whereas continuous schedules produce much less resistance. In the laboratory, behavior can be maintained in pigeons on a 1-in-10,000 response schedule (Skinner, 1953). My cat’s screen-scratching behavior is clearly on an intermittent schedule, with long intervals between reinforcements (see Box 8.4).

Punishment is the opposite of reinforcement; a punisher is anything that reduces the probability of a behavior occurring. For example, if I lock myself out of my house in the middle of January, I am strongly punished for this behavior because it results in (for me) an extremely aversive event (exposure to cold weather). It is unlikely that I will repeat this behavior, for sure.

Operant behavior is behavior that the organism freely emits. However, a desired behavior can be created by a process called shaping, in which responses that gradually more closely resemble the desired behavior are reinforced in a progression.

JaNelle wonders if operant learning could account for Shirley’s stealing behavior. From that perspective, stealing behavior would be reinforced by something. Normally, JaNelle might guess that the stealing behavior is reinforced by what Shirley acquires as a result. However, Shirley has indicated that she does not steal any particular object, which suggests that the objects themselves are not reinforcing. JaNelle guesses that the cessation of anxiety is highly negatively reinforcing to Shirley, so that leaving the store becomes a highly reinforced behavior. It is possible that on an earlier occasion Shirley experienced anxiety while in a store and resorted to a previously learned behavior of picking something up in a wild, almost random attempt to decrease her anxiety. She then fled the store. In a chaining process, the anxiety reduction reinforced the behavior of leaving the store, which then became a conditioned reinforcer that reinforced the stealing behavior.

Observational Learning

The idea that people can learn by viewing the behavior of others was developed by Bandura (1969, 1974). Also called social learning theory (Bandura, 1969), this approach incorporates the cognitive aspects of learning because what is learned through observation and later performed must be retained somehow, presumably in the brain. Observational learning plays a large part in the acquisition of new behaviors; it is much more efficient to learn a behavior vicariously than to randomly emit behaviors to be shaped by the environment (Bandura, 1969).

Consider learning to bowl. You’ve never bowled before, and your buddies drag you to the bowling alley. Trying to be a good sport, you put on your bowling shoes and take to the lanes. Almost automatically the first thing you do is watch someone else bowl. If one of your buddies is a teacher-type, they may take you through the process of a turn by showing you step by step how to wind up, move forward, and release the ball. Your buddy is the model. You learn the fundamentals without ever picking up the ball. Of course, you may need some practice to bowl a perfect game. Bandura (1969) pointed out that role-playing interventions often involve modeling because the client first observes the behavior on the part of the counselor before performing it.

Both dysfunctional and functional behavior can be learned through modeling. For example, a phobia can be acquired by watching someone else experience an anxiety-provoking event (Bandura, 1969; Wolpe, 1990). This phenomenon is called vicarious conditioning.

Modeling theory combines readily with operant theory because the consequences of the modeled behavior for the model influence the observer’s behavior as well (Bandura, 1969). If, for example, Marco sees other children praised for speaking up in class, he will be more likely to speak himself (if he values the teacher’s positive reinforcement). Likewise, punished behavior can be learned observationally and displayed when the punishment contingencies are not known to be in effect.

JaNelle wonders if modeling plays a role in Shirley’s behavior. Certainly, aspects of the stealing behavior could have been learned through modeling, but the observation that Shirley is not a successful thief would suggest otherwise. Had Shirley observed a good thief, she might have learned to be inconspicuous in her behavior and to hide the stolen object!

Theory of the Person and Development of the Individual

Traditional behaviorists are not interested in personality theory or developmental stages, although they do allow that personality is an abstract term that describes consistency in behavior across situations (Antony et al., 2020). They generally don’t see the term as very useful and prefer to discuss the individual’s learning history. Antony et al., (2020) acknowledge the role of all three identified models of learning (classical, operant, and social learning) in the development of what we like to see as personality, otherwise known as our learning histories.

JaNelle is not very interested in Shirley’s childhood. She is, however, interested in the history of the stealing behavior and asks Shirley to recount how it first started. Shirley remembers being in a store shortly after her mother’s death and getting panicky. She grabbed the first thing she saw (a really nice fountain pen) and left the store immediately. Afterward, she felt very guilty and ashamed, as well as fearful of returning to the store because they might catch her.

Health and Dysfunction

In the behavioral tradition, psychological health is seen as adaptive behavior, taking social and cultural context into consideration (Antony et al., 2020). Adaptive behavior is that which promotes the survival of the person. Although BT advocates acknowledge that genetics and biology have roles in behavior, they would assert that almost all behavior has learned components (Craske, 2017).

Psychological dysfunction is maladaptive behavior, and it arises from the same processes as adaptive behavior—namely, it is learned. In addition, maladaptive behavior can result from not learning—that is, deficits in skills (Spiegler, 2016). Whether a behavior is considered dysfunctional is dependent on whether it is adaptive or maladaptive for a given situation. Maladaptive behavior is not considered to be equivalent to mental illness or psychopathology, as it is in the medical model.

A classical conditioning perspective portrays psychological dysfunction as resulting from faulty conditioning of anxiety (or fear; the terms are used interchangeably) to behaviors (Wolpe, 1990). Essentially, fear is an unconditioned response that gets associated with a previously neutral conditioned stimulus. Although he did acknowledge that some behavior (e.g., nail biting, extreme stinginess, and nocturnal enuresis) is unrelated to anxiety (1990, p. 9), for Wolpe the majority of neurotic behavior is, in essence, simply habit learned in anxiety-provoking settings. Wolpe (1990) saw schizophrenia, antisocial personality disorder, and drug addictions as primarily biological in nature, although conditioning procedures could be used to alter some behavior patterns in these presentations.

Wolpe defined neuroses as “persistent maladaptive learned habits in which the foremost feature is anxiety” (1990, p. 23). These habits can be established in a variety of ways. First, neurosis can be based on simple classical conditioning, in which anxiety is aroused by a threatening situation and some stimulus in the situation is associated with the anxiety. This association can be established in one trial if the situation is traumatic enough. For example, the anxiety in a battle situation can become conditioned to the sound of gunfire or sirens. The individual knows that the sounds of gunfire or sirens are not immediately threatening but becomes anxious nonetheless when they hear them in a nonbattle situation.

Fear can also be vicariously conditioned, according to Wolpe (1990). Observing someone else’s extreme fear response to a stimulus might result in the observer acquiring a classically conditioned fear of that stimulus. If Damon, as a child, observed his mother reacting very fearfully to the sight of a Doberman Pinscher, he might develop the same fear of Dobermans, and maybe other large dogs, too.

In a similar process, neurotic fears can be brought about by misinformation (Wolpe, 1990). The old fear of masturbation causing blindness is a good example of this neurotic mechanism.

Although the classical conditioning approach appears to focus heavily on anxiety and the maladaptive behavior associated with it, Wolpe (1992) maintained that many forms of depression are based in anxiety as well. In fact, he estimated that 60% of depressions are neurotic, which in his view meant that they are based in anxiety.

JaNelle considers the possibility that Shirley’s anxiety in stores is classically conditioned somehow. When she asks Shirley about the history of her anxiety in stores, Shirley relates that she doesn’t remember anything in particular triggering the anxiety. She just started to get panicky while in a store one day. Although it is interesting that Shirley mentions that the attacks started shortly after the death of her mother, JaNelle does not consider this information particularly useful.

From an operant perspective, dysfunctional behavior is maintained by contingencies of reinforcement. Spiegler (2016) suggested two broad classifications of maladaptive behavior: behavioral excesses and deficits. Excesses are behaviors that are performed too strongly or too often (p. 55); I’d add to this group behaviors that are inappropriate or ineffective for a given situation. Behavioral deficits refer to situations in which individuals have failed to learn behaviors called for by the situation. From this perspective, excess behaviors are viewed as maladaptive responses maintained by existing environmental reinforcers. Deficit problems involve a lack of desirable behaviors—the individual just never learned them. A deficit in behavior can also result when the contingencies in a situation punish or simply do not reinforce the behavior.

A social learning perspective fits with the operant perspective because dysfunctional behavior can be learned, maintained, and suppressed by observations of models. If the individual is not exposed to the right models, they will not learn certain behaviors deemed important to a given cultural group, for example. If a child is never exposed to a dinner in which multiple forks are used, for instance, they will not know what to do when faced with a formal place setting.

