Integrative approaches to person-centered therapy

Integrative person-centered therapists subscribe to most aspects of Rogers’s therapeutic system but also blend or integrate with it their own life experiences and ideas or those from other compatible therapeutic approaches (e.g., existential, gestalt, experiential) into a cohesive whole. Worsley (2004) suggests that

Responsible integration within the Person-Centered Approach aims at an imaginative use of various theories and philosophies of therapy to stimulate an increased openness to experience within the therapist . . . [and] to link back the process of integration to the basic philosophy so as to demonstrate coherence. (p. 126)

Worsley goes on to suggest that integration implies an openness and receptivity to: (a) new conceptions of person-centered theory, (b) theory and insights from other models of therapy, (c) concepts generated from humanistic and other psychological theories, (d) philosophical knowledge that might inform therapy, and (e) various therapeutic practices that can be compatibly integrated.

Integrative models of person-centered therapy arose, in part, because some practitioners found the classical approach too constraining or lacking effectiveness in various ways. In terms of practice, an integrative approach suggests that person-centered therapy is implemented in a manner compatible with each therapist’s personal convictions and personal style. I suspect a substantial portion of person-centered practitioners are, in fact, integrative, as relatively few adhere to a strictly classical client-centered model. Variations occur, for some, in how the core conditions are implemented. For others, bringing their own perspectives to the client for consideration or engaging various aspects of the self of the therapist are viewed as integrative. Conversely, some concepts and therapeutic methods are generally seen as incompatible (e.g., behavioral) though such approaches may be negotiated with the client for brief periods. In Worsley’s view, whatever is incorporated “needs to be filtered through the fundamental philosophical stance of the person-centered approach” (2004, p. 139). Without such integration with the fundamental person-centered philosophy, the approach would be essentially eclectic, which would be more diverse in practice but lack cohesiveness.

Others who consider themselves integrative person-centered therapists tend to hold some of Rogers’s beliefs as essential while viewing others as of lesser importance, questionable, possibly unnecessary, or even wrong. Some integrative therapists experience ambivalence or discontent with classical practitioners and regard the requirement for absolute nondirectiveness in attitude and behavior as questionable and limiting. Regarding this issue, Merry states:

I aim to bring my whole self to my client as best I can. Sometimes it feels risky . . . but to confine the self is untherapeutic; I want to bring as much as possible of who I am, how I think and learn and feel, to my relationship with the client. . . . (Worsley, 2004, p. 132)

It is of critical importance that therapists’ integration enables them to feel grounded and congruent in what they believe, feel, and do. Thus, integrative person-centered therapy has its own challenges. Not only must the therapist do more thinking and experimentation, but the therapist also must be clear about who he or she is and how that self can best be engaged with the client in a conceptually cohesive manner.

CONTEMPORARY DEVELOPMENTS IN PERSON-CENTERED PSYCHOTHERAPY

Person-centered theory and practice continue to evolve, something Rogers always expected and hoped for. In 1986, within a year before his death, Rogers gave a speech at the University of Chicago during a “Beyond Words Symposium.” During his speech Rogers reminisced about the history of the client/person-centered movement. At the end of the speech Rogers offered some thoughts about the future:

. . . it’s part of the whole pushing forward that I feel is part of the client-centered ethos that we don’t stay in one spot. I hope. I hope we’re always on the move, to a new theory, new ways of being, to new areas of dealing with situations, new ways of being with persons. I hope we’re always a part of the “growing-edge.” (Cornelius-White & Cornelius-White, 2005, p. 396)

Clearly Rogers was hopeful that his theory and its manner of implementation would break new ground and continue to progress. I suspect he would be pleased that variations of his model have evolved. In the few decades since Rogers’s passing, there have been a number of advances in the ways person-centered psychotherapy might be conceptualized and practiced. In the next sections, I will review some of the most substantial advances, many of which have emanated from Europe.