Even though BT advocates don’t like formal diagnosis, they will still theorize about general diagnostic presentations. For example, some early operant theorists viewed depression as stemming from problems in the person’s range of actions, or what is called the behavioral repertory. Ferster (1973) conceptualized depression as resulting from an overuse of passive behaviors and a decreased incidence of adaptive, active behavior. Consequently, the depressed person receives little positive reinforcement from their environment (Ferster, 1983). Escape behavior is reinforced when the individual avoids the stress and anxiety of uncomfortable situations, such as when the passive, depressed individual avoids unpleasant events at work by staying home in bed. This conception of depression has led to the treatment strategy known as behavioral activation (BA; Dimidjian et al., 2011). The idea behind BA is to get the client moving so that positive reinforcement is obtained while blocking attempts to escape aversive experiences.

The cognitive behavior theorists have a lot to say about the role of cognition in psychological dysfunction; you will read more about these ideas in Chapters 9 and 10. Still other behaviorists point out that depression can result when an individual perceives no control over the world or, more accurately, when she perceives that there are no contingencies between her behaviors and outcomes. This “helplessness” view of depression suggests that the critical factor in affective states is “the person’s perception of his ability to control the world” (Goldfried & Davison, 1994, p. 234).

Social skills deficits, from an operant perspective, could be the result of faulty learning (i.e., the individual was reinforced for behaviors deemed socially inappropriate) or a simple lack of behaviors (i.e., the individual never learned social behaviors). Some social behaviors might have been punished.

JaNelle thinks that Shirley’s stealing behavior may be reinforced by the cessation of anxiety; that is, the stealing is negatively reinforced. When she enters a store, Shirley becomes anxious and then steals something so that she has to exit the store, thereby escaping the anxiety.

Nature of Therapy

Assessment

Assessment is very important in BT. Both formal and informal assessments are used, but behaviorists are most emphatic that they are not doing personality assessment or looking for underlying causes of symptoms. Multiple methods of assessment are recommended, from different sources (e.g., the client, their family, teachers). Assessment can be done with standardized instruments or just through simple observation. Spiegler (2016) recommended a multimodal assessment, covering overt behavior, cognition, emotions and physiological responses. The goal of assessment is to establish one or more target behaviors, which are to be modified in some way.

Traditionally, formal diagnosis (e.g., from the DSM-V) is not consistent with the BT model because it is based on the trait-oriented medical model and is thus far from a functional analysis of an individual’s behavior. However, Antony et al., (2020) wrote that many contemporary BT counselors have shifted toward a more symptom-oriented approach because recent research has been organized according to diagnoses, thereby creating treatment approaches to fit certain client presentations (e.g., panic disorder, phobia). BT therapists may also use formal diagnoses for pragmatic reasons, such as when required by third-party payers or specific treatment settings (Spiegler, 2016).

In BT, assessment is closely linked to intervention, and it focuses on the individual’s current behavior, with specific attention paid to antecedents and consequences, broadly speaking. A baseline, or frequency count of the target behavior over time, is typically established so that change in behavior can be clearly documented.

Assessment in BT can be seen as a functional analysis, and the acronym SORC tells us the elements of the analysis, which are stimulus, organism, response, and consequences (Antony et al., 2020). I think you know what S, R, and C are about at this point. The O for organism is there to account for individual differences, such as learning history and cultural factors. Another way to look at assessment is through the ABC model. A stands for antecedents, B for behavior, and C for consequences. From a BT perspective, assessment should cover all of these letters, and interventions can be made anywhere in the progression.

The most theoretically pure form of assessment is direct observation of the client by independent, trained raters across various life situations (Goldfried & Davison, 1994). Clearly, this is an expensive and cumbersome form of assessment, and it is rarely used except perhaps in institutional settings. Even in institutional settings, samples are used (e.g., a 10-minute observation taken eight times per day). Instead, BT counselors more often use their own observations (e.g., in-session role play or imagery techniques), those of the client’s significant others, or simply the client’s self-report.

Behavior therapists often ask clients to log the frequency of a behavior between counseling sessions, a technique called self-monitoring. There are three potential problems with self-monitoring. First, there is the question of whether the client can accurately and honestly monitor their behavior. Second, monitoring may disrupt normal routines, causing the client to become aggravated. Third, behavior has been known to change when monitored—most notably, unwanted behavior tends to decrease (Spiegler, 2016).

Formal assessment in BT involves the use of standardized instruments or symptom checklists. Wolpe (1990), for instance, was adamant that the use of the Willoughby Neuroticism Questionnaire and the Fear Survey Schedule is essential in BT. He said, “Failure to use these instruments is a serious deprivation of data, parallel to a physician’s nonuse of the electrocardiogram in suspected heart disease” (1990, p. xi).

Behavioral checklists and surveys are often used in cognitive-behavioral forms of BT (Spiegler, 2016). Clients might be asked to complete the Beck Depression Inventory (A. T. Beck et al., 1961), the Reinforcement Survey Schedule (Cautela & Kastenbaum, 1967), or the Test Anxiety Behavior Scale (Suinn, 1969). Many other such inventories exist.

JaNelle begins with a simple interview approach with Shirley. She asks a lot of questions about Shirley’s current situation, including her living situation, social activities, and financial supports. Shirley reports that, although she enjoys her community service, she wishes she had more friends with whom to spend off-hours. JaNelle thinks that an assessment of Shirley’s social skills, is warranted. To start, JaNelle closely observes as she and Shirley interact. She notices that Shirley seems a little shy at times, avoiding eye contact and speaking very softly.

Gently, JaNelle asks Shirley about the incident that got her to counseling. Initially reluctant, Shirley responds to JaNelle’s approach and tells JaNelle about the recent incident. She admits that this behavior happens about on a weekly basis. JaNelle asks many specific questions about these incidents, attempting to gain a step-by-step picture of Shirley’s behavior. She considers a live observation of Shirley’s stealing behavior, but then decides to have her role play the behavior in the counseling session.

Overview of the Therapeutic Atmosphere

Behavior therapists assume that behavior is predictable from antecedents, organismic variables, and consequences, so “clinical interaction constitutes a form of experiment” (Goldfried & Davison, 1994, p. 4). This emphasis on the scientific approach in BT has led, at times, to significant disagreement about the nature of, or necessity for, the counseling relationship in BT. At one extreme, Eysenck (1960) dismissed the transference-based relationship of psychoanalysis, saying, “Behavior therapy has no need of this adjunct, nor does it admit that the evidence for its existence is remotely adequate at the present time… . In certain cases, of course, personal relationships may be required in order to provide a necessary step on the generalization gradient; but this is not always true” (p. 19).

In contrast, others emphasize that the therapeutic relationship is essential to BT. Early on, Wolpe (1985) maintained that “trust, positive regard, and serious acceptance of the patient are part and parcel of behavior therapy practice” (p. 127). Contemporary behavior therapists are clear that the relationship is essential, well aware of the research documenting the consistent positive association between the therapeutic relationship and counseling outcomes (Antony, 2019).

Because Shirley does not really believe that she belongs in counseling, JaNelle knows that it is essential that she establish a solid relationship with her. JaNelle tries to be supportive, genuine, and caring in her interactions with Shirley.

Roles of Client and Counselor

The counseling relationship in BT is collaborative, and the client is seen as a co-therapist (Spiegler, 2016). The counselor is a model for the client (Goldfried & Davison, 1994) and takes the role of a consultant who is teaching the client the skills necessary to be their own behavior therapist. As you might guess, the therapist is very active and directive, and may do quite a bit of teaching.

The client is expected to contribute actively to the BT assessment and goal setting and to complete their homework faithfully because BT practitioners assume that most change in BT is a result of this practice (Antony, 2019). The client is a learner of the knowledge presented by the BT teacher/counselor.

JaNelle approaches Shirley as a collaborator, acknowledging that Shirley has not voluntarily come to counseling. She offers herself as a consultant to Shirley, suggesting that she has some ideas that might help Shirley better her life conditions. If Shirley accepts this offer, JaNelle will expect Shirley to be a partner in BT counseling, participating in goal setting and homework assignments.

Goals

The goal in BT is simple: reduce or eliminate maladaptive behavior and teach or increase the incidence of adaptive responses. Picking behaviors to modify sounds easier than it really is. Traditionally, BT has targeted very specific behaviors such as smoking, weight gain or loss, and specific phobias. These behaviors are easily observable and quantifiable. However, clients often present much more complicated pictures and often do not present their concerns in terms of specific, observable behaviors. For example, many clients come to counseling saying that they want to get rid of their depression or that they are unhappy with their relationships.

Spiegler (2016, p. 57) presented the “dead person rule: never ask a client to do something a dead person can do.” Only dead people can avoid behaving altogether, so it is generally better to prescribe behavior than to try to delete it. For example, it would be better for Robert to ask Steve to pick up his clothes after his shower than to admonish “Don’t leave your clothes on the bathroom floor.”

The process of setting goals is a critical part of BT (Antony et al., 2020). Clients and counselors generally work together to establish them, and it is the BT therapist’s job to make sure that they are specific and attainable.

Shirley and JaNelle set two goals for counseling: decrease the anxiety that seems to be connected to Shirley’s stealing behavior and increase her social skills in the interest of helping her find more friends. They also agree that some problem solving around Shirley’s desire to have more social contact in her life would be helpful.

The specific goals they establish are as follows: (a) Shirley will be able to enter a department store and purchase an item (or just browse) without stealing anything, (b) Shirley will learn new social behaviors, including increased eye contact and voice volume, and (c) Shirley will increase her social contacts (outside of her volunteer work) to at least three times per week.

Process of Therapy

BT practitioners see therapy as composed of two distinct phases: assessment and intervention. After the therapist has performed a functional analysis of the client’s behavior and goals have been set, it is time to intervene. At an early point in this process, the client is oriented to BT, which usually consists of giving them a brief explanation of how the BT counselor views problems and interventions (Spiegler, 2016). Goldfried and Davison (1994) were very clear that the client’s expectations about therapy are important to assess and address because misconceptions can get in the way of treatment. Clients may expect detailed explorations of childhood events, dream analysis, or free association. The BT counselor should be empathic about the client’s reasons for these assumptions, but should not necessarily accede to them (Goldfried & Davison, 1994). The counselor can listen to client history empathically, while also inserting comments to help the client redefine the problem in behavioral terms. In essence, the behavior therapist teaches the client the behavioral model.

BT counselors see the first session of counseling as critical. It has four goals: “(1) establishing rapport with the client, (2) understanding the client’s problem and selecting a target behavior, (3) gathering data about maintaining conditions, and (4) educating the client about the behavioral approach to treatment and issues of confidentiality” (Spiegler & Guevremont, 2003, p. 83). At the end of this session, the client and counselor may create a written therapeutic contract (Goldfried & Davison, 1994). The contract typically contains information about fees, cancellations, frequency of sessions, and other procedural details. It also outlines the expectations for the client’s and counselor’s behavior both within and outside of the counseling sessions (such as the expectation that the client will complete homework between sessions).

When clients behave in ways that suggest resistance to BT, the fault is laid squarely at the feet of the BT counselor. In discussing this issue, Goldfried and Davison (1994) maintained that “the client is never wrong. If one truly accepts the assumption that behavior is lawful—whether it be deviant or nondeviant—then any difficulties occurring during the course of therapy should more appropriately be traced to the therapist’s inadequate or incomplete evaluation of the case” (p. 17; emphasis in original). What other therapists (particularly of a psychoanalytic persuasion) would call transference and countertransference, the behavior therapist calls stimulus generalization (Beach, 2005). In the case of “transference,” for example, the person of the therapist is similar to a stimulus person in another realm or time of the client’s life, and the client responds to the therapist in the same way that they responded to the previous person.

JaNelle works to establish a good working relationship with Shirley. She describes the basics of BT to Shirley and explains that Shirley’s anxiety and stealing behavior are learned and can be unlearned if Shirley is willing to work on it. Shirley, the reluctant client, is not very happy about the ordeal of therapy, but she grudgingly agrees that getting rid of her stealing behavior might be a good thing. JaNelle empathizes with Shirley’s unhappiness about being compelled to undergo therapy. After Shirley and JaNelle agree on goals for counseling, JaNelle gives Shirley a written contract that states these goals, the duties of both parties, and the expected outcomes of counseling.

Therapeutic Techniques

A variety of techniques are used in BT counseling. The majority of these techniques focus on overt behavior, but others focus on internal events such as cognition (you will read more about these in Chapters 9, 10 and 16). Some of these techniques are implemented by the counselor, and others are taught to the client so that they can use them on their own. Many of the techniques presented have cognitive aspects.

Relaxation Training

In addition to being the basis for several other techniques in BT (e.g., systematic desensitization), progressive relaxation training is thought to be therapeutic by itself (K. E. Ferguson & Sgambati, 2009; Goldfried & Davison, 1994). Most commonly, clients are taught progressive muscle relaxation, in which they are taught to alternate between tensing and relaxing specific groups of muscles (Antony et al., 2020). For example, the counselor might begin by having the client tense their right hand, then relax it, and then study the difference. After several repetitions of this sequence, the therapist might direct the client to tense their arm, and so forth, progressing through all of the various major muscle groups in the body. It is important that clients practice their relaxation training, so various types of recordings are used at home between sessions. (You can bet there’s an app for that!).

JaNelle teaches Shirley progressive relaxation training, beginning by giving her an introduction to the process and why it is helpful. She then guides Shirley through a complete relaxation session. Shirley records the session on her phone so that she can practice at home.

Exposure Therapy

Used widely for phobias and other fears and for compulsive behavior, exposure therapy, also sometimes called flooding, requires that the client encounter the anxiety-provoking stimulus and not respond as they typically do (e.g., with escape or compulsive behaviors; Hazlett-Stevens & Craske, 2009; Levis, 2009). Mary Cover Jones’s work with Peter, described in Box 8.5, is an example of this technique. Exposure can be done imaginally or in vivo, and sometimes the therapist even accompanies the client in these situations to make sure the response is prevented. In other instances, a significant other is recruited to help with the procedure. For these reasons, the technique may be referred to as exposure with response prevention and is often used with individuals diagnosed with obsessive-compulsive disorder (Antony et al., 2020). For example, I once had a client who had a light switch compulsion. On his own, he discovered the technique of “just not doing it.” Even though he was anxious, he would refrain from touching the light switches in his home. He was doing self-directed exposure and response prevention. This technique was very successful for him; his light-switching behavior was virtually eliminated.

Box 8.5

Mary Cover Jones: A Pioneer in Eliminating Fear in Children

Mary Cover Jones was a graduate student who worked with John B. Watson, the American founder of BT. In two articles, she described her work, which was based on Watson and Rayner’s (1920/2000) study of fear in infants (the Little Albert study; see Box 8.2). In an article published in the Journal of Experimental Psychology, Jones (1924/1960a) related her efforts to eliminate fear in children, fear that had presumably been classically conditioned.

Jones selected 70 children from a group in an institution that we might call day care. These children were in this institution temporarily because they could not be cared for in their homes (e.g., a parent was ill, a mother worked). Jones (1924/1960a) selected kids who showed “a marked degree of fear under conditions normally evoking positive (pleasant) or mildly negative (unpleasant) responses” (p. 39). The children’s fears included such things as being left alone, loud sounds, and the sudden presentation of animals (rats, rabbits, snakes).

Jones tested a number of techniques in a case study format. For example, she found that “verbal appeal,” which consisted of talking about the feared object in a pleasant way, did not work. “Social repression,” in which the feared object was presented to a child in the presence of other children, was equally ineffective. Presaging Bandura’s (1969) ideas, Jones did find that social imitation showed promise as an intervention for fear. However, Jones maintained that the best method of eliminating fear was direct conditioning, which she detailed in a separate article, “A Laboratory Study of Fear: The Case of Peter” (1924/1960b).

Peter was a 2-year-old boy who demonstrated fears very similar to Little Albert’s—of a rat, fur coat, rabbit, cotton wool, and other white furry objects. After presenting a white rat to Peter (whereupon he screamed and fell over), Jones (1924/1960b, p. 46) observed the following reactions in a subsequent testing period:

Playroom and crib Selected toys, got into crib without protest

White ball rolled in Picked it up and held it

Fur rug hung over crib Cried until it was removed

Fur coat hung over crib Cried until it was removed

Cotton Whimpered, withdrew, cried

Hat with feathers Cried

Blue woolly sweater Looked, turned away, no fear

White toy rabbit of rough cloth No interest, no fear

Wooden doll No interest, no fear

Jones used two kinds of conditioning with Peter and reported that his fear was completely eliminated and that he even showed signs of affection toward a rabbit at the end of the study. In the first stage of conditioning, Peter was exposed to the rabbit in the presence of other children who were not afraid of it. Gradually, situations were introduced that required Peter to be closer to the rabbit. In a second stage of the procedure, a rabbit in a cage was brought as close as possible to Peter while he was eating, without disturbing his eating. Presumably, the rabbit was brought closer and closer every day.