BROADENING THE SCOPE OF THEORY AND PRACTICE

Although there has been understandable and expected resistance to expanding the scope of the therapist’s repertoire of responses and therapeutic methods, such alterations are inevitable and necessary if person-centered therapy is to become more effective with clients who do not respond well to the classical approach and with clients experiencing more severe and intractable forms of psychopathology. As in all therapeutic approaches, many practitioners modify and supplement their style of practice to meet the needs of challenging clients. In the person-centered community, a number of practitioners have advocated the incorporation of a variety of methods. One of the first to advocate for the “supplementation” of person-centered therapy was Reinhard Tausch, who is one of the most productive and respected researchers and practitioners in person-centered therapy and education. Aware that Tausch and his colleagues were incorporating methods drawn from other approaches (e.g., systematic desensitization) into the person-centered model of therapy, Rogers visited Tausch’s clinic in Germany and encouraged his broadened approach (Kirschenbaum, 2007). During a workshop in 1975 Rogers commented, “One thing about the client-centered approach is that I think it can utilize many modes from other points of view and yet keep a basically person-centered philosophy” (in Francis, 2009, p. 16).

In the late 1980s, Tausch’s research on the effectiveness of person-centered therapy led him to conclude that,

We as client-centered psychotherapists help some of our clients only insufficiently . . . it became clear to me [through research studies] that client-centered psychotherapy was a valuable experience in which many people changed significantly. However, some of the clients experienced little or no lasting changes toward greater emotional health. (Lietaer, Rombauts, & Van Balen, 1990, p. 447)

Tausch recognized a dilemma faced by all models of therapy, namely that there are inevitable limits to the effectiveness with some clients no matter how faithfully and competently the model is implemented by the therapist. Such clients are ultimately instructive because they cause us to constantly reevaluate the effectiveness of what we do and make needed modifications in practice. Tausch was also aware that “clients are occasionally looking for a stimulating facilitation of their self-explorative, cognitive restructuring, information about possibilities of alternative behaviors [and that] . . . many experience this as a very helpful support” (Lietaer, Rombauts, & Van Balen, 1990, p. 448). He recognized that if therapists were receptive, they would draw from the body of existing information in the fields of psychology, psychiatry, and various schools of psychotherapy on behalf of their clients’ well-being. In other words, the needs of a given client supersede the therapist’s allegiance to a theory and its typical manner of implementation. This is as it should be if we view helping clients grow and deal with their concerns as our primary commitment.

Tausch offered some useful criteria for choosing specific supplements to person-centered therapy. He posed the questions: “What is helpful for this client?” and “What does he need to facilitate his emotional health?” Thus, Tausch is pragmatically client-centered in searching for whatever might be effective. This was Rogers’s initial approach when he was beginning to develop his ideas in Rochester. As the reader will recall, Rogers’s guiding question was “Does it work?” Compatible with person-centered values, Tausch suggested that the therapist should not be directive in offering alternatives but, rather, respectful of the client’s phenomenal world and desires, thus supporting the client’s locus of evaluation. Tausch was clear that any possibilities offered to the client for consideration must be validated by empirical research. He also proposed that any supplements offered should not be a barrier to client-centered communication. Another criterion was that such supplementations facilitate the client’s independence from the therapist and have a positive effect on the client’s self-efficacy during and after therapy

Tausch proposed some specific supplementations, including (a) relaxation techniques; (b) fear- and stress-reducing techniques; (c) behavior therapy techniques (e.g., time management, skills training, self-control methods); and (d) medical treatment of biochemical disturbances. Tausch’s suggested supplements are obviously not exhaustive. Their main value is alerting the therapist to what else the therapist might do on behalf of the client who may not find traditional client-centered therapy to be sufficient in dealing with specific problems.

One of the more important implications of Tausch’s proposal is that it broadens the definition of “client-centered” to include offering “additional therapeutic possibilities which are suited to the individual client’s needs [including] . . . all the scientifically validated options which can help the individual client change his cognitions, emotional-physical reactions and behavior” (Lietaer, Rombauts, & Van Balen, 1990, pp. 453–454). This shift is of enormous import because it recognizes that the core conditions are not sufficient for some clients and provides clients viable options that are effective. Further, the therapist is freed to bring to the client any and all resources that may be of assistance to the client. Many other person-centered scholars and practitioners (e.g., Mearns & Cooper, 2005; Watson, Goldman, & Warner, 2002) have offered similar suggestions for integration of concepts and methods from other schools of thought with person-centered therapy.

On this topic, Art Combs, one of the primary developers of person-centered theory and practice, has noted that the therapist’s fundamental resource is his or her self. In using one’s self, Combs suggests, “Professional helpers must be creative persons able to select or invent appropriate responses on the spot” (1989, p. 96).