Jones reported extinction of the fear behavior not only toward the rabbit, but also in response to the white cotton, fur coat, and the other objects to which he initially reacted. Peter also seemed to be less fearful of new animals or unfamiliar situations. Although his fears appeared to be gone, Jones reported that Peter returned to a rather diminished and discouraging home environment, in which his mother used fear to control his behavior (“Come inside Peter, someone might steal you!” M. C. Jones, 1924/1960b, p. 51). Unfortunately, we have no further information about the fate of Peter.

A variety of theoretical conceptualizations have been offered for the underlying mechanisms supporting this technique. Although theoretically based in extinction, Massad and Hulsey (2006) warned that the prudent behavior therapist should know that exposure does not eliminate underlying conditioning in associations established by trauma; it merely weakens them. Other theorists argue that exposure builds new associations alongside the old, which inhibit the expression of the anxiety-ridden ones (Zalta & Foa, 2012). Recent conceptualizations also emphasize that learning to tolerate anxiety during exposure is more important than reducing it (Law & Boisseau, 2019).

Exposure is a tricky technique to use. Several critical considerations in the success of it are (a) an accurate assessment and conceptualization by the therapist, (b) proper client preparation, and (c) a strong therapeutic relationship (Zoellner et al., 2009). The counselor must also be ready to deal with the real distress experienced by the client because, theoretically, terminating the exposure too soon may result in the failure of the technique or even an increase in the anxiety (Marshall & Gauthier, 1983). Flooding involves exposure to the client’s worst fear for extended periods of time, and Zalta and Foa (2012) reported that it is not often used currently because clients prefer gradual exposure. In addition, flooding has been found to be no more effective than gradual exposure. For gradual exposure, a fear hierarchy, described in the following section on systematic desensitization, is developed to guide the exposure (Antony et al., 2020).

JaNelle thinks that in vivo exposure and response prevention is a potentially useful technique for Shirley. Shirley will have to enter a store, experience her anxiety, and refrain from stealing anything. JaNelle begins by taking a “field trip” with Shirley. She and Shirley enter numerous stores, and JaNelle makes sure that Shirley does not take anything.

Systematic Desensitization

This technique evolved from Wolpe’s (1990) idea that, if a response that is incompatible with anxiety (or other undesirable behavior) can be produced in the presence of a stimulus classically conditioned to fear, the fear will become disassociated with the stimulus. He called this process reciprocal inhibition because one response (anxiety) is inhibited by a presumably opposite one. Nowadays systematic desensitization is seen as simply another form of exposure therapy. Most commonly, step-by-step graduated exposure to the feared stimulus is paired with deep muscle relaxation (Spiegler, 2016). However, other responses, such as pleasant imagery, humor, and sexual arousal, have been used in this procedure, along with drugs (tranquilizers) and carbon dioxide inhalation.

The first steps in systematic desensitization are (a) teaching the client progressive relaxation procedures and (b) constructing an anxiety hierarchy to be used in the procedure (Head & Gross, 2009). Progressive relaxation, as described earlier, consists of teaching the client to alternatively contract and relax muscle groups in the body, progressing from one part of the body to another.

The anxiety (or fear) hierarchy is a list of situations that evoke fear in the client, ranked from least to most threatening, on a 1-to-100 scale. Goldfried and Davison (1994) recommended that jumps between items be 10 points or less; if a gap is more than 10, at least one additional item should be constructed to bridge the gap. Hierarchies are usually composed of 12 to 24 items.

Once these tasks have been accomplished, the actual desensitization procedure begins. The client is relaxed and is instructed to imagine the item or scene lowest on their fear hierarchy. They are taught to give some kind of a signal, usually by raising one finger, when the image creates anxiety. The image is visualized for 5–7 seconds, after which the counselor helps the client get back to the relaxed state (Head & Gross, 2009). The idea is to keep the level of anxiety relatively low so that it is counteracted by the relaxation. The item is then presented again until the client can visualize the scene without anxiety. When the client is successful, they are asked to visualize the next item on the hierarchy. Antony et al., (2020) reported that the hierarchy can be used in other ways, such as randomly choosing items or starting with very difficult items and progressing quickly if the client is amenable.

JaNelle decides that systematic desensitization would be ideal for Shirley’s anxiety episodes connected with her stealing behavior. She explains the procedure to Shirley, and they work on Shirley’s anxiety hierarchy. As expected, Shirley’s most feared image is of being in a store by herself. This scene she rates as a 100. The remainder of Shirley’s hierarchy is shown in Figure 8.1.

JaNelle begins the procedure in the next session, asking Shirley to relax and taking her through a progressive relaxation sequence. She then asks Shirley to imagine being in her apartment and thinking about going to a store. Immediately, Shirley’s finger shoots up, and JaNelle asks her to again relax and to “wipe the picture out of your mind.” JaNelle presents the image repeatedly until Shirley no longer indicates anxiety, and then they progress to the next item in the hierarchy.

Figure 8.1. Shirley’s Hierarchy of Anxiety.

100 Standing in a store by herself

95 Walking through the door of the store

90 Getting off the bus near the store

80 Riding the bus to the store

75 Getting on the bus to go to the store

65 Walking to the bus stop

55 Leaving her apartment to go to the store

50 Looking at an item she has stolen

40 Telling someone she is going to the store

30 Thinking about going to a store

Shaping

The process of teaching a new behavior is called shaping. First, the BT counselor gets the client to respond in some way, usually by using verbal prompts. Modeling can also be used in this stage. The therapist can demonstrate the behavior, or the client can watch a videotape. After the initial response is established, the therapist will reinforce only responses that move a step closer to the desired response (Antony et al., 2020). Verbal coaching by the therapist can move the process along more quickly.

Shaping could be used to address Shirley’s social skills deficits, JaNelle thinks. She plans to model eye contact and appropriate voice tone for Shirley and then praise her when she attempts these behaviors. At first, Shirley’s attempts will be tentative, but JaNelle will reinforce them and coach Shirley to improve them. She will then reinforce Shirley’s improved behaviors.

Reinforcement

The BT counselor can use positive and negative reinforcement to increase the occurrence of a desired behavior. For instance, praising the client for completing an assigned homework activity would tend to increase the probability of homework getting done. Negative reinforcement is probably used less often because it is difficult to find a situation in which a negative stimulus could be discontinued upon the appearance of a desired behavior. An important source of reinforcement in BT is the counselor’s verbal responses to the client, which Beach (2005) called verbal conditioning. He opined that the therapist must be alert in the counseling situation to the kind of verbal behavior they are reinforcing—for instance, differentially reinforcing verbalizations about problems (by “uh hming” every time the client speaks of these and not responding to nonproblematic or successful behavior) might make the client’s situation worse (Beach, 2005).

Often clients are taught to self-reinforce. If the client, for example, went to the gym and worked out, they would reward themself with a hot bath or a special cookie.

JaNelle thinks that positive reinforcement would be a good technique to use with Shirley. She praises Shirley for coming to counseling and reinforces Shirley’s discussions of her life with attention and head nods. JaNelle will use positive reinforcement to teach Shirley assertive skills and will reinforce her for completing homework assignments. She will also use positive reinforcement when Shirley survives an in vivo experience in a store.

Extinction

Extinction involves removing a reinforcement that is maintaining a behavior. A very common example is when parental attention is reinforcing a child’s tantrum behavior. The parent simply does not respond to the tantrum. When using extinction procedures in isolation, it is important to be sure one can tolerate the possible intensification in the target behavior that might result when the intervention is first implemented. For the parent tolerating a tantrum, this can be a very stressful experience, as you can guess! Extinction also may take some time, so it might be wise to reinforce an alternative, desired, behavior during the extinction process (Antony et al., 2020) Telling clients about time frame is likely to be helpful, lest they be tempted to let up in situations where they are implementing the extinction procedure, such as when parents are addressing temper tantrums or a child having trouble getting to sleep at night.

Time-out from reinforcement is a form of time-limited extinction, in which positive reinforcers are removed for a specified period of time. A familiar example of this procedure is seen in classrooms, when a child displaying disruptive behavior is removed to a time-out room. The critical element is that all sources of reinforcement are unavailable to the child; in practice, this is fairly difficult to achieve, which makes the procedure less effective (Spiegler, 2016). When using time-out, there are some good guidelines to remember: (a) always explain what is happening, why, and how long the time-out will last; (b) time-out should only be ended if the undesired behavior has stopped and the specified time period is up; and (c) time-out should not be used if it allows a child to escape situations they don’t like (Spiegler, 2016). Usually, the access to reinforcers is removed only for a short period of time (e.g., a minute or two) because longer intervals do not increase the effectiveness of the time-out intervention. Spiegler (2016) recommended 5 minutes or less, and for children up to age 5, one minute per each year of age.

For Shirley, applying extinction to her stealing behavior would mean virtually the same thing as in vivo exposure because JaNelle thinks that the stealing is partly maintained by the anxiety reduction Shirley experiences. However, operant extinction might require that Shirley perform a very difficult behavior—picking up an item in the store and not leaving the store. JaNelle could then praise Shirley, which would be differential reinforcement of another behavior.

Punishment

Punishment, remember, is when the consequences of an event are linked to a decrease in or disappearance of the behavior. For the purposes of intervention, two kinds of punishment can be identified (Milan, 1990; Skinner, 1953). First, and most familiar to us, an aversive event can be applied following the undesirable behavior, which is sometimes called punishment by contingent stimulation (Milan, 1990). Spanking a child falls under this category. I will pause here to note that physical discipline has been found to be ineffective and potentially harmful in addressing misbehavior in children (Glicksman, 2019).

A second kind of punishment results when a desirable set of conditions is terminated when an unwanted behavior occurs. For instance, Dad can turn off Liza’s favorite television show if she is slapping her little brother. Because this kind of punishment can be seen as the termination of a positive reinforcer, it is referred to as punishment by contingent withdrawal (Milan, 1990). A similar procedure is response cost, in which an individual is required to surrender something reinforcing, such as when you pay a fine at the bank for bouncing a check.

Punishment as a behavior change technique has drawbacks. First, because punishment only suppresses behavior, such behavior is likely to reappear when the contingencies are no longer in effect (Skinner, 1971). Also, humans are motivated to escape or avoid aversive conditions, so punishment can create these behaviors—the best way to avoid punishment is to avoid the punisher. Punishment can also result in aversive emotional states, such as shame, anger, frustration, anxiety, or depression (Spiegler, 2016). Individuals may resort to dysfunctional behaviors to avoid these aversive states, such as refusing to think about the punished behaviors or engaging in risky behaviors such as drinking alcohol or doing drugs to blunt these feelings. Finally, these negative feelings may become associated with the agents of punishment, such as parents, school, or law enforcement officials (Kazdin, 2012). Consider also that using punishment models the use of aggressive behavior. For these reasons, punishment should be a last resort and used very carefully (Antony et al., 2020).

If punishment must be used, it should be immediate to the undesired behavior (Spiegler, 2016). A consistent, continuous schedule is more effective than intermittent punishment.

JaNelle doubts that punishment would work for Shirley’s stealing behavior unless Shirley would agree to self-punish. In a sense, she already does that by making herself feel guilty and ashamed after she steals, and this has not been effective in deterring her behavior. Getting arrested can be seen as a punishment, but not one that is likely to happen every time, making it an ineffective punisher.

Social and Communication Skills Training

Social skills training involves just that—teaching clients how to interact with others. Specific skills can be identified, such as eye contact, body orientation, or paraphrasing what another is saying, modeled, and then positively reinforced.

Historically, much attention was focused on a special form of social skills recently, assertiveness training (AT). Much less attention is focused on this type of intervention recently, prompting Speed et al., (2018) to call it “a forgotten evidence-based treatment” (p. 1). Originally, Wolpe conceptualized AT as a treatment for social anxiety, defining it as “socially appropriate verbal and motor expression of any emotion other than anxiety” (Wolpe, 1990, p. 135). Wolpe thought that anxiety got (classically) conditioned to social responding, and through reciprocal inhibition, assertive responding should compete with the anxiety and weaken the conditioning.

Other BT theorists acknowledge an operant (i.e., skills deficit) view in using this technique (Duckworth, 2009; Speed et al., 2018). After assertive behavior is defined for the client, the assertive behavior is modeled for the client, or they could be verbally prompted to perform the behavior. The behavior therapist then shapes the client’s behavior, reinforcing better and better assertiveness responses. Primarily, the behavior therapist could use praise as the reinforcer unless they are working with a child, in which case other kinds of reinforcers might work (such as food).

Assertiveness training is perfect for Shirley. JaNelle will teach her to make eye contact, speak with more volume, and ask for things she wants. For example, JaNelle will help Shirley practice asking a fellow volunteer to go out to a movie or dinner with her.

Stimulus Control

Stimulus control can be used to produce or eliminate behaviors. First, many behaviors are under the control of one or more stimuli. As noted earlier, these stimuli are termed discriminative stimuli. The most commonly used examples of these types of behavior are sleep management, cigarette smoking, and eating. People who smoke tend to have specific triggers for smoking behavior, such as finishing a big meal. If you eat popcorn in bed at night, just getting in bed may cause you to feel an urge to eat. The idea is to identify the triggering event and either eliminate or modify it (Spiegler, 2016). In other cases, the client might need to associate a behavior with one or more stimuli to get it under control. For example, if Julie has a problem with eating too much too often, it might be helpful for her to limit eating to full meals at a set table. She would not be allowed to eat while watching television or in any other location.

A second form of stimulus control is a prompt. Prompts are stimuli that remind us to do a behavior, such as when Anton reminds little Amy to pick up her toys (Spiegler, 2016). It’s important to reinforce the behavior when it appears after the prompt, and I daresay that not enforcing a prompt will be ineffective. Too many unsuccessful prompts becomes nagging, right?

JaNelle decides that Shirley’s stealing behavior is cued by the stimulus of a department store. Shirley reports that she rarely steals at the grocery store or in other kinds of stores. JaNelle decides that to extinguish the association between the store and stealing, Shirley will avoid the department store for a while. She is assigned the task of going to the grocery store once a day for a week. The first day she is to walk into the store and immediately walk out. The second day she is to walk down one aisle and then out of the store. After each of these forays, she is to positively reinforce herself in some way. A gradual progression in the amount of time she spends in the grocery store is prescribed until she reports no anxiety or impulses to steal. JaNelle then transfers this program to the department store.

Modeling

Modeling is a flexible technique that often is combined with other kinds of interventions. The most basic form of modeling is simple observation, in which the client watches a model perform a target behavior. The model will typically progress through harder and harder tasks. For example, if a client is afraid of heights, they might observe a model standing on a step stool and so on until the model is looking over the balcony rail of a 20-story hotel.

Another version of modeling is participant modeling, also known as guided participation (Spiegler, 2016). In this approach, the client actually practices the target behavior after the model (usually the therapist) has demonstrated it. The model coaches the client through successively more difficult behaviors.

JaNelle uses modeling to help Shirley learn new social skills. She demonstrates appropriate vocal tone and eye contact and then asks Shirley to practice these in the counseling session. Together, JaNelle and Shirley identify situations in which Shirley might have behavioral deficits and then generate new responses for Shirley. JaNelle first models these behaviors, and then Shirley tries them out for herself.

JaNelle considers using modeling as an initial step in desensitizing Shirley to department stores. She could video a model entering a store, choosing an item to buy, purchasing it, and then leaving the store. Shirley could watch the video between counseling sessions until she could do so without experiencing anxiety.

Evaluation of the Theory

BT has evoked a great deal of controversy over the years, comparable to that associated with psychoanalytic theory. Historically, behavior therapists have been accused of being cold-hearted because of their scientific approach and language (Goldfried & Davison, 1994). The emphasis on prediction and control of behavior led to accusations that BT denied the rights and freedom of clients (Franks & Barbrack, 1990) and that it ignores the importance of emotion in human behavior. As Sweet (1984) put it, “Behavior Therapy is viewed as the cold and mechanical application of techniques, previously tested on sub-human species, and often delivered in a dangerous and impersonal fashion” (p. 254).

Behavioral approaches are seen as simplistic and most applicable to discrete and narrowly defined problems, such as phobias. The first applications of BT were with extremely dysfunctional clients (e.g., mentally challenged or psychotic clients), so its utility for a wider range of clients was questioned (Franks & Barbrack, 1990).