RELATIONAL DEPTH

One of the major changes in person-centered therapy is the therapist’s increasing use of self in more diverse, intimate, and creative ways. While Rogers embraced this direction as he became aware of how impactful his focused presence was on the client, others have developed further how the person of the therapist may be used constructively on the client’s behalf. David Mearns and Mick Cooper, coauthors of Working at Relational Depth in Counseling and Psychotherapy (2005) make a powerful case for the level and quality of contact between therapist and client. They define relational depth as a “state of profound contact and engagement between two people, in which each person is fully real with the Other, and able to understand and value the Other’s experiences at a high level” (p. xii). Relational depth refers to moments of intense and intimate encounter as well as an enduring quality of contact and interconnection between two persons. Therapists working at relational depth have a high level of presence and are immersed in, accessible to, and responsive to their clients. They are sensitively attuned and resonate intuitively to all aspects of their client’s communication, behavior, and being. They are receptive to being affected and influenced by their clients as they experience a sense of “weness” in their contact. Quite naturally, the therapist appreciates and affirms the client as a person of value. Relational depth also involves a dialogical relationship in which there is more mutuality of engagement and spontaneous expression by therapist and client than there is in the typically more one-sided relationship of the classical client-centered approach where therapists share relatively little of themselves as they focus primarily on entering their clients’ worlds.

Person-centered therapists such as Mearns, Thorne, Cooper, and Schmid, along with humanistic, existential, gestalt, and relational psychoanalysts and feminist therapists, are leading the way in reconceptualizing the therapeutic endeavor. In this evolving model, therapist and client are partners in cocreating a relationship that is dialogic, egalitarian, and bidirectional in influence and that views the quality of the relationship as a source of experiential learning that enables clients to relate to the therapist, themselves, and others in a more present, intimate, disclosing, rich, satisfying, and healthy manner. Judith Jordan captures the sense of “mutual intersubjectivity” that characterizes relational therapies as she points to how the therapist and client are

. . . both affecting the other and being affected by the other; one extends oneself out to the other and is also receptive to the impact of the other. There is openness to influence, emotional availability, and a constant changing pattern of responding to and affecting the other’s state. There is both receptivity and active initiative toward the other. (1991, p. 82)

In essence, clients learn to be more effective social beings by participating in a mutual and vibrant meeting with their therapists. By so doing, clients experience themselves in different ways that result in the alteration of their self-concepts and quality of relationships with others.

A major shift in the theory of how the person is conceived is at the heart of how a more “relational” person-centered therapy might be understood and practiced. In Rogers’s theory, the person is understood in primarily individualistic terms, viewed as a discrete and autonomous being. Since this view holds for therapist and client, person-centered therapy is conceived as a meeting between two separate persons.

An alternative and increasingly emerging view is that persons exist primarily in relationship to each other, rather than as separate entities. In this view, many contemporary philosophers and psychologists take the position that we are inextricably intertwined with each other and that we are best understood as “beings-in-relationship” (e.g., Friedman, 1985; Mearns & Cooper, 2005) From birth on, we exist first with others and only in relationships do we become ourselves and know ourselves. As infants, we can only know and define ourselves in interaction with our significant others. As Harry Stack Sullivan (1947) argued, we form our identities through the reflected appraisals of our parents and significant others. Throughout the life cycle we continue to alter our self-concepts based on the way we see ourselves through others’ eyes. Further, in our daily lives much of what we think, feel, or do has reference to others, even though we may not think in these terms in the moment. We often have fantasies about others or “mental conversations” with people who are not present or are deceased. Much of our lives are spent in a wide variety of interactions with others—family, friends, teachers, coworkers, salespersons, people in novels, professional athletes, and so forth. As Cooper and Mearns note, “at the level of lived-being, we are constantly interacting with others, or thinking about others, or imagining doing things with others “(2005, p. 5). In short, most of our lives are related, in one way or another, to other people. Further, in many cultures the “self” is viewed not as an separate entity but rather as interdependent, interconnected, in relationship to others, as part of a larger whole that includes the physical world.

The case can be made that both positions, individualistic versus beings-in-relationship, are useful lenses through which we might conceive of ourselves. Subjectively, we often feel ourselves to be separate and independent entities when we are alone or even in the presence of others. Yet that perspective cannot fully define what it means to be a person since we are inevitably part of various social groups and institutions and cannot ignore the reality that much of our lives are peopled. What seems to happen is that, at moments, a more individual and separate sense of self emerges into our experiential foreground, while at others our individual self recedes into the background while a more interconnected sense of ourselves as a “person-in-relationship” emerges as primary. Barret-Lennard points to an emerging understanding that “Person-centered thought is transcending the philosophy of individualism in which it was rooted, while preserving its belief in the worth and dignity of each person” (Cooper et al., 2007, p. 135).