BT has been criticized for its emphasis on observable behavior at the expense of thought and feeling. However, as we have seen, most behavior therapists today attend to cognition and other inferred events as important aspects of human behavior. Neglect of the client’s past is also cited as a weakness of behavioral approaches, to which the behaviorists would retort that reinforcement (learning) histories are very important in understanding the client’s current presentation.

Behavior therapists are also said to ignore the role of interpersonal relationships in the generation and maintenance of psychological dysfunction (Marshall & Gauthier, 1983). For example, Marshall and Gauthier (1983) suggested that failures in BT procedures could result when improvement results in decreased dependence of the client on family members or other significant others.

Currently, BT, or probably more accurately cognitive-behavior therapy, is considered a mainstream, evidence-based form of therapy. Because its techniques are so structured and easy to understand, it lends itself to easily manualized and disseminated forms of treatment, even interactive, computer-based treatment (see www.stoppulling.com for an example of a treatment for trichotillomania, or hair pulling).

Qualities of the Theory

Precision and Testability

BT theorists maintain that theirs is the most scientific approach because it is rooted in “established principles and paradigms of learning” (Wolpe, 1997, p. 633). Certainly, it is very precise to count behaviors following the institution of a reinforcer and observe changes from baseline rates of behavior. If one is studying nodding behavior, clearly this behavior can be operationalized fairly easily. The complex behaviors involved in client presentations and in the counseling process, however, are not as easily specified and targeted.

Arguments abound about the exact definition of some BT terms, such as reinforcement. Some critics assert that the definition of reinforcement is circular: What is a reinforcement? Something that makes behavior increase. Why did that behavior increase? Because it was reinforced. The classical conditioning model has also been criticized, particularly by advocates of social learning theory (Bandura, 1969). They maintained that the effects of classical conditioning procedures are simply that the person builds a mental image that affects their behaviors rather than establishing a relatively permanent conditioned reflex. Still other authors noted that attempts to tie BT techniques to the principles of learning from experimental laboratory study are fruitless and that these very principles (e.g., reinforcement) are questionable as explanations for learning even though they can at times predict performance (Breger & McGaugh, 1965/1973; Jacobson, 1997).

Empirical Support

Overall, BT has received support from outcome research. It is important to note, though, that many studies test cognitive-behavior therapy (in a multitude of forms) rather than pure BT (if such a thing really exists). As indicated earlier, the validity of the theoretical bases of BT is much less clear.

Research Support

Outcome Research

In some ways it is easy to approach the effectiveness question regarding BT, but in other ways, it is difficult. Why? The answer is because there are very few recent studies of BT that test a purely behavioral approach. Most studies with adult samples offer some form of cognitive-behavioral therapy (CBT), making it possible to say that there is overwhelming research support for this approach. For example, in what is considered an authoritative source on psychotherapy effectiveness (Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change; Barkham et al., 2021), the relevant chapter reviews outcome research under the heading CBT, defining it “broadly to include behavioral therapy, cognitive therapy, and cognitive behavior therapy to denote initial (so-called “first and second wave”) therapies that have evolved from Skinnerian (Skinner, 1963), Pavlovian (Pavlov, 1994), and social learning (Bandura, 1974) theories, and functional analyses (Ferster, 1983)” (Newman et al., 2021, pp. 469–470, quotes in original). Hundreds of studies are included in this review, and it is no surprise that Newman et al. concluded that CBT is effective for most client presentations, including depression, anxiety-related disorders, eating disorders, some personality disorders, and psychosis. However, we should note, as do the authors, that CBT does not routinely prove to be more effective than other treatments. For example, in addressing depression, Newman et al. stated that “CBT reduces symptoms at least as much as antidepressant medication, interpersonal psychotherapy, dynamic psychotherapy, and supportive psychotherapy” (p. 493).

Newman et al.’s (2021) findings are consistent with a long history of outcome research, beginning with M. L. Smith and Glass (1977), who suggested a slight superiority for behavioral and cognitive-behavioral approaches over the other approaches in the analyses. However, these effects tend to disappear when methodological variables are controlled (M. L. Smith et al., 1980). These methodological issues involve the reactivity of the measures used—how responsive the outcome measures are to the demands of the experimental situation (Lambert & Ogles, 2004). Behaviorally oriented studies generally use measures that are more susceptible to these influences. Also, when allegiance effects (i.e., the theoretical allegiance of the study’s authors) are controlled, differences between approaches tend to disappear (Wampold & Imel, 2015). Overall, then, we can be pretty certain that BT is effective, but probably not superior to other therapeutic approaches (which of course is the typical conclusion for all of the major approaches to counseling, as you read in Chapter 1). Because the research is so voluminous, I am only going to review selected literature and leave further investigation to interested readers.

One area in which BT based interventions don’t do so well is with substance abuse. Let’s start with an extinction-based model, in which cues for substance use are presented while preventing the behavior, which according to the BT model should extinguish the substance use behavior. Newman et al., (2021) report a long history of ineffectiveness for these types of interventions, culminating in a fairly recent meta-analysis that found that that cue exposure was only effective when compared to relaxation alone or assessment only (no treatment) conditions (Mellentin et al., 2017). Even these differences were suspect due to methodological issues and potential for investigator bias. Studies of cognitive therapy and relapse prevention produced similar results, with treatments showing equal but not superior effects compared to other approaches, such as 12-step programs. Interestingly, the BT folks adopt motivational interviewing (MI) as their own (Rollnick et al., 2023; see Chapter 5 for a brief description), although it is not based in a behavioral model. Some studies show some, typically small, effects of MI over no treatment for alcohol use and smoking cessation, but MI does not appear to do better than other active treatments (Newman et al., 2021). On the flip side, behavioral couples therapy appears to have small effects in addressing alcohol use and increasing relationship satisfaction. Schmit et al., (2022) meta-analyzed 17 RCTs of BCT, finding small effects, but also cautioned that publication bias (in favor of publishing studies that find differences in favor of BCT) could be influencing their results. They cautioned that counselors should probably not consider BCT to be superior to other approaches.

You might find it interesting and useful to know that CBT is generally considered to be effective for clients who are diagnosed with psychosis (Newman et al., 2021). In fact, some evidence indicates that CBT is an acceptable alternative (combined with treatment as usual) for individuals who do not want to take antipsychotic medication (Morrison et al., 2014). Also, CBT appeared to be equivalent to antipsychotic treatment in one large trial that compared CBT, antipsychotic medication, and CBT plus antipsychotic medication, and the participants in the two CBT groups had fewer side effects (Morrison et al., 2018).

Theory-Testing Research

Discussing the role of theory in BT is difficult because BT is not a theory per se; it is more a collection of techniques said to be based on theories of learning. BT scientists had little use for the “hows” of their technologies, prompting Tryon (2005) to opine “the cognitive revolution in psychology occurred partly because functional statements made by behaviorists lacked causal mediating explanatory mechanisms. The search for causal mediators and moderators is evidence that behavioral scientists value explanation in addition to novel prediction” (p. 69). Still, most investigations of BT have focused on the effects of a given technique on the incidence of a target behavior (or symptoms). There is currently some interest in assessing the predictions of behavior theory, and in general, I would say that the support for behavior theory is not terribly strong.

For example, several causal models for the effects of systematic desensitization and other forms of exposure have been proposed. However, none has gained strong empirical support. Here is an example: Wolpe (1990) thought that pairing an incompatible state (e.g., relaxation) with the undesirable one (e.g., anxiety) would cause deconditioning (i.e., reciprocal inhibition). Because research seems to show that relaxation is not necessary, Wolpe’s causal scheme is undermined (Emmelkamp, 1990). However, a meta-analysis of relaxation treatment (Manzoni et al., 2008) found that relaxation was effective with a wide range of presentations in which anxiety was central. Regardless, exposure to the feared object or situation is currently considered to be the curative factor for anxiety disorders, but there is little agreement about how it actually works (Abramowitz, 2013; Emmelkamp, 2013; Tryon, 2005). Still, the fact that exposure and response prevention seem to help when fear avoidance responses are present would seem to support a hypothesis that these behaviors are maintained by avoidance conditioning. At the same time, you probably recall that behavioral and cognitive interventions are equally effective in treating depression and anxiety, and the two treatments, said to have different underlying mechanisms, produce similar changes in both cognitive and behavioral indicators (Emmelkamp, 2013; Goetter et al., 2021; Podina et al., 2019). If the underlying explanation for how anxiety and depression are learned are different (e.g., exposure vs. lack of positive reinforcement), then it would seem that exposure and pure cognitive intervention would be differentially effective for these syndromes. Crits-Christoph and Gibbons (2021) also surveyed the research on two other (cognitive-behavioral) models of change thought to underlie the effectiveness of exposure therapy, finding less than impressive support.