The view of persons as beings-in-relationship is especially relevant to how we understand our clients’ problems. The most frequent reason clients seek psychotherapy is for problems in interpersonal relationships. These problems may take many forms, including depression, social anxiety, loneliness, paranoia, anger, extreme self-consciousness, conflicts with spouses or other people, and difficulties in acculturation, among others. Problems in relating to others, and especially the inability to form close and mutually supportive relationships, are common in our clients. Dean Ornish, author of Love and Survival (1997), has even dubbed loneliness, isolation, and depression as the “real epidemic in our culture” leading to a loss of “social structures that used to provide us with a sense of connection and community” (pp. 12–13).

Clearly, a large portion of the concerns clients bring to therapists are primarily interpersonal, and even problems that seem primarily intrapersonal (e.g., low self-esteem) often have interpersonal components.

Since problems in relating and lack of close and supportive relationships are at the core of many of our clients’ problems, one could readily make the case that intimate relationships are good for one’s sense of well-being and mental health. Ornish (1997) provides substantial evidence for the healing power of intimacy. One of the major conclusions of the research he reviewed was that anything that enhances one’s sense of love, intimacy, connection, and community is good for our mental and physical health. Conversely, anything that promotes a sense of isolation often led to illness and suffering. Simple observation, experience, and common sense tell us that good relationships promote our sense of well-being, while poor relationships or a lack of relationships adversely affect our sense of well-being.

Given the interpersonal basis for our clients’ sense of well-being or lack thereof, the quality of the therapist–client relationship becomes central to client adjustment and growth. Therefore, as Mearns and Cooper suggest, an optimal therapeutic relationship is one “in which dialogue and interaction take more center stage: one in which it is the encounter between the therapist and client, rather than the provision of a particular set of conditions/or the client” (2005, p. 9). This approach enables the therapeutic relationship to serve as a “social learning lab” in which client and therapist collaborate as participants and observers who experiment with ways of engaging that enable the client to live more effectively in the moment and to take such experiences into other relationships.

DIALOGIC ASPECTS

All real living is meeting.

—Martin Buber (1958, p.11)

Increasingly, person-centered therapists such as Mearns and Cooper (2005) are incorporating into their work aspects of dialogical psychotherapy, defined by Buber scholar and psychotherapist Maurice Friedman as “a therapy that is centered on the meeting between the therapist and his or her client . . . as the central healing mode” (2002, p. 11). This “healing through meeting” is a two-person, bidirectional psychotherapy that emphasizes the authentic meeting or encounter between therapist and client. Consequently, self-actualization is viewed more as a byproduct of the quality of meeting between two persons rather than something one strives for by developing one’s qualities or potentials. There is an intuitive wisdom to this notion as many persons, clients included, often attribute aspects of their growth to extraordinary experiences with a special person in their lives.

The healing through meeting of dialogic engagement means that the therapist’s fundamental intent is to make meaningful and authentic contact with the client rather than trying to enable the client to be different or to achieve a specific outcome deemed desirable by the client or therapist. Instead, the client’s spontaneous and authentic engagement with the therapist is supported, encouraged, and reciprocated. Such extraordinary meetings between therapist and client may take various forms and are often experienced as intense, novel, touching, intimate, loving, rich in personal learning, and unforgettable. For authentic meeting to have a therapeutic impact, the therapist needs to be fully present to and engaged with the client. As Yontef states: “A requirement of dialogic contact is the therapist’s willingness to be ‘genuine and unreserved’ by honestly revealing anything that the therapist believes will enable the ongoing dialogue” (2007, p. 21).

Existential and gestalt therapists (e.g., Friedman, 1985; Yontef, 1993) identify inclusion as a critical component of dialogic encounter. Inclusion or “imagining the real” is an expanded empathic process during which the therapist imagines what the client is experiencing and grasps the client’s unique being-in-the-world. Inclusion also represents the therapist’s “bipolar experiencing of the other side of the relationship without leaving one’s own ground” (Friedman, 1985, p. 199). In other words, the therapist remains a separate self and brings forth that self-existence and perspective in service of the client. Friedman contrasts inclusion with empathy, which “attempts to get over to the other while leaving oneself” (1985, p. 200). In inclusion, there is more mutuality in sharing than is usual in the classical person-centered style of empathic responding, which primarily limits itself to grasping and communicating the client’s experiencing. Inclusion also provides a means for a greater depth of relating and intimacy between client and therapist.