Crits-Christoph and Gibbons (2021) also reviewed the evidence testing the underlying causal assumptions in behavioral activation (BA) for depression. The assumption, as indicated earlier, is that depression is the result of reduced levels of response-contingent positive reinforcement, and BA leads to increases in positive reinforcement, thereby decreasing depressive symptoms. “Response-contingent” here just means that the positive reinforcement is linked to specific client behaviors rather than being random. This explanation would seem to be a purely behavioral one—no cognitions need apply. Of the studies reviewed, only one found strong evidence for specific links between higher levels of activity and reward and decreases in depression (Dimidjian et al., 2017), prompting Crits-Cristoph and Gibbons to call for more research in this area before any strong conclusions could be drawn. Fernández-Rodríguez et al., (2023) did just that—they compared outcomes for BA, acceptance and commitment therapy (ACT), and CBT, looking at the role of theory-specific variables in the change process. This study will be discussed further in Chapter 10, which includes ACT, but here, I will note that BA seemed to play a role in all three approaches (which did not differ in effectiveness according to most outcome measures)—when behavior was activated, anxiety and depression symptoms decreased. However, it should be noted that theory-specific variables associated with ACT and CBT also changed in expected directions over the course of treatment—Fernandez-Rodríguez argued that the changes in BA were stronger and longer lasting than those associated with the other variables (fusion and emotional regulation; see Chapter 16).

Some BT researchers would point to single-subject intensive case studies as providing evidence for the theoretical underpinnings of BT. A baseline is established on a target behavior, an intervention is made (e.g., instituting reinforcement or extinction), and then the intervention is withdrawn. Changes in behavior with the presentation and withdrawal of the intervention are thought to be evidence of the validity of behavioral techniques. Often, the intervention is reinstituted to further strengthen confidence that the treatment resulted in any observed behavior change (Heppner et al., 2016). Again, these types of studies can demonstrate relationships between interventions and performance of a given behavior, but they provide little evidence for the theoretical foundations of BT.

Issues of Diversity

It is probably no surprise that there are abundant discussions of the applicability of behavioral approaches with clients of diverse backgrounds and identities. Most reviews focus on cognitive-behavioral therapy (CBT) rather than classic BT, which makes sense given that many, if not most, BT practitioners include cognitive techniques in their work. In the review following, I will sample sources on BT, where available, and some addressing CBT, selectively. I will include brief summaries of older literature, because it contains arguments relevant today.

Newman et al., (2021) concluded there is strong evidence indicating that CBT must be culturally adapted to be fully effective. Fong et al., (2017) called for increasing diversity understanding in ABA, writing that “cultural competency is no longer an option but a necessity for serving an increasingly multicultural background of consumers” (p. 103).

Historically, BT was looked upon with suspicion by people of color and other oppressed groups; BT was viewed as a technology used to control those in less powerful positions. The BT aversive interventions to change sexual orientation used in the 60s (discussed earlier) are just one example of how disempowered folks could have a negative view of BT. Other groups who have historically experienced oppression and marginalization, such as individuals who are of Black, American Indian, or Alaska Native heritage, and those of diverse sexual orientations and identities, may also be reluctant to engage in an enterprise that changes them rather than the problems they perceive around them. However, many theorists and therapists point to strengths inherent in a BT approach that make it an excellent way to help a wide range of people. However, I will pause to agree with Spiegler (2016) that many of the observations in the following summary are based on cultural stereotypes, and it is critical for counselors to recognize this issue and remember that diversity within a given cultural or identity group is likely to be as great as differences between groups. It’s important for the therapist to carefully assess a client’s sense of identity and maintain a sense of cultural humility (see Chapter 1), while continuously striving for greater cultural competence and awareness.

Spiegler (2016) maintained that BT’s emphasis on the role of the environment in problematic behavior is particularly suitable to clients who are of diverse backgrounds because cultural differences are part of the context considered by BT therapists. Some specific features of BT are thought to be consistent or ill-fitting for certain groups, however. The structure inherent in BT, as well as the therapist’s directiveness, might appeal to clients from Asian backgrounds, as would the relative de-emphasis on expression of emotion (Shen et al.,2006; Sue et al., 2022). The concrete and immediate nature of the BT approach might fit well for American Indians and Alaskan Natives because they tend to be present-oriented. However, Spiegler specifically called out assessment procedures, warning that the direct questioning in behavioral interviews may be insulting to individuals from some cultural backgrounds (e.g., Native Americans, Japanese). Other cultural factors in assessment include how dysfunction is manifested; for example, clients from Asian cultures may evidence depression via somatic symptoms rather than sad mood.

Although the collaborative approach emphasized in BT can be a good fit for clients of some identities, it could be problematic for others. Individuals of Asian or Hispanic/Latinx backgrounds may expect a more formal approach from the counselor because of the emphasis on hierarchy found in these cultures (Frew, 2016). In addition, cultures that are high context (i.e., more reliant on nonverbal than verbal communication) might be less than comfortable with the structured, direct nature of BT intervention. Many clients from non-White cultures adopt a more collectivistic view of life, so the emphasis on individual assessment and goal setting in BT might be problematic. However, there is no inherent reason why important others in the client’s life can’t be brought into the BT process, if the client desires it.

Early critics charged that practitioners used BT to control and subjugate Black children (Neal-Barnett & Smith, 1996). Both historical and current discrimination play into how Black families parent, and similar concerns should be recognized with other groups that have experienced various forms of oppression (Crouch & Andrew, 2022). Forehand and Kotchick (1996) discussed the cultural embeddedness of parenting, providing a summary of parenting values and practices in a number of different cultural groups, but these should be viewed with caution and with respect to intersectionality and within group variability. Some BT advocates have found ways to adapt BT parenting programs to make them accessible and relevant to Black families. Neal-Barnett and Smith described some of these adaptations, which include integrating the Seven Principles of Kwanza into parent training, following the work of M. Hill (1992). Neal-Barnett and Smith found that in establishing parenting workshops for women who identified as African American it was essential that the therapists be perceived as part of the community.

The future orientation implicit in the BT emphasis on goal setting could create discomfort for clients who value a present-centered orientation, such those of American Indian and Alaska Native (AI/NA) heritage. Historically, individuals from these backgrounds have not exactly trusted health professionals due to the trauma experienced by their ancestors and by discrimination and oppression experienced currently. Similarly, Crouch and Andrew (2022) reinforced the need to recognize the historical and current oppression experienced by AI/NA people, but at the same time, they summarized research that demonstrated that culturally adapted variants of BT (e.g., dialectical behavior therapy, cognitive processing therapy) were effective with these groups. Graziosi et al., (2021) encouraged BT professionals to understand and integrate spirituality into treatment for clients from AI/NA backgrounds where appropriate. All of these writers pointed out that, when possible, it is wise to partner with the community involved, as well as its leaders and traditional healers, in designing and implementing interventions.

Some aspects of BT are compatible with feminist values. Historically, feminists reacted positively to the behavioral principle that learning is a function of environmental factors, seeing this as a departure from traditional approaches that blame the individual for their problems (Kantrowitz & Ballou, 1992; Worell & Remer, 2003). BT emphasizes self-help and encourages client self-direction, values that are consistent with feminist philosophy (Hunter & Kelso, 1985). BT’s emphasis on skills development and goal of giving the client more control over the environment are also consistent with feminist ideology.

At the same time, the behaviorists have, in the past, been criticized for ignoring the sociopolitical context of their clients’ lives. Kantrowitz and Ballou (1992) argued that defining health as behavior that is adaptive is problematic. Who decides what is adaptive? They maintained that the norms of the dominant social group (i.e., White males) defined adaptiveness, which is an unfair, biased standard, particularly for women and other historically oppressed groups. Further, BT’s emphasis on a rational, scientific approach to human behavior is a reflection of White, male, European values, which may be very different than those of women and members of other ethnic or cultural groups (Kantrowitz & Ballou, 1992). One thing to keep in mind is that any counseling with clients who are members of groups that have experienced oppression and discrimination should provide a safe and supportive space to process experiences of racism, sexism, and other forms of prejudice and discrimination (Carvalho et al., 2022; Ching, 2022; Scheer et al., 2022). Scheer et al., (2022) supported a feminist framework in working with sexual minority woman, as well as appreciation for intersectionality. Ching (2022) added that it is also important to assist Asian American clients to address the effects of the model minority myth (i.e., the belief in Western, particularly U.S., culture that individuals of Asian descent are smart, hardworking, and so on). However, most writers in this area allow that adaptations of this sort do not preclude the use of many BT and CBT procedures.

Balsam et al., (2019) wrote about the use of CBT with sexual and gender minority people (SGM). The term SGM refers to individuals who are marginalized based on sexual identity/behavior (lesbian, gay, or bisexual) and those marginalized on the basis of gender identity/expression (transgender or gender nonconforming). Noting that SGM adults are more likely to undertake therapy compared to heterosexual individuals, Balsam et al. found a number of strengths in a CBT approach for these clients. These strengths include CBT’s empirical basis, attention to environment and social context, collaborative approach, a skills training focus, a view of behavior as functional or not functional (as compared to good or bad), and the inclusion of cognitive techniques that can combat internalized trans- or homophobia. Weaknesses of CBT for SGM clients include distrust among some clients who are aware of the attempts to “cure” homosexuals in the 1960s and a relative lack of empirical studies of CBT for these clients. Carvalho et al., (2022) echoed these same strengths of CBT with SGM, and reminded therapists that in CBT, affirmation “does not imply a preferred outcome, i.e., a push towards a certain gender identity (transgender, cisgender, or otherwise) or presentation, especially when working with children who identify” (p. 6). They specifically referenced the ESTEEM program (see the research summarized below) which includes consciousness raising, self-affirmation, emotional awareness and acceptance, modification of automatic thoughts related to minority stress, decreasing avoidance, and assertiveness training

An area of diversity receiving attention of late is neurodiversity, which is concerned with individuals who are diagnosed with autism spectrum disorder (Leaf et al., 2022). Neurodiversity advocates have criticized the use of applied behavior analysis (ABA) with individuals so diagnosed. Critics point to the use of punishment or extinction procedures, contending that the implementation of ABA is abusive and leads to trauma. In this view, ABA is dedicated to creating individuals who conform to societal expectation rather than honoring the diversity among those diagnosed as autistic/on the autism spectrum. Leaf et al. reviewed these contentions and provided detailed responses. The issues are complex and often historical (i.e. some criticisms are based on procedures that are now very rarely used, such as aversive conditioning), so it is difficult to provide a succinct summary here. Advocates of ABA point to the positive effects of behavior modification but also advocate for investigation into claims of negative outcomes. If you are interested in learning more about ABA and the controversy, Leaf et al.’s article should be required reading.

Currently, advocates for culturally sensitive BT and CBT are all over the place. Several resources interested readers could peruse are Multiculturalism and Diversity in Applied Behavior Analysis (Conners & Capell, 2021), and Culturally Responsive Cognitive Behavior Therapy (Iwamasa & Hays, 2019). Also, research has been accumulating on adaptations of BT and CBT with diverse clients. Although again, most are focused on CBT, I will review several recent studies here; others will be found in Chapters 9, 10, and 16.

Sivaraman and Fahmie (2020) reviewed telehealth ABA treatments for individuals diagnosed with autism outside of the United States. They reviewed 9 studies, finding adaptations that addressed the structure and process of service delivery, and importantly, the involvement of community members in the process of adaptation.

Gregory (2016) meta-analyzed 12 studies of CBT for individuals of African descent. Most of the clients in the studies included in the analyses were persons diagnosed with anxiety disorders. Only 4 of the studies were RCTs; the remaining 8 were pre- and post-test investigations with no control groups, which weakens causal conclusions that can be drawn from them and thus, the meta-analysis as a whole. Across both groups of studies, Gregory documented large effect sizes that indicated that CBT was effective for individuals of African descent. To their credit, Gregory noted that although it could be that CBT is effective regardless of the background of clients, it is also possible that the effectiveness of CBT was a result of common factors (e.g., the therapeutic relationship, and counselor empathy). Without specific tests of the mechanisms of change in studies, there is no way to differentiate between these explanations.

Pachankis et al., (2022) described a randomly controlled trial featuring a program called ESTEEM (Effective Skills to Empower Effective Men), an adaptation of CBT to work with sexual minority men. They compared the ESTEEM intervention to what they considered to be the most common services available in the community, LGBQ-affirmative counseling and one session of HIV testing and counseling. They were interested in risky sexual behavior (in terms of HIV transmission), but also assessed other outcomes (e.g., depression, anxiety, general psychological distress). Results showed that although the direction of changes over follow-up assessments (4, 8, and 12 months) favored ESTEEM, the differences among the three groups were generally not statistically significant. Pachankis et al. wanted to attribute the lack of statistical significance to several factors, including the robust effects of the comparison conditions and low statistical power. Earlier, a version of the ESTEEM program developed for sexual minority women, EQuIP (Empowering Queer Identities in Psychotherapy) was compared to the outcomes of individuals on a waitlist (Pachankis et al., 2020). Participants in the EQuIP program showed significantly decreased depression and anxiety over treatment and follow up, and smaller, marginally significant differences in alcohol use problems. I will pause to note that waitlist participants in this study were assigned to receive treatment at 3 months after the study began. Also, stratified random assignment was used to equalize the number of White and racial/ethnic minority participants in each condition. Interestingly, the control group showed greater increases in social support compared to the treatment group. Pachankis et al. speculated that the participants in the waitlist group had taken advantage of referral resources given to them (24% did) or that being placed on the waitlist motivated them to seek support from important others around them over the waiting period.

Noting that most adaptations of CBT for sexual minority young people (SMYP) are designed and tested in Western cultures, Y. Huang et al., (2021) conducted a qualitative study of participants in a culturally adapted CBT in Taiwan and Hong Kong. Huang et al. asserted that beyond the factors that typically contribute to adverse mental health outcomes for SMYP (social exclusion, interpersonal victimization), Chinese sexual minorities also experience culture-specific stressors such as norms promoting obedience to parents and pressure to marry. They adapted an eight-session manualized intervention with the goals of improving coping skills and reducing psychological distress, that had shown good outcomes in Canada and the United States, for Chinese SMYP. To facilitate this adaptation, they gathered input from practitioners and potential users regarding important considerations in adapting the program in Hong Kong and Taiwan. A sample of 15 sexual minority youth and 18 frontline practitioners who worked with SMYP participated in a focus group where they were provided with information about the intervention and discussed potential adaptations. The participants pointed to issues with translation of terms and the need to promote the intervention in ways that avoided emphasizing that it was for individuals seeking psychological treatment because of the cultural norms around the acceptability of therapy in Chinese culture. They further noted the need to assist SMYP with self-differentiation in relation to parents and families specific to Chinese cultural norms. Finally, participants strongly emphasized that the program should help SMYP develop pragmatic, safe, plans for coming out to parents and families.

The Case Study

The story of Shirley is, in many ways, an ideal fit for the BT approach. Her primary problem behavior, the shoplifting, is fairly specific, and BT approaches are easily applied. It is less clear that BT approaches will directly affect Shirley’s loneliness, although it does seem to make some sense that increasing Shirley’s social contacts would help to some degree with this problem. However, if Shirley’s loneliness is associated with feelings that are not addressed by increased social contacts, such as mourning, this approach might be less useful. Shirley is a White, heterosexual, and presumably a cisgender woman so the applicability of a BT approach may be appropriate from a diversity standpoint because it was largely developed with White clients of Western-European backgrounds and appears to be consistent with many features of this cultural worldview.

Summary

Behavior therapy rests on a psychological model that emphasizes the learned nature of behaviors, whether they are adaptive or maladaptive. Three general models of learning are identified (classical, operant, and social learning), although the validity of these models and their direct connections to some techniques can be questioned. A variety of techniques is associated with BT, and most have been found to be effective.

BT has been the target of criticism and controversy. The traditional approach to BT emphasizes behaviors and their environmental rather than personal determinants. This emphasis, less common today, may lead to less attention to emotional and cognitive factors in behavior.

In some ways, BT seems to be an approach that is applicable to a range of clients—if carefully applied. Some client groups may respond favorably to the problem-focused, direct techniques used in BT. However, BT’s lack of attention to societal norms that influence behavior in ways that discriminate against some groups is a potential pitfall associated with this approach.

https://research-ebsco-com.lopes.idm.oclc.org/linkprocessor/plink?id=2b769e17-41a4-385d-8368-351f3eb840d4

https://psyctherapy-apa-org.lopes.idm.oclc.org/Title/777700298-001