Therapist confirmation of the other is another powerful aspect of healing through meeting. It includes, but also goes beyond, acceptance by confirming clients as they are in the present as well as what they may become. For Jourard, “confirmation is an act of love through which one acknowledges the other as one who exists in his own peculiar form and has the right to do so” (Friedman, 1985, p.134). As Buber contends:

Confirmation means . . . accepting the [other’s] potentiality. . . . I not only accept the other as he is, but I confirm him, in myself and then in him, in relation to this potentiality that . . . can now be developed. . . . “I accept you as you are” . . . does not mean “I don’t want you to change,” but . . . I discover in you just by my accepting love . . . what you are meant to become. (Friedman, 1985, pp. 135–136)

Thus, in dialogical encounter, the therapist first accepts clients as they are but also may confront and challenge them to become their potential. Friedman expanded on this notion when he said that the therapist “is not only concerned with the person [the client] is at that moment, but also with [the client] becoming what he or she is called to become”:

It is not that I judge you from above or that I moralize at you. Yet our relationship is a demand on you as on me. . . . The therapist may have to wrestle with the patient, for the patient and against the patient. He is not only concerned with the person he is at that moment, but also with his becoming what he or she is called to become. (1985, p. 137)

Another characteristic of dialogical engagement is a commitment to “the between,” that which transpires between therapist and client. In this process, the therapist’s perception is not privileged or considered objective or “truth” but is subject to change in the interaction. In other words, the therapist and client mutually influence each other, and both can be changed by the other. Thus, the therapist is willing to be vulnerable, accountable, and receptive to being affected by the client and does not hide behind a professional facade but instead meets “self to self.” This does not negate the reality that the primary focus of the therapist is the client and the client’s concerns or that each has different roles. While there are moments when both therapist and client benefit from the encounter, more often the commitment to the between primarily facilitates the process of the therapy.

One of the primary contributions of the dialogical approach is that it makes more room for therapists to bring relevant aspects of themselves to the client. The therapist also understands that each client has multiple selves that come forth at various moments, sometimes in discord with each other.

PLURALISTIC SELVES PERSPECTIVE

Rogers’s conceptualization of the self or self-concept as a unitary phenomenon has been reexamined and refined by theorists. Some person-centered experts believe that a more accurate view is that individuals have multiple aspects of self that emerge in various moments and contexts. Cooper (2007) notes that these “multiple elements” may be variously conceived as “configurations of self,” “modes of being,” “inner persons,” “subselves,” “voices,” or “parts” (p. 86). This altered view of the self has arisen as therapists noted that clients often refer to various parts of themselves.

Clients often articulate these various aspects of self or selves-in-conflict when they say such things as “part of me wants to be married while another part likes the freedom of being unattached.” Sometimes clients speak of aspects of self that are related to specific roles (e.g., “I’m a good mother”). The regard clients hold for themselves may vary as different aspects of self emerge and become figural. For example, a client who has just expressed rage at his son feels ashamed, while that same client feels proud of a recent accomplishment as a scientist. The existence of multiple selves may be understood as a natural outcome of the complexity of human beings engaging in a vast variety of life experiences that produce physical, social, spiritual, cognitive, emotional, or psychological selves, among many other possibilities for being. From a narrative perspective stories are created, remembered, and told (and retold) that reflect specific qualities of self or ways of being. Each aspect of self may have varying experiences of the world. For example, a soldier whose religious values lead him to adopt a pro-life stance in terms of abortion may hold a view that it is fully justifiable to kill on the battlefield. These various selves often communicate with each other in silent or overt self-dialogue. In simple terms, we often talk to ourselves as if we are relating to the different persons who exist within us. For example, a person who perceives himself to have acted immaturely may state, “When are you ever going to grow up?” One’s diverse selves may exist in harmony or in conflict and may be isolated or integrated into a more cohesive sense of “I” or “me.”

Stiles, a person-centered theorist, proposes an assimilation model in which people are construed “as composed of many pieces . . . [where] each piece consists of the traces of an experience or of a constellation of related experiences” (Watson et al., 2002, p. 406). Stiles refers to these experiences as voices and proposes that,

The voice metaphor underlies our understanding that traces of experience—including problematic experiences—are active agents within people. That is, the voices can speak and act. . . . Theoretically, in successful therapy, a problematic, unwanted, outcast voice establishes contact with the dominant community of voices within a person, negotiates an understanding and is assimilated into the community. (Watson et al., 2002, p. 407)

These aspects of self, when problematic, are often polarized, antagonistic (e.g., “I hate this part of myself”), unaccepted (and unacceptable), and thus alienated from the lager sense of self. In order to more accurately grasp these various selves in the client, therapists need to shift their perspective from a unitary and executive self to one that recognizes the multiplicity of ways clients view and experience themselves at various moments. A challenge for clients and their therapists is to find ways to reconcile and integrate different aspects of the same person, especially when they are incongruent and in conflict with each other.

To summarize, there is no longer one form of person-centered therapy, although Rogers’s “necessary and sufficient conditions” model is still the most widely known and accepted. Rogers himself recognized that there was no one way to practice person-centered therapy He took the position that,

The approach is paradoxical. It emphasizes shared values, yet encourages uniqueness. It is rooted in a profound regard for the wisdom and constructive capacity inherent in the human organism—a regard that is shared by those who hold to this approach. At the same time, it encourages those who incorporate these values to develop their own special and unique ways of being, their own ways of implementing this shared philosophy. (1986, pp. 3–4)

Rogers expected person-centered therapy to continue to evolve and supported others in taking his ideas to the next levels. Developments in theory and corresponding advances in practice have been substantial in the last 25 years. Such progress is likely to continue as students of person-centered therapies continue to break new ground. This is as things should be in order for person-centered therapists of various persuasions to become increasingly more effective in assisting their clients.

In the next chapter, I will discuss how the theory of person-centered therapies might be put into practice and address the processes and mechanisms by which constructive change occurs.

The Therapy Process

In this chapter, I will begin with the paramount role of the therapist–client relationship, followed by the specific contributions of therapist and client, individually and collaboratively. Throughout the chapter I will attempt to articulate the various mechanisms of change that foster client growth.

ROLE OF THERAPIST–CLIENT RELATIONSHIP

One of the most fundamental premises of person-centered/humanistic psychotherapy is that an optimal therapeutic relationship is considered to be a primary source of constructive change in the client. A mutually engaged relationship between therapist and client often promotes growth in and of itself. When clients and therapists meet at relational depth, each often has an experience of how one can and might live with others. Through consistently good contact and extraordinary moments of encounter with their therapists, clients may experience themselves in ways that are rich, fresh, hopeful, and even transformative. Over time this quality of engagement with the therapist takes hold and is enacted in relationships with others. In addition to promoting constructive change in and of itself, the relationship provides an atmosphere conducive for intrapersonal and interpersonal learning.

In person-centered therapy, the core therapist qualities of empathy, unconditional positive regard, and congruence, enhanced by the therapist’s presence, work synergistically and holistically to create a safe and supportive environment for learning and growth. Each therapist quality or condition augments the impact of the other. Before clients can feel accepted and valued, they must first perceive that their therapists “see” them clearly and have a sense of who they are, what it is like to be them and to live in their worlds. It is also essential that the client’s sense of being accepted and prized be based in an experience that the therapist is congruent and trustworthy. Otherwise clients may feel that their therapist are simply “doing their job” by being accepting and trying to help them feel better or improve their self-esteem. These attitudes are enhanced to the degree that the therapist is fully present and immersed in the moment-to-moment unfolding of the client’s world, and to the degree that the client is able to receive and absorb the therapist’s regard. Person-centered therapist’s optimism about their clients’ resourcefulness and capacity to actualize their potential also creates a sense of hopefulness and encouragement that strengthens client’s beliefs that they can grow and effectively address their problems. The quality of the relationship is influenced as well by what the client brings to it since it is created and influenced by both therapist and client. Mutual affirmation between therapists and clients, in particular, creates a congenial and supportive atmosphere that enables clients to engage their courage to struggle with their issues.

As therapy proceeds, clients often internalize their therapists’ attitudes of empathy, acceptance, and congruence. They learn to listen more sensitively to themselves and increase self-awareness and self-understanding. They gradually become less critical and more self-accepting as they incorporate their therapists’ views of them. Clients learn to be more congruent as they see themselves more clearly and develop the courage to be known and to express thoughts and feelings they previously tended to withhold. Equally important, they become more empathic, accepting, and congruent in their relationships with others, thereby engaging others in more meaningful and satisfying ways.